Every finding on record at Calvert City Convalescent Center

Based on interview, record review, and review of facility policy, the facility failed to provide a written hospital transfer and discharge notice for 3 of 3 sampled residents, (Resident (R)1, R2, and R3). The facility failed to provide R1, R2, and R3 with the written hospital transfer notice and/or discharge notice as required. The Director of Social Services (DSS) confirmed no written hospital transfer notice and/or discharge notice had been provided to the residents.The findings include:Review of the facility's policy titled, Transfer and Discharge (including Against Medical Advice), copyrighted 2026, revealed, The facility's transfer discharge notice will be provided to the resident and resident's representative in a language and manner in which they can understand. Per policy review, the notice, at the time it was provided, was to include the reason for: the effective date; and specific location of the transfer/discharge. Further policy review revealed the notice was to include appeal information, and the Ombudsman's information.1). Record review revealed the facility admitted R1 on 09/18/2024, with diagnoses that included Parkinson's disease with dyskinesia, posttraumatic stress disorder, and chronic obstructive pulmonary disease, unspecified. Review of Annual Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 01/25/2026, revealed the facility assessed R1 as having a Brief Interview for Mental Status (BIMS) score of 14 out 15, which indicated the resident was cognitively intact. Attempts to contact R1's resident representative was made on 08/25/2026 at 12:20 PM, and at 2:10 PM; however, the attempts were unsuccessful, and no voicemail was available. In an interview with the Director of Social Services (DSS) on 08/25/2026 at 3:53 PM, she stated no written hospital transfer, and discharge notice was provided to R1 and/or resident representative.2). Record review revealed the facility admitted R2 on 01/30/2026, with diagnoses of malignant neoplasm of bladder, unspecified, chronic ischemic heart disease, unspecified, and depression, unspecified. Review of R2's Annual MDS Assessment, with an ARD of 02/13/2026, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 6 out of 15 which indicated the resident was severely impaired.On 08/25/2026 at 12:26 PM, R2's representative declined to be interviewed.Review of the facility's discharge list revealed R2 was transferred to a Hospice on 02/13/2026. In interview with DSS on 08/25/2026 at 3:53 PM, the DSS confirmed R2 was transferred to a Hospice at the resident's representative's request. In continued interview with the DSS on 08/25/2026 at 3:53 PM, she stated however, no written discharge notice had been provided to R2 or the resident's representative. 3). Record review revealed the facility admitted R3 on 07/10/2026, with diagnoses of atherosclerotic heart disease of native coronary artery without angina pectoris, chronic kidney disease, and depression, unspecified. Record review revealed no MDS Assessment was available for review, as R3 had been discharged the day after admission.In an interview on 08/25/2026 at 12:30 PM, R3's representative, she stated R3 had been transferred to the hospital and chose to send the resident to another facility at the time of the resident's hospital discharge.In an interview with Director of Social Services on 08/25/2026 at 3:53 PM, she stated R3 had not received a written hospital transfer notice. In an interview with the Administrator on 08/25/2026 at 5:11 PM, he stated hospital transfer notices were completed by phone, and discharge notices were provided only when a discharge was planned.

Based on interview, record review, and review of facility investigation documentation and policy, the facility failed to ensure residents were free from misappropriation of property for 1 of 19 sampled residents, (Resident (R)48). On [DATE], the facility's Registered Nurse (RN) 1, the Assistant Director of Nursing (ADON) misappropriated R48's liquid oral morphine concentrate by injecting water into the multi-dose vial in order to correct the volume loss reported by a staff nurse. RN 1/ADON admitted to the facility that she injected water into R48's morphine vial. The facility failed to ensure a medication administration record of oral liquid morphine concentrate on [DATE] at 2:30 AM for R48. The facility implemented plans of correction regarding the incident and alleged past non-compliance date of [DATE]. The findings include: Review of the facility policy entitled Prohibiting Abuse, Neglect, Misappropriation, and Exploitation, undated, revealed the facility believed each individual (resident) had the right to be free from (all) abuse, as well as neglect and exploitation. Continued review revealed residents of the facility were not to be subjected to abuse by anyone including, but not limited to facility staff, other residents, or others serving the residents, including family members. Review of the facility policy entitled, Medication Administration General Guidelines, dated 2006 and last revised ,d+[DATE], revealed medications were administered as prescribed in accordance with good nursing principles and practices, and only by persons legally authorized to do so. Continued review revealed personnel authorized to administer medication were to do so only after they had been properly oriented to the facility's medication distribution system. Per policy review, personnel authorized to administer medication were also to do so when the facility had a medication distribution system to ensure safe administration of medication without unnecessary interruptions. Review of the policy revealed when administering high risk medication in liquid form, or those requiring precise measurement, such as morphine, devices provided by the manufacturer or obtained from the provider pharmacy, such as oral syringes were to be used to allow accurate measurement of doses. Further review of the policy revealed the individual who administered the medication dose was to record the administration on the resident's medication administration record (MAR) directly after the medication was given. In addition, review revealed at the end of each medication pass, the person administering medication was to review (residents') MARs to ensure necessary doses were administered and documented. Review of the facility's medical record for R48 revealed the facility admitted the resident on [DATE], with diagnoses that included: chronic pain syndrome, right sided sciatica, and generalized muscle weakness. Further review revealed R48 was noted as deceased as of [DATE]. Review of the Quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date of [DATE] revealed the facility assessed R48 to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the resident was cognitively intact. Review of R48's care plan date initiated [DATE], revealed the resident had a problem for potential for alteration with pain or comfort related to osteoarthritis. Continued review revealed the facility's goal for R48 was for the resident not to have an interruption in normal activities due to pain through the review date. Per care plan review, the resident had an order for as needed pain medication, with intervention that included administering pain medication as ordered per the Physician. Review of the facility's MAR for R48 for [DATE], revealed a current order for morphine sulfate concentrate solution 20 milligrams/milliliter (mg/ml). Continued review of the MAR revealed R48 was to receive 0.25 milli units by mouth every four hours for pain. Further review of R48's MAR revealed doses of PRN morphine sulfate concentrate solution were also ordered for the resident. Review of the facility's Long-Term Care Facility Self-Reported Incident Form submitted to the State Survey Agency revealed an incident report noting a diluted morphine vial revealed the date of the incident noted was [DATE]. Per review, staff involved in the incident included Registered Nurse (RN) 1 and Licensed Practical Nurse (LPN) 10. Review of the facility's Five-Day Follow up Form/Five-Day Final Investigation Report Summary dated [DATE], revealed on [DATE], a morphine bottle was 2 milliliters (ml) short of the amount that should have been in it. Per review, the Administrator was informed and an investigation was started in to why the bottle was short of the amount that should have been in it. Review of the Five-Day Final Investigation Report Summary, revealed the ADON was measuring the amount in the one morphine bottle in question that was low. Continued review of the Summary revealed LPN 10 was present in the medication room and was asked to step outside the room leaving the ADON alone. Review of the Summary revealed the ADON asked LPN 10 to come back into the medication room and the nurses measured the amount in the vial of morphine together, which was noted to have measured the correct amount. Further review of the Summary revealed LPN 10 questioned the ADON as to if the bottle had been diluted with water to bring it to the proper level. Additional review revealed LPN 10 did not feel comfortable administering medication from the morphine vial and contacted management. In continued review of the facility's Five-Day Follow up Form/Five-Day Final Investigation Report Summary dated [DATE], for the incident on [DATE], involving R48's morphine revealed to ensure no resident received any medication from a bottle that had been tampered with, it was agreed the bottle (vial of morphine) would be taken out of circulation and locked away. According to review of the Summary, that vial was immediately replaced with a new bottle at the expense of the facility. Review further revealed at no time was there any medication administered from a tampered bottle and no resident missed any doses or were late on their medication times. In addition, review revealed when the ADON was questioned about the incident, she confirmed she had diluted the morphine vial to bring it up to the proper level. The Summary review further revealed based on the investigation findings, the facility verified that medication tampering had taken place. In interview with RN 1 (former ADON) on [DATE] at 1:40 PM, she stated she recalled the incident in question regarding the morphine vial for R48. She stated she was approached by a staff member (LPN 10) on [DATE], who was concerned that an oral morphine vial was missing medication volume. RN 1 stated she did some research and found that the narcotic (narc) logbook for signing medications out against the MAR was also not correct. She stated in an effort to correct the problem, she injected water into the vial of liquid morphine concentrate to refill it to the correct level. Per RN 1 in interview, she did that in the presence of another nurse (LPN 10) who reported her for doing that. She said and she was terminated for her actions the next day. RN 1 stated that during the time she was investigating the matter, she had been unable to specifically identify individuals who might have failed to sign the narc log or MAR. She stated the incident was reported to the State Board of Nursing, and she was investigated and reprimanded for the matter by the Board of Nursing. RN 1 further stated she did not know why the doses in the morphine vial were off. She additionally stated the diluted morphine concentrate in the vial was never administered to R48. In interview with LPN 10 on [DATE] at 4:00 PM, she stated she recalled the incident in question. LPN 10 stated R48's morphine had been short and I did not want to sign the narc log because it wasn't right. She stated she tried to get help from the ADON who told her to let the night shift nurse go home and she would take care of it. Per LPN 10, when she went back to the patient care area, no one was looking into the morphine shortage and the ADON had not told the DON about the problem. According to LPN 10 in interview, the ADON said I'm going to fix this and you are not going to like it. She stated at that point the ADON added water to the vial of morphine to replace the missing volume and told her R48 would never notice, just give her that. LPN 10 stated the ADON did not care and she left but, I was concerned that she was covering it up so I called my manager first and then the administrator of the building and the doctor. The LPN said when she came on shift and started counting the morphine with the nurse from the previous shift (LPN 11) she found a major discrepancy. She stated I was not comfortable with that. LPN 10 stated she did not question the other nurse who worked before her about it and did not ask her what happened. She further stated she had not thought the previous nurse had done anything wrong, but, that nurse was permitted to leave. In addition, the LPN said the ADON had been trying to cover it all up and that was my problem. Review of the facility's controlled substance use record or narc logbook revealed on [DATE], five individual doses oral morphine were all administered from the same vial. Per review of the narc logbook, LPN 11 noted administration of three doses on [DATE] at 12:00 AM, 2:30 AM, and 6:00 AM. Continued review revealed LPN 10 noted two doses of morphine were administered on [DATE] at 12:00 PM and 2:36 PM. Review of the MAR for R48 revealed LPN 11 recorded administration of morphine at 12:00 AM and at 6:00 AM on [DATE]; however, the LPN failed to record the morphine dose on [DATE] at 2:30 AM, that was signed as given on the narc log. Further MAR review revealed LPN 10 noted two doses of morphine administered at 12:00 PM and 4:00 PM on [DATE]. In interview with the Administrator on [DATE] 8:43 AM, I got a call after I left work from an employee that ADON/RN 1 had diluted a morphine bottle. Per the Administrator in interview, I remembered thinking this cannot be right, why would the ADON have done this? He stated he talked with the Medical Director and decided for purposes of immediacy pull the vial and replace it with a new bottle so no diluted medication was given. The Administrator stated it was indisputable that ADON/RN 1 had diluted the morphine bottle after review of the facility's (video) tape. He stated he terminated the ADON the next day and the facility's report was submitted to the SSA. According to the Administrator, the practice of the dilution of the morphine bottle caused us to report and turn that information in to the State Board of Nursing. In continued interview with the Administrator on [DATE] 8:43 AM, he stated checking the morphine level was a big part of our investigation and was how the facility improved because of doing that. He said the facility switched syringe types also which had helped with solving a slight variation problem. The Administrator stated staff education and demonstration was a big part of what we needed to do so all nurses understood how to use the syringe and learned to read it the same way. He stated we did not feel like anyone here was trying to take advantage of the situation by stealing medication. According to the Administrator, we ended up installing level shelving for measurement so that we get the same reading every time. When the SSA Surveyor asked the Administrator what a potential outcome was if a resident's care plan for pain medication was not followed or the medication had been diluted, he stated, an outcome would be that the resident would still be in pain. In interview with the Director of Nursing (DON) on [DATE] at 2:00 PM, she stated she was aware of what the ADON had done and to her knowledge the morphine was not given to R48. She stated they opened a new bottle at that time because a dose was due for R48. Per the DON in interview, the ADON was dismissed after admitting to what she did. The DON stated she did not recall ever speaking with LPN 11 about why the dose from R48's MAR was missing for the date of [DATE]. She stated the ADON/RN 1 admitted to diluting the morphine vial and we went back and forth on termination versus education for her and we went with termination in the end. She stated they went with termination of the ADON/RN 1 because of the potential for R48's pain to not have been controlled due to her actions. The DON stated if R48's care plan had not been followed, increased pain could have been a negative outcome, if the diluted morphine had been administered to the resident. She stated she could not recall specifically what LPN 10 said her concerns were, but did recall that the LPN was refusing to document on the narc log after the morphine had been diluted by the ADON/RN 1. In continued interview with the DON on [DATE] at 2:00 PM, she stated We looked through documentation, syringes, etc to try to find causation and we found that a problem had arisen with the way the syringes were reading. She said so they educated nurses to that and got rid of the old syringes and put the new syringe type in place. The DON stated other measures, such as lock boxes were put into place and nursing staff had been instructed to notify us immediately if any discrepancy was detected. According to the DON, We also installed level shelving to identify morphine volume for measurement. She stated she thought the problem was stabilized today, but measurement of the product was the challenge and that's why the shelving was installed. When the SSA Surveyor asked the DON about the key improvements from the facility's internal plan of correction she stated, shelving in place for leveling the volume, new syringe type in place is much more accurate for measurement and that makes it easier for nurses. The DON stated the nursing education provided included how to draw the medication up properly and lock boxes were installed to keep bottles upright and to prevent leakage. She further stated discussions about accuracy of the narc log and MAR documentation had also been included.

Based on observation, interview, record review and facility policy review, the facility failed to ensure its policy was followed regarding the prompt resolution of all grievances related to residents' rights, including those with respect to care and treatment furnished by the facility, which had the potential to affect all residents expressing a grievance. When conducting the entrance conference with the Administrator, the prior six months of resident grievances were requested as part of the survey process. The Administrator stated there were no resident grievances formally documented or logged other than resident council. The findings include: Review of the facility policy titled, Resident and Family Grievances, dated 02/01/2023, revealed it was the facility's policy to support each resident's and family member's right to voice grievances. Continued review revealed staff members receiving a resident's grievance was to record the nature and specifics of the grievance on a designated grievance form, or verbally route the grievance up to the appropriate department. Further review revealed the department manager over the specific area of concern was to keep the resident appropriately apprised of progress towards resolution of their grievances. In addition, review further revealed the facility was to make prompt efforts to resolve (residents') grievances. During a resident council meeting, on 10/01/2024 at 2:09 PM, the residents (all in attendance) stated the council met the first Tuesday of each month. Per the residents in the meeting, the Social Services Director (SSD) was always involved with the council and assisted the residents as needed. In an interview with R45, during the resident council meeting, she stated residents reported their requests or grievances to the Activities Director (AD) or SSD. R45 stated the AD or SSD had acted on the residents' requests; however, residents were not provided the status on the action taken while waiting for a resolution. In an interview with SSD, on 10/03/2024 at 11:30 AM, she stated she and the AD were in the resident council meetings the majority of the time. She stated other department heads attended as well if there were concerns in those areas. The SSD stated resident council was the formal meeting in which all residents could attend, but she had discussed with residents that grievances or complaints could be made at any time to any department staff. She stated she ensured residents' concerns were given to the appropriate department. Per the SSD in interview, the facility had addressed residents' concerns, but had failed to have a system of documentation in place to track the grievances, actions taken, resident updates, and resolutions. She stated she understood that was not an acceptable process. The SSD stated once a grievance or concern was reported her expectation was that the department head would be responsible for addressing and seeking a resolution for the resident. She further stated the department head was to share the progress or delay of grievances with residents, until a resolution was found. In an interview with the Administrator, on 10/03/2024 at 4:31 PM, he stated regarding family grievances many family members had called him directly with their concerns. He stated if it was something related to a specific department the grievance was routed to the correct department. The Administrator stated that allowed the department head to address the concern and provide a resolution. He stated it was his practice to follow-up by contacting the family members with an update; however, he said he had no documentation process other than a progress note. The Administrator stated depending on the area of concern, management might note the investigation details in their department. Per the Administrator in interview, historically, the department head over the area of concern was responsible to investigate and find a resolution to grievances. In continued interview on 10/03/2024 at 4:31 PM, with the Administrator, he stated moving forward with the Performance Improvement Project (PIP) that had been initiated on 09/30/2024, the SSD would be the grievance official. He stated however, the grievance form utilized going forward included a space for the Administrator as the final signer to ensure the grievance process was completed from beginning to end. The Administrator stated having a grievance process in place was important to ensure residents' concerns had not fallen through the cracks. He said residents and their families would be provided a more formal follow-up. The Administrator stated all department heads were provided the new grievance forms which included a monthly log. According to the Administrator, once implemented any grievance reported to any department would not have to wait to notify the SSD of the grievance. He stated the departments could initiate the grievance process by completing the document and start investigating to determine a root cause analysis. The Administrator further stated the SSD was to follow up with the departments to ensure outcomes, but his signature was the final confirmation once a resolution was reached.

Based on observation, interview, record review and facility policy review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Observation of the kitchen revealed food items not dated, labeled, or stored properly to prevent potential contamination. The findings include: Review of the facility policy titled, Food Storage, revised 07/11/2024, revealed food items should be stored in accordance with good sanitary practice. Per review, all products were to be dated upon receipt, when opened, and when prepared. Continued review revealed staff were to use the Use-By dates on all food stored in refrigerators. Review revealed leftovers were to be dated according to policy by remembering to cover, label, and date when being stored. Additionally, review revealed freezer food items were to be stored in the original containers, but foods to be frozen were to be stored in airtight containers and all to be labeled and dated. Observation of the kitchen on 09/30/2024 at 10:00 AM, revealed staff preparing pie slices for the lunch meal; however, there were six full pies stored uncovered on a cart. Observation of the reach-in refrigerator revealed a metal pan on an upper shelf with prepared sandwiches that were individually bagged in flip top storage bags, with two sandwich bags not sealed. Observation of the freezer revealed a bag of tator tots and a bag of frozen biscuits in their original box; however, they were not sealed or dated. Further observation of the walk-in refrigerator revealed a box of sausage links not sealed properly which had not been dated. In interview with Dietary 2, on 10/03/2024 at 11:40 AM, she stated she had worked in the facility for [AGE] years. She stated she had received training yearly and the Dietary Manager conducted monthly in-services or reeducation whenever necessary. She stated refrigerated food such as sandwiches should be dated when prepared and sealed properly to prevent bacterial growth or contamination. Dietary 2 stated food items in the freezer in bulk were to be in the original containers, but the items should have the received date noted. She said all packaging must be sealed to prevent freezer burn or other contamination. Dietary 2 stated all opened and stored food items should be sealed and include the opened date and disposal date. She further stated that would ensure residents were not served contaminated food and prevent residents from getting sick. In an interview with Dietary 1, on 10/03/2024 at 11:55 AM, he stated he was aware of the food storage process and had received training and in-services as needed. He stated all stored food should be dated when opened and include the use by date. Dietary 1 stated any opened food items in the refrigerator or freezer should be sealed properly to prevent contamination and ensure residents received food of good quality, but also safe for them. He stated anything dietary staff prepared and stored was to be sealed, labeled, and dated for overall resident safety. Dietary 1 further stated the reality was that if staff were not following the facility's policy and procedures for food safety, residents could get sick or potentially suffer more serious harm. In an interview with the Dietary Manager (DM), on 10/03/2024 at 3:00 PM, she stated she had been in her position since 11/02/2023. She stated processes for food safety included dating food items, temperature control, properly securing packaging, dry goods storage; off the floor, labeled, dated, and rotated to ensure freshness. The DM stated any opened food item, whether packaged or prepared, required an opened by and use by date. She said if food items were out of the original package they should be stored in a new container. Per the DM in interview, refrigerated foods that were prepared were kept for no more than five days; however, other purchased food items that were opened were good for seven days. She stated those procedures were very important to prevent contamination, ensure good quality of the food, and reduced the likelihood of pathogens and bacteria growth that could make residents ill. The DM stated she had an in-service weekly on different topics. She stated the current awareness of food (not stored properly), was an opportunity to complete an in-service and provide a demonstration on how to properly seal, label, date the food items to ensure staff were practicing food safety skills. The DM further stated her expectation for the dietary department and dietary staff was to follow the facility's policy and procedures to provide residents the best quality of care and service.

Based on observation, interview, and facility policy review, the facility failed to ensure it maintained an infection control and prevention program staff to provide a safe and sanitary environment for 3 of 13 residents. (Residents (R)5, R71, and R73). Facility policy revealed oxygen tubing, masks, or cannulas were to be changed weekly as an infection control measure. However, observation on 10/01/2024, revealed R71's oxygen tubing was dated 09/20/2024, and the oxygen tubing and cannula for R5 and R73, were not dated to indicate when they were last changed. The findings include: Review of the facility policy titled, Infection Prevention and Control Risk Assessment , revised 06/21/2022, revealed the facility documents a risk assessment that utilizes an all-hazards approach. This risk assessment will be used for prioritizing activities of the facility's infection prevention control program. Review of facility policy titled, Oxygen Administration, revised 04/01/2024, revealed the facility is to change oxygen tubing and mask or cannulas weekly and also as needed if it becomes soiled or contaminated as a measure of infection control. During observation on 10/01/2024 at 9:15 AM, the State Survey Agency (SSA) Surveyor Agency observed R71's oxygen tubing was dated 09/20/2024. Further observation revealed R5's and R73's, oxygen tubing cannula did not have a date listed for when the tubing and cannulas were last changed. In an interview with Licensed Practical Nurse (LPN) 5 on 10/03/2024 at 1:33 PM, she stated a resident's oxygen tubing was changed weekly by an outside vendor. She stated sometimes when a resident was newly admitted or had switched oxygen containers they might have tubing that was not dated. LPN 5 stated it was the nurse's responsibility to check the oxygen tubing behind the vendor to make sure the tubing was dated, clean and in good repair. She further stated that if a resident was found with no date on their oxygen tubing it was facility policy to get new tubing and date it. In an interview with Registered Nurse (RN) 3 on 10/03/2024 at 10:40 AM, she stated the oxygen and tubing was supplied by an outside vendor, who came to the facility weekly. She further stated that nursing was responsible for making sure the tubing was dated. In an interview with the Infection Preventionist (IP) Nurse on 10/03/2024 at 4:02 PM, she stated she would have to contact the oxygen vendor to see if their policy on the tubing co-existed inside of the facility policy and ask what they recommended. She further stated if it was not being changed out as scheduled it could potentially cause infections to residents wearing the tubing. In an interview with the Director of Nursing (DON) on 10/03/2024 at 1:50 PM, she stated it was possible the resident was a newer resident and might not have been seen by the vendor yet and it had gotten missed by the nurse. She stated if a resident was found with tubing that was not dated the nurse should have changed it out and placed the correct date on it. She further stated the vendor came to the facility weekly and the nurses were to go behind them to check and make sure the tubing was being changed. In a follow up interview with the DON on 10/03/2024 at 4:19 PM, she stated she expected her staff to follow the facility's infection control policies as they trained them, and try to follow the Centers for Disease Control and Prevention (CDC) guidelines. In an interview with the Administrator on 10/03/2024 at 4:41 PM, he stated an outside vendor supplied oxygen to the facility and they were responsible for replacing portable oxygen tanks, oxygen tubing, servicing the concentrators, and changing the filters out. He stated nursing was to follow up behind them as well when they were doing their checks. The Administrator stated the standard was for weekly checks and if they went past that weekly time frame he expected staff to change out any tubing that was found not dated and get a new one and put the new date on it.

Based on observation, interview , record review and facility policy it was determined the facility failed to ensure First In/First Out, and rotation of stock. The facility failed to ensure Ready Care Vanilla Shake supplement was disposed of by due date of [DATE]. Two and one half (2.5) cases of Ready Care Vanilla Shake supplement had been placed in freezer with expiration date of [DATE] and not disposed of and would not be available for residents consumption. The findings include: Review of facility policy revealed with effective date of [DATE], and entitled and Nutrition: Food Safety Requirements, revealed food will be stored, prepared and served in accordance with professional standards for food service safety. Food service safety refers to handling, preparing, and storing food in ways that prevent forborne illness-with foodborne illness referring to an illness caused by the ingestion of contaminated food or beverages. Procedures: food safety practices shall be followed throughout the entire food handling process; to include storage of food in a manner that helps prevent deterioration or contamination of the food, including from growth of microorganisms. Facility should inspect all food, food products and beverages, refrigerated storage foods that require refrigeration shall be refrigerated immediately upon receipt or placed in freezer, with practices to maintain safe refrigerated storage to include: labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use by date, or frozen. Review of facility policy dated 2013, and entitled, Food Storage, revealed Frozen foods: all food should be covered, labeled,and dated. All foods would be checked to assure that the foods will be consumed by their safe use by dates or discarded. Observation, on [DATE] at 11:30 AM, revealed two (2) cases and twenty-one (21) cartons in another case in a walk-in freezer with expiration date of [DATE]. Interview on [DATE] at 11:40 AM, with Cook #1 revealed that stock is supposed to be rotated so that it is used before the expiration dated and before the product goes bad. Additionally, Cook #1 stated that it is a waste of product it can go bad, and the resident may get sick. Interview, on [DATE] at 11:35 AM and [DATE] at 11:08 AM, with Dietary Manager revealed [DATE] date for the cases of Ready Care Vanilla Shake Supplements (there were two cases-fifty in each case and 21 loose cartons) was the best use by date and the product needed to go out. Dietary Manager stated dietary aides and cooks are supposed to rotate the stock out and check the dates of product. Dietary Manager further stated that normally rotates stock and that he has no system in place to ensure it is done. Additionally, Dietary Manager stated, all staff are trained to put away stock and of First In/First Out (FIFO) dates. Dietary Manager stated his expectation is was for stock to be rotated so that the oldest stock is coming out first. Dietary Manager further stated, the outcome of product/stock not being rotated properly would be stock will sit there and the old stock will be put in the back and not used properly; stock/product will become outdated and has the potential to be used therefore, being potentially dangerous to individuals with a compromised immune system. Interview, on [DATE] at 11:58 AM and [DATE] at 12:45 PM, with Dietician revealed the dates of products has been an ongoing issue to educate the staff. Dietician stated the cases of Ready Care Vanilla Shake Supplements was out of rotation due to safety and cost. Dietician stated that she did not really think would hurt anyone, but immuno compromised, she would not want to take a chance, and no one has been appointed to rotate the stock. Dietician further stated, the Ready Care Vanilla Shake Supplements were to be given to residents that do not eat well and/or losing weight and can be given as a snack as well for someone hungry. Additionally, Dietician stated the outcome of serving the outdated product/stock was that it could make someone sick and they could get a food borne illness. Dietician stated they do try to smell and check the products but if a resident with dementia received the product they could get diarrhea or get sick, but in the freezer bacteria doesn't grow much. Interview, on [DATE] at 2:26 PM, with Assistant Director of Nursing (ADON), revealed she did not deal with dietary but they should make sure to use the oldest product first; and the outcome would be that something may come out to the floor that is expired and could make residents sick or ill. ADON further stated her expectations to ensure that it did not happen would be when stock is brought to the floor, staff ensure that it is not expired and rotate the stock when it is received. Interview, on [DATE] at 2:56 PM with Director of Nursing (DON), revealed she was not familiar with health regulations associated with dietary department and would defer to dietary because not familiar with those regulations. However, DON stated related to outcome, the concern would be [CONDITION(S)] from an epidemiology standpoint of serving outdated food, and it could affect this population through foodborne illness, diarrhea and things like that. DON further stated she could not speak on whose responsibility it was because that was dietary. Interview, on [DATE] at 3:27 PM, with Administrator revealed the new product/stock goes to the back and anything past due is discarded. Administrator stated his expectation is when stock comes in, it is dated and put where it belongs and the new stock is rotated and the old stuff discarded immediately. Additionally, Administrator stated that the outcome from outdated food could be: spoiled food that could cause ailments and food poisoning and stuff, and the responsibility belongs to the dietician and the dietary manager.

Based on observation, interviews, and facility policy it was determined the facility failed to follow designated recipes for residents to promote nutritional value. Cranberry Glaze was used for the lunch time meal in conjunction with turkey. However, Cranberry Glaze recipe utilized in preparation of the meal was printed off computer, with no serving size of recipe or documentation of how to increase for use in facilty, nor was the recipe a designated recipe to be utilized in the facilty or nutritional value of the recipe listed in the document. The findings include: Review of facility policy with effective date of 10/05/2021, and entitled Food and Nutrition revealed, Facility would prepare foods in a manner to preserve or enhance a resident's nutrition and hydration status. The facility cooks shall prepare menu items following the facility's written menus and standardized recipes. Review of email, dated 05/17/2022, from Dietician revealed attachment of the actual recipe to be utilized for Cranberry Glaze, and that the recipes are scaled to fit whatever portions that are needed. Review of provided actual recipe for Cranberry Glaze, revealed the following: Sixteen Tablespoon portion of zero point zero fifty pounds (0.050 pounds) - or sixteen (16) Tablespoon of - zero point eight hundred and three (0.803) ounces each, with recipe quantity of (16) sixteen Tablespoons, ingredients used: Jelly Cranberry Sauce, condensed (1) one cup per single recipe); Honey bulk Jug, zero point two hundred fifty (0.250 cup per single recipe) combine in sauce pan and cook over medium heat. Record review of facilty policy undated and entitled, Standardized Recipes, revealed; the policy of the facility is to have a file a standardized recipes, adjusted to appropriate yield; with recipe located in the kitchen. The dietary manager will maintain a file of standardized recipes for all menu items. The recipes are to include: all ingredients in order of introduction to the recipe, preparation method, total yield, standard serving size, equipment needed, extentions to meet the census of diets; with preparation of all foods to be done following those recipes to produce the same results, and exact number of servings needed. In doing so it makes it possible to predict food cost, therefore making purchasing more accurate, and eliminate waste. Observation of menu on 05/10/2022, revealed the following menu for Lunch: Cranberry Glazed Turkey, Onion Roasted potatoes, green bens, apricot crisp and a roll. Observation in kitchen, on 05/10/2022 at 11:22 AM revealed recipe unlabeled and unnamed lying on prep counter with the following ingredients and notations: one and a fourth (1-1/4) cups of jellied cranberry sauce, two-thirds (2/3) thawed unsweetened apple juice concentrate, two (2) tablespoons of Butter, one (1) bone in Turkey Breast five to six pounds (5-6 pounds). Interview, on 05/10/2022 at 11:20 AM and 05/14/2022 at 11:40 AM, with Cook #1 revealed, the menu book tells the recipe per servings and is always followed. However, Cook #1 stated the recipe for the cranberry glaze was printed by dietary manager, was lying on the counter, and had to multiply it to serve residents, but she did not know how many servings the recipe provided because it was not printed. Additionally, Cook #1 stated, recipes for the menus are supposed to be in the binders, but sometimes the staff go online and find a recipe, if they do not know how to make it; she further stated she may ask the cook from the day before on how to cook something or she will ask the dietary manager to look one up and he will print it off. Cook #1 stated that the purpose of the standardized recipes that are to be used was when the dietician fixes the menu and schedule/portions and recipes in the binder are to be utilized together and the purpose of that recipe is to ensure that the residents get the right amount of proteins, and essential vitamins, and the recipe should have the serving size to know how to increase the servings so it will be appropriated for the census of the facility, and to have a balanced meal. Cook #1 further stated that the outcome of not having appropriate recipes would be that the resident would not get the correct portion and therefore not receive their needed nutritional value. Interview, on 05/10/2022 at 11:35 AM and 11/14/2022 at 11:08 AM, with Dietary Manager revealed he had forgotten to print out the serving size of the unlabeled and unnamed recipe on the counter. Additionally, Dietary Manager further stated recipes are required in order to follow the menus because recipes inform of the serving size and how much nutrition is in the serving size. Dietary Manager further stated that they are assigned by the dietician to ensure that it has the nutritional value to follow for that meal. Dietary Manager stated the outcome of not following a recipe designated by the dietician would be improper nutrition required for the meal, and it is overseen by the dietary manager and the dietician. Interview, on 05/10/2022 at 12:12 PM and 05/16/2022 at 12:45 PM, with Dietician revealed the unlabeled and unnamed recipe on the prep counter was not a standardized recipe for the cranberry glaze and no supposed to use a recipe without approval, and the recipe has to be on the spreadsheet. Dietician further stated, that the staff does not use a recipe on their own and they should all know that, and had done an inservice in 01/2022 not to adjust the recipes. Additionally, Dietician stated the standardized recipe is critical within that population and are available within the kitchen; staff need to look ahead and let the dietary manager know about the recipe because it goes along with the menu and the spreadsheet for the meals. Dietician additionally stated that recipes ensure nutritional adequacy, everything within the daily menu makes sure the nutritional needs are met, and the corporation that oversees the meals have dietician that write the menus so as to ensure daily requirements. Dietician further stated that if the menus are edited that she still has to go through and approve to ensure calories, protein, minerals, it will have enough fruit and vegetables. The outcome of not having the recipe and following the standardized recipe could be not having the proper nutrients, vitamin and mineral deficiency, skin breakdown, and weight loss. Interview, on 05/15/2022 at 4:16 PM, with Unit Manager (UM) #1 revealed she would expect recipes to be followed in the kitchen, due to the specifity of the residents diets. UM #1 further stated, she did not know much about kitchen meals, but if they go by recipes, it would be for a reason. Interview, on 05/16/2022 at 2:26 PM, with Assistant Director of Nursing (ADON) revealed she thought the reason to follow recipes for the facility menus, would be to ensure the residents were receiving their proper nutritional allowances and proper diets. ADON further stated the responsibility would be the Dietary Manager's; ADON stated she did not know where recipes were located, but it should be in a binder for easy access Interview, on 05/16/2022 at 2:56 PM, with Director of Nursing (DON) revealed recipes should be followed for menus and food intake, individualized according to nutritional and health care regulations. The outcome of recipes being followed according to nutritional requirements and how it pertains to nursing care, would be through the resident's Braden scale, and their wound status. The DON further stated these were measurable objectives that revealed how recipes could impact the immune system, skin and wounds. Interview, on 05/16/2022 at 3:27 PM, with Administrator revealed that the cook pulls the recipe and follows it, with oversight by Dietary Manager and Dietician to ensure the it is beneficial to the residents. Additionally, Administrator stated that the recipes are to follow nutritional guidelines and make sure the same time and time again when the facility has it. Administrator stated the outcome of not following them would be that they would not have the nutritional value, not taste well or it might taste better; Administrator stated he did not know how it may affect the status of the resident because he is not medical but would say if had too much salt in something it may affect the blood pressure.

Based on observation, interviews, record review and review of facility policy, it was determined the facility failed to ensure notification had been completed for a fall related to one resident, (Resident #1). Resident #1 fell from the bed while using remote to bed with no notifications made to the physician or responsible party until the following day. The findings include: Review of facility policy, dated 10/01/2018, and entitled Resident Fall Policy, revealed the residents' physician was to be notified with information regarding the circumstances of the event and any identified injury. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of facility policy, copyrighted 2022, and entitled Notification of Changes revealed the purpose of the policy was to ensure the facility promptly informed the resident, consults the resident's physician, and notifies, consistent with his or her authority, their residents representative when there was a change requiring notification. The facility would inform the resident, consult with the resident's physician and or notify the resident's family member or legal representative when there was a change requiring such notification. Circumstances requiring notification include: accidents resulting in injury, significant change in a residents physical, mental or psychosocial condition, life threatening conditions or clinical complications. Circumstances that require a need to alter treatment may include, new treatment, discontinuation of current treatment due to adverse consequences, acute condition, or exacerbation of a chronic condition. Additional conditions of facility for competent individuals also included: the facility would still contact the resident's physician and notify resident's representative, if known. Record review revealed the facility had admitted Resident #1 on 08/27/2019, with the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Brief Interview Mental Status (BIMS) dated 04/03/2022 revealed Resident #1 to be cognitively intact with a score of fourteen / fifteen (14/15). Review of quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #1 required limited assistance of one (1) assist with activities of daily living (ADLs) that included bed mobility, transfer, walk in his/her room, and locomotion on/off unit. Additionally, section J0300.0 of 04/08/2022 quarterly MDS, revealed no presence of pain for resident. Review of Fall Assessment, dated 04/08/2022 at 2:13 PM, revealed the resident with previous falls with last fall on 11/05/2021, and no falls in last three (3) months. Additionally, there was not fall risk score noted. Review of 04/08/2022, Pain Interview revealed Resident #1 with no pain in the last (5) five days; been on scheduled pain medication regimen of Tylenol three hundred-twenty-five (325) mg. four (4) times a day (QID)and Tylenol three hundred-twenty-five (325) (2) twice a day , Biofreeze to knee at hour of sleep (HS), and resident stated no pain. However, there was no follow up pain assessment after the 04/11/2022 fall. Review of facility fall investigation, dated 04/11/2022 at 11:15 AM, revealed Resident #1 fell in his/her room, with no notification documented on the fall investigation area for notification; with pain assessments of moderated verbal response and vocal complaints of pain by resident. Review of Fall Assessment, dated 04/11/2022 at 11:45, revealed injury to left knee, open area two centimeter (2 cm) by two centimeter (2 cm) and skin tear to right wrist. Intervention put in place was: reminder to resident to call for assist. There was no fall risk score noted on Fall Assessment. Review of 04/19/2022, Post Fall Review revealed intervention of velcro on bed controller, no notification indicated on document to physician, or family with vocal complaints of moderate pain Review of 04/11/2022 at 11:23 AM, facility progress notes, documented by LPN #3, revealed Resident #1 attempted to remove an object from the night stand with limited vision and LPN #1 entered room with resident attempting to kneel on floor and resident lowered to floor by LPN #1, LPN#3, PT #1, with scrape to left knee/small opening two centimeter (2 cm) by two centimeter (2 cm) and skin tear to right wrist. Review of 04/12/2022 at 2:07 AM, facility progress notes documented by LPN #2, revealed she was called to Resident #1's room related to complaints of discomfort to right heel, with assessment findings of two (2) areas of purple discoloration observed and heel elevated on pillow. Review of 04/12/2022 at 9:17 AM, facility progress notes, documented by LPN #3, revealed call to physician with message to nurse for x-ray for right ankle and increase for pain medication Review of 04/12/2022 at 10:20 AM, facility progress notes documented by SDC/Fall Investigator revealed Resident #1 began to complain of heel pain after incident with x-ray ordered. Review of facility progress notes, dated 04/12/2022 at 11:08 AM, documented by LPN #3, revealed nurse for Physician #1 called with order for x-ray but no new order for pain medication. Review of 04/12/2022 at 4:14 PM, facility progress note documented by LPN #3, revealed Physician #1 called with new orders for Tylenol one-thousand milligrams (1000 mg) given by mouth three times a day (TID) and placement of boot to right lower extremity and re-x-ray in one (1) week. Review of 04/12/2022 at 4:34 PM, facility progress notes documented by LPN #3, revealed family member was notified concerning Calcaneal fracture, with explanation of orders to family, no questions or concerns voiced. Review of x-rays, dated 04/12/2022 at 1:56 PM, for right ankle related to right ankle pain revealed: calcaneal fracture. Additionally, 04/12/2022 X-ray of right foot two (2) views, revealed evidence of proximal calcaneal fracture, and 04/19/2022 X-ray of right foot (2) two views revealed a healing fracture of the posterior calcanous again suspected. 05/09/2022, X-ray of right foot two (2) views revealed comminuted fracture of the calcaneus. Review of x-rays, dated 04/12/2022 at 2:06 PM, for right foot revealed evidence of proximal calcaneal fracture. Attempted interview with Responsible Party (RP) of Resident #1, with time frame of 05/09/2022 through 05/16/2022, revealed three (3) attempts on 05/09/2022 at 11:15 AM, 05/13/2022 at 1:24 PM, and 05/16/2022 at 5:24 PM. The attempt to contact Patient Representative (RP) was without success and no available avenue to leave a message. Interview, on 05/12/2022 at 4:40 PM, with Resident #1 revealed that his/her injury was doing better, treated well and no concerns with pain. However the Resident did not respond to questions concerning the circumstances of the fall. Interview, on 05/13/2022 at 1:15 PM, with Certified Nursing Assistant (CNA) #2 revealed she had been there the day of the fall for Resident #1 and went to help when called, and an hour or so later the resident's foot was hurting him/her. CNA #2 further stated that she did not make calls to family or anything; it is the nurses responsibility and she did know x-ray was called but did not know if it was then or later. Interview, on 05/13/2022 at 1:20 PM, with CNA #1 revealed she was not aware of notifications but thought it was the nurses responsibility to notify right after a fall. Interview, on 05/13/2022 at 2:38 PM, with Physical Therapist (PT) #1 revealed that he had assisted Resident #1 back into the bed, after what he guessed was a fall, and informed later that Resident #1 had hurt his/her foot and ankle. Additionally, PT #1 stated that it is up to the nurses to make notification calls. Interview, on 05/13/2022 at 1:57 PM, with Medication Nurse (MN) #1/Licensed Practical Nurse (LPN) #1 revealed she had heard Resident #1 call for help, and entered room where resident was slid off the bed and on his/her knees holding on to a bedside dresser. MN/LPN #1 revealed that three (3) other staff members entered the room to assist resident. MN/LPN #1 stated Resident #1 was then assessed by charge nurse (CN)#1/LPN #3, but they all had to fill out reports. Additionally, MN/LPN #1 stated that CN/LPN #3 was responsible for notification to the physician and family and would have thought done immediately but did not know the time frame for notification. MN/LPN #1 further stated that she did not know the facility procedure or the answer. However, the outcome of the physician and family not being notified would be the staff would be held accountable. If the physician and the family were not notified, the outcome would not be any better, they would not know so would not have a way to improve, and the plan of care would not be what it needed to be. Interview, on 05/13/2022 at 1:26 PM, with LPN #2 revealed she had not been on shift when Resident #1 had his/her fall but had come on shift afterwards with Resident #1 complaining of pain and LPN #2 stated she had noticed discoloration of the heel. Interview, on 05/13/2022 at 2:47 PM, with Charge Nurse/LPN #3 revealed falls are her responsibility, to assess the resident and find out what happened/why they fell . Make the physician aware and the family aware, but the first priority was to make the resident safe. Additionally, Charge Nurse/LPN #3 stated that the notification is documented in the progress notes and she had filled out the call investigation, and had CNA(s) complete and sign their form. Charge Nurse/LPN #3 further revealed that Resident #1 did not complain of pain, but the next day when she returned to work, the resident's foot was dark, he/she was complaining of pain, and resident was set up for x-ray. Charge Nurse/LPN #3 stated that she thought RP did not answer his/her phone but the call would have been documented in the progress notes regardless, and she was not aware of place to document in the fall investigation and only place to document is in the progress notes. Charge Nurse/LPN #3 further stated she would still have documented in the progress notes because she has done progress notes before related to leaving messages to make individuals aware. Interview, on 05/15/2022 at 4:16 PM, with Unit Manager #1 revealed Resident #1's fall on 04/11/2022 at 11:15 AM with the expectation that physician and family be notified the same day. UM #1 further stated that documentation would be on the paper fall form and she would document it in the nurses notes as well. If the fall form had no place to document notification, then she would put the notification in the progress notes, under health status/incident notes, for notification documentation to the family and physician soon after the fall. UM #1 stated especially if a resident was injured they would be notified; and she would expect and hope notification be documented in the progress notes before it is a day old However, UM #1 stated she had not filled out a fall form yet. Interview, on 05/13/2022 at 1:58 PM, with Staff Development Coordinator (SDC)/Fall Investigator revealed Resident #1 had to completely fallen in the floor but was helped the rest of the way down by LPN #1. No immediate injuries were noted but then the resident started complaining in the early morning hours, so the next day an x-ray was ordered. Additionally, SDC/Fall Investigator stated the physician and family should be notified immediately after resident is cared for, family/physician notified and she would expect it to be done in an hour or so, as soon as the resident gets situated. Interview, 05/16/2022 at 2:26 PM, with Assistant Director of Nursing (ADON) revealed the nurse is supposed to notify the family, the physician, and whomever is on call and she would expect notification to be charted before the next day. ADON stated that the progress notes are charted on regularly and also on the paper fall report that is filled out. Additionally, ADON stated her expectations regarding notification was to be done after the nurse assesses and the resident was comfortable and be done immediately. The ADON further stated, she expected it to be charted before the next day, but she did not remember what the fall form looked like so she could not answer if the notification was on the fall form. However, ADON further stated the charge (floor) nurse assesses the resident, makes notification, fills out the fall report (form) and then the SDC/Fall Investigator gets the fall report. The Falls report is then taken to the Interdisciplinary Team Meeting (IDT) and everyone will go over the falls. ADON stated she guessed the Unit Manager would ensure the notifications were done and the report was followed through, ADON did not provide further information related to the IDT going over notifications of falls, and she did not know exactly and had not had to fill out a fall investigation yet. Interview, on 05/16/2022 at 2:56 PM, with Director of Nursing (DON) revealed the fall process is monitored by the SDC/Fall Investigator, with assessment and notifications done by the floor nurse. DON further stated the responsibility of notification belonged to the nurse assigned to the resident and she expected notifications, to the physician and family, once the resident is stable and safe; with physician notified first then the family and should be done as soon as the resident is assessed and stable. DON stated she would not expect the notification be done the day after the fall, and she would expect documentation be done in the progress notes done by the nurse assigned to the resident. Interview, on 05/16/2022 at 3:27 PM, with Administrator revealed he referred falls to nursing, the process and responsibility, however, the Administrator stated he did expect notification to physician and family regarding falls until the resident had been assessed and was comfortable. The Administrator revealed the notifications needed to be done within a time frame of minutes and once the resident is settled. Additionally, the Administrator stated his expectation is that it should be documented in the electronic record, done by the nurse in charge of the resident, unless the information had been turned over to the nurse supervisor. The Administrator stated he would expect family and the physician to be notified at the time of the incident or relatively close to time of the incident. Interview, on 05/13/2022 at 1:43 PM, with Physician #1 revealed the facility generally lets her know of falls, but if an injury or have to go somewhere they call/or she is faxed. Physician #1 further stated that she would expect to be notified and would expect the notification to be documented in the progress notes.

Based on interview, record review, and facility policy review, it was determined the facility failed to ensure two (2) of four (4) sampled residents received adequate supervision and assistive devices to prevent accidents (Resident #1 and #2). The facility assessed and care planned Resident #1 to be at risk for falls and required the assistance of two (2) staff for bed mobility and during incontinent care. On 12/04/2020, State Registered Nurse Aide (SRNA) #1 provided incontinent care to the resident without the assistance of another staff member and the resident rolled off the side of the bed. The resident sustained a laceration to the left foot, left parietal scalp, and a subdural hematoma (brain bleed). The resident was hospitalized and discharged to Hospice. The facility assessed and care planned Resident #2 was at risk for falls. Resident #2 sustained falls on 11/08/2020, 12/02/2020, 12/03/2020, 12/31/2020, and 01/09/2021 when he/she transferred without staff assistance. After each fall, an intervention was put in place to educate/remind resident to call for assistance even though the resident continued to get up without calling for assistance. The facility failed to provide increased supervision or assistive devices to ensure staff would know when the resident was transferring/ambulating without assistance to try to prevent further falls. The findings include: Review of the facility's policy titled, Resident Fall Policy, dated 10/01/2018, revealed residents are comprehensively assessed for fall risk to avoid injury related to falls and maintain maximum physical functioning as much as possible. Residents are comprehensively assessed upon admission, quarterly, with any significant change of condition and/or with the Minimum Data Set (MDS) schedule. A standardized initial fall assessment and post fall assessment is used to accurately document possible causative factors, revision of interventions to prevent further occurrence and any medical treatment required. The post fall assessment is completed after any fall along with the fall incident report, and forwarded to the Interdisciplinary Team (IDT) for review at regular meetings. In case of any unwitnessed fall or fall with known head injury, a neurological assessment is also completed. Closed record review revealed the facility readmitted Resident #1 on 08/14/2014 with diagnoses which included Alzheimer's Disease, [CONDITION(S)], [CONDITION(S)], Contractures, Urinary Incontinence, and Major Depressive Disorder. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment, dated 09/18/2020, revealed the facility assessed Resident #1's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of zero (0), which indicated the resident was not interviewable. Further review of the MDS assessment revealed the resident was totally dependent on two (2) or more staff for bed mobility and toileting. Review of Resident #1's Comprehensive Care Plan for Risk For Injury Related to History of Falls, dated 08/11/2016, revealed a goal for the potential for injury from a fall to be lessened through the next review date, with a target date of 01/01/2021. Further review of the care plan revealed an intervention of extensive assistance with turning and repositioning for bed mobility when providing care. Review of the Progress Note, dated 12/04/2020 at 7:00 PM, revealed the nurse was called to the resident's room by SRNA #1 for a resident fall. Further review revealed Resident #1 was found on his/her left side on the floor by the chest of drawers. Continued review revealed blood was noted to be pooling from under the resident's left side of his/her head. Record review revealed, Towels placed around head to collect blood flow. Resident also noted to have laceration on left foot, blood pressure 94/56, heart rate 148, respirations 20 oxygen saturation 96% on room air. Resident remained stationary on floor - unmoved to prevent possible further injury. Nurse remaining with resident. EMS (Emergency Medical Service) contacted for transport. Review of Resident #1's Computed Tomography (CT) scan, dated 12/04/2020, revealed the resident sustained a three (3) centimeter (cm) by six-tenth (0.6) cm subdural hematoma to the left frontal side of his/her head. Review of Resident #1's hospital Discharge Summary, dated 12/08/2020, revealed the resident was seen by the Neurosurgery Team in-house, with no indication for neurosurgical intervention. The resident remained hospitalized for four (4) days to monitor the subdural hematoma and was transferred to another long term care facility under Hospice care on 12/08/2020. Review of Resident #1's Post Fall Assessment Tool, dated 12/04/2020, revealed during provision of incontinent care in his/her bed, Resident #1 rolled off the bed onto the floor and sustained a laceration to his/her left foot and a laceration to the scalp. Further review revealed State Registered Nurse Aide (SRNA) #1 provided incontinent care without assistance of another staff member, per care plan. Interview with SRNA #1, on 01/21/2021 at 8:57 AM, revealed she provided incontinent care to Resident #1 on the evening of 12/04/2020 and The resident coughed forcibly which caused him/her to roll off the bed. SRNA #1 stated she did not ask for assistance prior to performing incontinent care for Resident #1, and was aware the resident was care planned for two (2) staff to provide toileting. She stated, The call light was on, I answered the call light and when leaving the room, I noticed (Resident #1) needed incontinent care. SRNA #1 stated, I should have gotten assistance before performing incontinent care. However, I have provided care to the resident by myself in the past with no problem, but this particular incident (he/she) started coughing and I just was not able to prevent (him/her) from falling off the bed. Interview with SRNA #6, on 01/25/2021 at 2:38 PM, revealed she was working on the East Hall on 12/04/2020 when Resident #1 fell out of bed when receiving care. SRNA #6 stated she was not asked to assist with the resident's care. She further stated the resident required two (2) staff for bed mobility, turning, repositioning, and incontinent care due to the resident's immobility and inability to provide any of his/her own care. Interview with Licensed Practical Nurse (LPN) #1, on 01/21/2021 at 4:05 PM, revealed she was assigned on the East Hall on 12/04/2020 when SRNA #1 notified her Resident #1 was on the floor. LPN #1 stated when she arrived to the resident's room, she observed the resident face down on the floor beside his/her bed with blood pooling underneath the resident's head. LPN #1 revealed she assessed Resident #1 while he/she was on the floor for injuries, and noted a laceration to the resident's head and left foot. She stated Resident #1 remained on the floor beside the bed until EMS arrived to transport him/her to the emergency room (ER). LPN #1 further stated she expected SRNA #1 to obtain staff's assistance before she provided Resident #1's incontinent care. Further interview revealed the resident was care planned for assistance of two (2) staff for toileting and bed mobility and she was on the unit at the time of fall; however, SRNA #1 failed to ask for assistance with the resident's care. Interview with the Director of Nursing (DON), on 01/26/2021 at 1:10 PM, revealed Resident #1 was care planned for extensive assistance of staff for bed mobility, turning, repositioning, and toileting. The DON stated extensive assistance was two (2) or more staff. The DON stated staff was aware the resident was unable to assist with bed mobility; therefore, he/she required two (2) staff to ensure the resident's safety when incontinent care was provided. The DON further revealed SRNA #1 received verbal education and instruction to always have another staff assist with all residents that were totally dependent with care which involved turning, repositioning or bed mobility and to never provide care alone. Additionally all direct care staff were educated on what each level of assistance required. However, there was no documented evidence staff were educated on following the resident's care plan. 2. Record review revealed the facility readmitted Resident #2 on 09/16/2019 with diagnoses which included Supraventricular Tachycardia, Diabetes Type 2, Congestive Heart Failure (CHF), [CONDITION(S)], History of Falling, and [CONDITION(S)]. Review of the Quarterly MDS assessment, dated 10/03/2020, revealed the facility assessed Resident #2's cognition as intact with a BIMS score of fifteen (15), which indicated the resident was interviewable. Further review of the MDS revealed the facility assessed that Resident #2 required limited assistance of one (1) staff, with bed mobility and transfers. Review of the Quarterly Fall Risk Assessment, dated 10/21/2020, revealed Resident #2 continued to be at risk for falls due to impaired mobility. Review of Resident #2's Comprehensive Care Plan titled, At Risk for Injury Related to Falls due to Gait/Balance Problems, Weakness, Attempts to Transfer Self, and History of Falls, dated 01/14/2020, revealed interventions: to anticipate and meet resident needs; be sure resident's call light is in reach and encourage use; resident needs prompt response; ensure resident is wearing appropriate footwear; educated on importance of asking for assistance, and reminded on importance of applying brakes to wheelchair before attempts to stand. Review of Resident #2's Falls History revealed he/she had unwitnessed falls on 11/08/2020, 12/02/2020, 12/03/2020, 12/31/2020, and 01/09/2021. Review of Resident #2's Post Fall Assessment, dated 11/08/2020 at 3:24 PM, revealed the resident was found on the floor in his/her room next to his/her bed and sustained a bruise to the right shoulder blade, skin tear to the left lower leg, and a knot to the back of his/her head. The facility determined the root cause of the fall was the resident had decreased safety awareness and was non-compliant to call for staff's assistance with transfers. Further review of the Post Fall Assessment revealed the facility initiated an intervention to remind the resident to call for help with transferring and to obtain an x-ray to the right shoulder. Review of Resident #2's Post Fall Assessment, dated 12/02/2020 at 5:00 PM, revealed the resident self transferred to the bathroom and became tangled in his/her wheelchair and resulted in a fall in the bathroom with no injury. The facility initiated an intervention for Resident #2 to call for assistance when going to the bathroom which was the same intervention put in place on 11/08/2020 which was ineffective, Review of the Interdisciplinary Team (IDT) follow up on the effectiveness of the intervention revealed the intervention was resolved. However, the IDT did not initiate another intervention. Review of Resident #2's Post Fall Assessment, dated 12/03/2020 at 3:30 PM, revealed the resident was noted sitting on the floor in his/her room with no injury. Review of the Post Fall Investigation revealed the facility determined the root cause of the fall was non-compliant with safety due to transferring self to the floor to retrieve something from his/her dresser. The facility's intervention for the fall was the resident was assessed for injury and assisted to a wheelchair and given a shower. However, there was no intervention put in place to address the resident's continuation of transferring without assistance. Review of Resident #2's Post Fall Assessment, dated 12/31/2020 at 10:45 PM, revealed the resident was found sitting on the floor in his/her room with no injury. The facility determined the root cause of the fall was Resident #2 attempted to transfer self to bed. The facility's intervention for the fall was for staff to assist the resident with transfers, and the resident was educated to make sure the brakes on his/her wheelchair were locked before transferred. However, there was still no intervention put in place to address the resident continuing to get up without the assistance of staff. Review of Resident #2's Post Fall Assessment, dated 01/09/2021 at 6:15 AM, revealed the resident attempted to transfer self from the bed to the wheelchair putting his/her weight on the wheelchair arms which caused the wheelchair to roll. Resident #2 fell and attempted to get up without assistance with his/her right lower leg underneath the dresser. The facility determined the root cause of the fall was the resident transferred from his/her bed to the wheelchair without assistance. The facility initiated intervention was every fifteen (15) minute observations of the resident which were conducted 01/09/2021 through 01/12/2021. Review of additional interventions revealed the resident was evaluated and treated for non weight bearing to the right lower extremity with therapy services. However, there was still no intervention to address the resident's continued getting up without assistance. Review of Resident #2's x-ray results dated 01/09/ revealed a non-displaced right fibula fracture. Resident #2 had a follow up appointment with the Orthopedic Physician on 01/27/2021 and a two (2) view x-ray of the right tibula/fibula was obtained which revealed evidence of an old fracture of the proximal fibula and subacute or a healing fracture of the tip of the lateral malleolus (bony prominence of ankle). Further review of the assessment revealed status post fall, small right ankle effusion, and suspected small old lateral malleolus fracture. Interview with Resident #2, on 01/20/2021 at 1:50 PM, revealed he/she forgets to use the call light at times. The resident stated, By the time they (staff) get here, it's too late. Further interview revealed the resident stated, I rather just go than have to wait. Interview with SRNA #7, on 01/25/2021 at 4:05 PM, revealed Resident #2 rarely used his/her call light for assistance. SRNA #7 stated the resident was care planned for assistance with transfers and bed mobility. However, the resident becomes impatient and does not allow staff time to respond to provide assistance. Interview with Registered Nurse (RN) #1, on 01/28/2021 at 1:21 PM, revealed Resident #2 was non-compliant with calling for assistance before transferring. She stated the resident was educated on hazards of transferring self, but he/she continued to exhibit decrease in safety awareness. RN #1 revealed the resident would say, I didn't use the light, thought I could make it. Interview with the Falls Coordinator, on 01/27/2021 at 2:15 PM, revealed she reviewed the care plan interventions in the Post Fall Investigation, then they were reviewed by the IDT. Continued interview revealed the team followed up on the interventions seven (7) days later to assess their effectiveness and to determine if they were appropriate to meet the resident's care needs. She stated there were repetitive interventions related to Resident #2's falls due to the resident not always being compliant with using his/her call light and/or requesting assistance with transfers and bed mobility. Interview with the Director of Nursing (DON), on 01/27/2021 at 2:15 PM, revealed the nurse initiated the initial intervention after a fall which was reviewed in the Post Fall Investigation. The Falls Coordinator and the IDT initiated and implemented interventions that were attainable for the resident. However, due to the resident's impulsivity and non-compliance the interventions were ineffective. The DON stated without increased supervision and prompt response when the resident used the call light, the resident was at increased risk of falls with major injury.

Based on interview, record review, and review of the facility's policy and procedure, it was determined the facility failed to implement the comprehensive care plan for one (1) of four (4) sampled residents (Resident #1). The facility care planned Resident #1 to require the extensive assistance of two (2) staff for turning, repositioning, and bed mobility. However, on 12/04/2020, one staff provided incontinent care without assistance of an additional staff member. The resident rolled off the bed. The resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 was transferred to the hospital and diagnosed with a subdural hematoma The findings include: Review of the facility's policy titled, Care Plans-Comprehensive Person-Centered, dated 10/25/2018, revealed a comprehensive, person-centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs should be developed and implemented for each resident. The Interdisciplinary Team, in conjunction with the resident and his/her family or legal representative, should develop and implement a comprehensive, person-centered care plan for each resident. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. Closed record review revealed the facility readmitted Resident #1 on 08/14/2014 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment, dated 09/18/2020, revealed the facility assessed Resident #1's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of zero (0), which indicated the resident was not interviewable. Review of Resident #1's Comprehensive Care Plan, Risk For Injury Related to History of Falls, dated 08/11/2016, revealed the intervention of extensive assistance with turning and repositioning for bed mobility when providing care. However, Review of the POS [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Computed Tomography (CT) scan, dated 12/04/2020, revealed the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's hospital Discharge Summary revealed the resident was seen by the Neurosurgery in-house Team; had no indication for neurosurgical intervention; and remained hospitalized for four (4) days to monitor the subdural hematoma. The resident was transferred to another long term care facility under Hospice care on 12/08/2020. Interview with State Registered Nurse Aide #1, on 01/21/2021 at 8:57 AM, revealed on 12/04/2020 while providing incontinent care to Resident #1, The resident coughed forcibly which caused (him/her) to roll off the bed. She stated she was on the right side of the bed, and the resident rolled off the left side of bed. SRNA #1 stated, I was aware the resident was care planned for two (2) staff to provide toileting; however, I did not ask another staff assistance with task. She stated Resident #1 was not able to assist with bed mobility. Interview with SRNA #6, on 01/25/2021 at 2:38 PM, revealed she was working on the East Hall on 12/04/2020 and was on the unit during the time of Resident #1's fall. However, she was not asked to assist with turning and repositioning Resident #1. Interview with Licensed Practical Nurse (LPN) #1, on 01/21/2021 at 4:05 PM, revealed she was assigned on the East Hall on 12/04/2020 when SRNA #1 notified her that Resident #1 was on the floor. LPN #2 stated the resident was care planned for the assistance of two (2) staff for toileting and bed mobility to ensure the resident's safety due to the resident's body posture, and he/she was not able to assist with bed mobility. She stated she was available on the unit but SRNA #1 failed to ask for assistance with the resident's care. LPN #1 stated she expected SRNA #1 to follow the care plan when providing resident's care. Interview with the Director of Nursing (DON), on 01/26/2021 at 1:10 PM, revealed Resident #1 was care planned for extensive assistance of two (2) staff for bed mobility, turning, repositioning, and toileting as the resident was unable to assist with bed mobility. The DON stated she expected staff to follow the resident's care plan when providing the resident's care.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to review and revise one (1) of four (4) sampled residents (Resident #2) person-centered comprehensive care plan related to falls. Resident #2 had falls on 11/08/2020,12/02/2020, 12/03/2020, 12/31/2020, and 01/09/2021 with an intervention put in place after each fall to educate and or have resident to ask for staff assistance. Resident #2 sustained injuries related to falls on 11/08/2020 and 01/09/2021. However, the facility failed to identify that the intervention was ineffective; and failed to revise the care plan with a new intervention to address the resident's transferring/ambulating without staff assistance. The findings include: Review of the facility's policy titled, Care Plans-Comprehensive Person-Centered, dated 10/25/2018, revealed the comprehensive, person-centered care plan describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Assessments of residents are ongoing and care plans are reviewed and revised as information about the resident and the resident's condition changes. Record review revealed the facility readmitted Resident #2 on 09/16/2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Comprehensive Care Plan Alteration in Bed Mobility-requires assist to turn and reposition in bed, dated 08/17/2016, revealed an intervention to provide extensive assistance with bed mobility. Review of Resident #2's Post Fall Assessments revealed he/she had unwitnessed falls on 11/08/2020, 12/02/2020, 12/03/2020, 12/31/2020 and 01/09/2021. Further review of the assessments revealed the falls on 11/08/2020, 12/02/2020, 12/03/2020, 12/31/2020, resulted when the resident attempted to transfer without staff assistance and an intervention was put in place to educate and/or have the resident call for staff assistance before transfer. Continued review revealed on 01/09/2021, the resident fell while attempting to transfer without staff assistance and was placed on fifteen minute observations from 01/09/2020 until 01/12/2021. However, further review of the Comprehensive Care Plan for falls revealed the facility failed to revise the care plan with a new intervention to address the resident continuing to transfer without staff assistance after identifying education was ineffective; and, after the resident was no longer on fifteen minute observations. Record review revealed Resident #2 sustained a bruise to the right shoulder blade, skin tear to the left lower leg, and a knot on the back of the head with the fall on 11/08/2020. The resident had a fall on 01/09/2021 and sustained a non-displaced right fibula fracture. During the follow up appointment with the Orthopedic Physician on 01/27/2020, a two (2) view x-ray of the right tibula/fibula was obtained which revealed evidence of an old fracture of the proximal fibula and subacute fracture at the tip of the lateral malleolus (bony prominence of ankle). Further review revealed the assessment noted that status post [MEDICAL RECORD OR PHYSICIAN ORDER] Interview with Resident #2, on 01/20/2021 at 1:50 PM, revealed he/she 'forgets to use the call light at times. He/she stated, By the time they (staff) get here, it's too late. Further interview revealed the resident stated, I rather just go than have to wait. Interview (Post Survey) with Licensed Practical Nurse (LPN) #4, on 02/10/2021 at 10:22 AM, revealed the intervention she put in place after Resident #2's fall on 11/08/2020, was to remind the resident to call for help with transferring. LPN #4 stated the resident knew he/she had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Further interview revealed LPN #4 stated the resident had been educated on the safety hazards of self transferring. However, the resident continued to refuse to call staff for assistance and chose to get into his/her wheelchair without asking for assistance. LPN #4 stated she knew the interventions to use the call light, and staff to assist with transfer were used before, but she felt they were appropriate interventions because the resident was self transferring when he/she fell . Interview with the Falls Coordinator and the Director of Nursing (DON) on 01/27/2021 at 2:15 PM, revealed there were repetitive interventions related to Resident #2's falls due to the resident not using his/her call light and/or requesting assistance with transfers and bed mobility. The Falls Coordinator stated the care plan interventions were reviewed by the IDT and the team followed up on interventions seven (7) days later to assess the effectiveness and to determine if they were appropriate to meet the resident's care needs. The DON stated the IDT initiated and implemented interventions that were attainable for the resident; however, due to the resident's impulsivity and non-compliance, the interventions were ineffective. Interview (Post Survey) with Fall Coordinator, on 02/10/2021 at 10:56 AM, revealed she conducted investigations of resident falls before they were reviewed by the IDT. The Fall Coordinator stated Resident #2 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated the resident's BIMS score was high and he/she had no problems with memory in the past, but he/she continued to fall. She stated the resident continued to self transfer even though safety risks were involved; and there was a lengthy list of interventions with interventions repeated.

Based on observation, interview, record review and facility policy review, it was determined the facility failed to ensure the infection prevention and control program was followed while providing direct resident care during COVID 19 pandemic. Observation revealed Licensed Practical Nurse (LPN) #1 failed to wash/sanitize hands per facility poicy when she entered and exited Resident #2's room; after handling dirty items that were picked up off the floor; and, prior to providing care to residents. In addition, LPN #1 failed to handle a dirty towel and pillow case in a manner that prevented the transfer of microorganisms to others and to the environment per facility policy, when she carried the items in her hand from the resident's room to the dirty linen room. The findings include: Review of facility policy titled, Standard Precautions Infection Control, dated 03/18/2020, revealed all staff are to assume that all residents are potential infected or colonized with an organism that could be transmitted during the course of providing resident care services. Therefore, all staff shall adhere to Standard Precautions to prevent the spread of infection. Standard Precautions represents the infection prevention measures that apply to all resident care, regardless of suspected or confirmed infection status of the resident, in any setting where healthcare is delivered. Hand Hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR). Further review of the policy for Standard Precautions Infection Control Protocol revealed hand hygiene should be completed after touching blood, body fluids, secretions, excretions, and contaminated items; before and after removing personal protective equipment (PPE); and, between resident contacts. Gloves should be used for touching blood, body fluids, secretions excretions; contaminated items; and, for touching mucous membranes, and non-intact and intact resident skin. Textiles and laundry should be handled in a manner that prevents transfer of microorganisms to others and to the environment. Observation on 05/04/2020 at approximately 11:07 AM revealed Licensed Practical Nurse (LPN) #1 exited a resident's room and entered Resident #2's room. LPN #1 failed to wash hands when she entered room. LPN #1 picked up a pillow and a towel off the floor and removed the pillowcase from the pillow and placed pillow in chair. Further observation revealed LPN #1 then proceeded to remove Resident #2's hand from his/her oxygen nasal cannula and placed the nasal cannula in the resident's nostrils, without washing her hands after handling the dirty towel and pillowcase. LPN #1 then left the room with pillowcase and towel in her hands, stopped and talked to another resident who was sitting in alcove, and then went into soiled linen room on the isolation/COVID unit and disposed of the towel and pillowcase. LPN #1 failed to ensure the dirty towel and pillowcase were handled in a manner that prevented transfer of microorganisms to others and to the environment. Interview with LPN #1 on 05/04/2020 at 11:25 AM and 05/05/2020 at 11:30 AM revealed she did not wash/sanitize hands when entering and exiting resident rooms; prior to placing nasal cannula (oxygen) on Resident #2; or when going to attend to another resident sitting in the alcove. LPN #1 stated she did not think about washing her hands at the time, but did wash her hands when came back to the nursing station. She revealed she had left her sanitizer at the nursing station and did not use it or have gloves on. Interview with the Staff Development Coordinator (SDC) on 05/04/2020 at 11:12 AM and 11:17 AM revealed LPN #1 was the nurse working on the isolation unit/COVID unit with (5) five residents at this time. The SDC stated LPN #1 had received individual training and nurses were expected to wash hands before and after resident care, and before and after gloves are used. She revealed this practice was vital for infection control. Interview with Infection Control Nurse (ICN) on 05/04/2020 at 11:43 AM revealed handwashing/sanitizing of the hands should be completed when entering/exiting resident rooms, prior to and after caring for a resident, and after picking up a dirty towel from the floor. She stated staff were given sanitizers to carry in their pockets. Interview with Director of Nursing (DON) on 05/04/2020 at 12:35 PM revealed staff should wash hands before and after care of residents and should wear gloves. She stated staff should wash hands after picking up items off the floor and prior to putting oxygen on a resident.

Based on observation, and review of facility policy, it was determined the facility failed to serve food in accordance with professional standards for food service safety related to lack of hand sanitation during meal pass. The findings include: Review of facility policy, not titled or dated, revealed staff to use hand sanitizer or wash your hands after each tray passed. 1. Observation during meal pass on 11/12/19 at 11:25 AM, revealed the Dietary Aide was passing beverages in the dining room and not using hand sanitizer between the passes. She was also noted to touch her hair and face during the observation. Interview with the Dietary Aide, on 11/14/19 at 10:19 AM, revealed she should have used hand sanitizer between passing food trays and other times after touching soiled objects. She stated she was the only one in there and she was kind of busy and might have forgotten. Interview with the Dietician, on 11/14/19 at 10:38 AM, revealed staff should sanitize hands while distributing drinks to residents. 2. Observation during a meal pass on 11/12/19 at 4:54 PM, on the two-hundred (200) hall, revealed a staff member failed to sanitize her hands while distributing and setting up trays for three residents. Interview with Registered Nurse (RN) #1 on 11/12/19 at 5:05 PM, revealed she should have sanitized her hands between each resident, as it is considered unsanitary not to do so. Interview with the Director of Nursing (DON) on 11/14/19 at 1:55 PM, revealed she would expect staff to sanitize with hand gel between each resident to decrease cross contamination.

Based on interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of five (5) sampled residents maintained acceptable parameters of nutritional status (Resident #11). On 10/13/19 , the facility identified a significant weight loss of 10.8% for Resident #11; however, the facility failed to place Resident #11 on weekly weights after identifying a significant weight loss per facility policy. The findings include: Review of the facility document, Weight Monitoring and Intervention Policy, last updated 01/18/19, revealed the interdisciplinary team will monitor and intervene for undesirable weight loss or gain for residents. The Dietician will review the weight record to follow individual weight trends over time. Negative trends will be evaluated to determine if a significant weight change has occurred and make any recommendations, if indicated. Record review revealed the facility admitted Resident #11 on 05/03/19, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Sets (MDS) assessment, dated 010/23/19, revealed the facility assessed Resident #11's cognition as impaired with a Brief Interview for Mental Status (BIMS) score of four (4), which indicated the resident was not interviewable. Review of Resident #11's Comprehensive Care Plan for Alteration in Nutritional Status related to a [DIAGNOSES REDACTED]. Review of Resident #11's Weight Record revealed the resident weighed 161.5 pounds on 05/07/19 and 144.0 pounds on 10/13/19 (weight loss of 17.5 pounds), which was a significant weight loss of six percent (10.8%) in five (5) months. However, further review of the record revealed the resident was not placed on weekly weights per facility policy. Review of the Weight Record revealed the resident was not weighed again until 11/13/19 (one {1} month later) when he/she weighed 142.5 pounds (weight loss of 1%). Interview with the Registered Dietitian (RD), on 11/14/19 at 10:31 AM, revealed after reviewing her notes she saw where Resident #11 triggered for significant weight loss and should have been placed on weekly weights on 10/13/19. She stated it was an oversight on her part and she would have made a recommendation for weekly weights. The RD further stated there were interventions in place for Resident #11 such as Resource with all meals. Interview with the Director of Nursing (DON) from a sister facility, on 11/14/19 at 1:55 PM, revealed she would expect a resident with significant weight loss to be placed on weekly weights to ensure appropriate interventions and monitoring the effectiveness of those interventions.

Based on observation, interview, and record review, it was determined the facility failed to ensure each resident receives necessary respiratory care and services that is in accordance with professional standards of practice for one (1) of one (1) sampled resident reviewed for respiratory care (Residents #16). Observations on 11/12/19 and 11/13/19, revealed Resident #16's nebulizer mouthpiece was not being stored properly when not in use. The findings include: Interview with the Director of Nursing (DON) on 11/14/9 at 1:55 PM, revealed the facility did not have a specific policy regarding the storage of nebulizer equipment. She further stated the facility follows state and federal regulations and the facility policy would be updated to reflect the storage of nebulizer equipment. Record review revealed the facility admitted Resident #16 on 08/20/19, with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Sets (MDS) assessment, dated 08/27/19, revealed the facility assessed Resident #16's cognition as intact with a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated the resident was interviewable. Review of Resident #16's physician's orders [REDACTED]. Observation on 11/12/19 at 1:06 PM and 2:09 PM, revealed Resident #16 was up in a wheelchair in his/her room. Further observation revealed his/her nebulizer mouthpiece laying on a beside table, located near the resident, not stored in a plastic bag. Continued observation on 11/13/19 at 8:50 AM, revealed the nebulizer mouthpiece was laying on a bedside table and not stored in a plastic bag. Interview with Certified Nurse Assistant (CNA) #1 on at 11/14/19 at 10:59 AM , revealed the nebulizer mask, when not in use, should be stored in a plastic bag. CNA #1 revealed she had not noticed the nebulizer mask not being stored appropriately. Interview with Licensed Practical Nurse (LPN) #1 on 11/14/19 at 11:05 AM, revealed when the nebulizer mask is not in use, it should be stored in a plastic bag. She stated after nursing administered the treatment, proper storage is needed to keep the mask from being dropped on the floor and to keep it clean; decreasing infection risk for the resident. Interview with the Director of Nursing (DON) on 11/14/19 at 1:55 PM, revealed she expected the nebulizer mask to be stored properly in a plastic bag when not in use to decrease contamination of the respiratory equipment.

Based on observation, interview, facility policy review, and review of Sani-Cloth Germicidal Disposable cloths container's caution statement, it was determined the facility failed to ensure the residents environment remains as free of accident hazards as possible. Observation on 11/12/19, revealed cleaning wipes were left unattended on a counter at the nurses station. Review of the facility wandering list revealed there were four (4) residents who had behaviors of wandering. The findings include: Interview with the Director of Nursing (DON) on 11/14/19 at 1:55 PM, revealed the facility did not have a specific policy on the storage of the germicidal wipes. She stated the facility follows state and federal regulations in regards to storage of chemical containing agents. Observation on 11/12/19 from 4:00 PM through 4:47 PM, revealed a container of germicidal cleaning wipes was left unattended on the outer counter of the nurses station on the two-hundred (200) hall, with one (1) resident observed nearby and two (2) staff members. Review of the Sani-Cloth Germicidal Disposable Cloths container revealed caution should be used and kept out of reach of children. Interview with Certified Nurse Aide (CNA) #1 on 11/14/19 at 10:59 AM, revealed the germicidal wipes should be stored out of residents' reach due to being a possible hazard. Interview with Licensed Practical Nurse (LPN) #1 on 11/14/19 at 11:05 AM, revealed the germicidal wipes should be kept out of residents' reach for their safety. Interview with the Director of Nursing (DON), on 11/14/19 at 1:55 PM, revealed she expected all staff to ensure the germicidal wipes or any other items containing cleaning agents to be kept out of residents reach or not left unattended.

Based on interview, record review, review of the facility investigation, and review of the facility Abuse policy, it was determined the facility failed to implement the facility Abuse policy related to immediately reporting to the Administrator and removing the alleged perpetrator from the building after receiving an allegation of abuse of one (1) of three (3) sampled residents (Resident #1). State Registered Nurse Aide (SRNA) #1 reported to Kentucky Medication Aide (KMA) #2 that Licensed Practical Nurse (LPN) #1 allegedly abused Resident #1 on 11/19/18 at approximately 9:30 PM. However, the alleged abuse was not reported to the Administrator and the alleged perpetrator was not suspended per facility policy until 11/20/18 at approximately 8:00 AM (approximately 10 hours later). The findings include: Review of the facility policy titled, Adult and Child - Abuse and Neglect, Misappropriation of Resident Property, Unexpected/Suspicious Death, Suspicion of a Crime, not dated, revealed the policy was to establish a uniform policy and procedure for reporting and responding to all abuse/neglect allegations and deaths. Further review revealed if an employee witnessed, is told of, or suspects an incident of abuse, exploitation, neglect, misappropriation of resident property, suspicious death or had a reasonable suspicion of a crime had occurred, the employee will report immediately, but no later than two (2) hours after the allegation is made if the events that cause the allegation involve abuse or result in serious bodily injury. In addition, further review revealed residents should be protected and the alleged perpetrator should be removed from the building and grounds immediately. Record review revealed the facility admitted Resident #1 on 11/07/18 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment, dated 11/14/18, revealed the facility assessed Resident #1 was not able to completed the Brief Interview of Mental Status (BIMS) and was hie/her cognition was severely impaired. Review of the facility Self Report Incident Form, dated 11/20/18, revealed on 11/19/18 at approximately 9:30 AM, LPN #1 and SRNA #1 responded to Resident #1's call light. When they entered the room, SRNA #2 and #3 were assisting Resident #1 who was attempting to self transfer from the bed. LPN #1 asked SRNA #2 and #3 to leave the room and motioned for SRNA #1 to assist with placing Resident #1 into the bed safely. The resident was combative and continued to try to exit the bed. LPN #1 told the resident in a stern voice you are not getting out of bed. Resident #1 then struck LPN #1 across the chest. LPN #1 took a hold of Resident #1's wrists and crossed his/her arms across his/her chest. The resident began kicking LPN #1 with his/her left leg and LPN #1 placed her left leg over Resident #1's leg and placed her knee on the resident's groin area. LPN #1 then stated. We are not playing these games tonight, you're going to bed. In a few moments, LPN #1 and SRNA #1 assisted Resident #1 to a wheelchair and took him/her to the nursing station for observation. Interview with SRNA #1 on 11/27/18 at 4:30 PM, revealed on 11/19/18 around 9:30 PM, Resident #1 was trying to get out of the bed and LPN #1 grabbed the resident's shoulders and pushed him/her back on the bed and asked him to get the resident's legs. The resident then hit her across the chest. SRNA #1 stated LPN #1 then grabbed both of the resident's wrists and crossed them across the resident's chest and told the resident sternly We're not playing these games tonight, you are going to bed. SRNA #1 stated at that point the resident kicked at LPN #1 with his/her left leg and LPN #1 crossed her left leg over the resident's and placed her knee in the resident's groin. He stated the aggressive tone in LPN #1's tone of voice was made him think she had done this deliberately. He revealed LPN #1 then held the resident in that position for a while while the resident continued struggling. SRNA #1 revealed after placing Resident #1 in wheelchair in commons area he told SRNA #2 and #3 what happened and asked what he should do since LPN #1 was the Supervisor. He stated they told him to tell KMA #2 so he told her and she called Registered Nurse (RN) #2, Supervisor. He stated RN #2 told KMA #2 to have him write a statement and he did that. He stated LPN #1 continued to work to the end of her shift which was the next morning. Interview with KMA #2, on 11/27/18 at 2:50 PM, revealed SRNA #1 had reported he saw LPN #1 grab Resident #1's wrists, cross the resident's arms across the resident's chest, and place her knee into the resident's groin. She stated she called RN #2 at home since LPN #1 was the supervisor that night and RN #2 told her to have SRNA #1 write a statement stating what had happened. She stated RN #2 told her to place the statement in an envelope and place under her door. She further stated she did not report the allegation to the Administrator because she thought RN #2 would report it and RN #2 did not tell her to remove LPN #1 from the building. She revealed LPN #1 worked the rest of her shift until the next morning. Interview with RN #2, Supervisor, on 11/27/18 at 5:20 PM, revealed she received a phone call on Monday night (11/19/18) from KMA #2 who stated that SRNA #1 witnessed LPN #1 cross Resident #1's arms across the resident's chest and placed her knee in the resident's groin after the resident hit her in the chest. She stated she told KMA #2 to have SRNA #1 write out a statement. She stated she did not call the Administrator to make him aware of the allegation of abuse and did not have LPN #1 removed from the building per facility facility policy. Interview with the Director of Nursing (DON) on 11/17/18 at 3:20 PM revealed she received a text from RN #2 on 11/20/18 at 7:49 PM about the allegation of abuse made the previous evening. The DON stated she asked RN #2 if she called anyone and/or removed LPN #1 from the building per facility policy; and RN #2 stated she did not. She stated she immediately called the Administrator and called LPN #1 to make her aware she was suspended until the investigation was completed.

Based on interview, record review, review of the facility investigation, and facility policy review, it was determined facility staff failed to protect residents when they failed to remove Licensed Practical Nurse (LPN) #1 from resident care after receiving an allegation that LPN #1 had abused one (1) of three (3) sampled residents (Resident #1). State Registered Nurse Aide (SRNA) #1 reported to Kentucky Medication Aide (KMA) #2 that Licensed Practical Nurse (LPN) #1 allegedly abused Resident #1 on 11/19/18 at approximately 9:30 PM. However, LPN #1 was not removed from resident care until 11/20/18 at approximately 8:00 AM (approximately 10 hours later). The findings include: Review of the facility policy titled, Adult and Child - Abuse and Neglect, Misappropriation of Resident Property, Unexpected/Suspicious Death, Suspicion of a Crime, not dated, revealed the policy was to establish a uniform policy and procedure for reporting and responding to all abuse/neglect allegations and deaths. Further review revealed investigations for incidents should begin immediately by the Charge Nurse. Residents should be protected and the alleged perpetrator should be removed from the building and grounds immediately. Record review revealed the facility admitted Resident #1 on 11/07/18 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment, dated 11/14/18, revealed the facility assessed Resident #1 was not able to completed the Brief Interview of Mental Status (BIMS) and was hie/her cognition was severely impaired. Review of the facility Self Report Incident Form, dated 11/20/18, revealed on 11/19/18 at approximately 9:30 AM, LPN #1 and SRNA #1 responded to Resident #1's call light. When they entered the room, SRNA #2 and #3 were assisting Resident #1 who was attempting to self transfer from the bed. LPN #1 asked SRNA #2 and #3 to leave the room and motioned for SRNA #1 to assist with placing Resident #1 into the bed safely. The resident was combative and continued to try to exit the bed. LPN #1 told the resident in a stern voice you are not getting out of bed. Resident #1 then struck LPN #1 across the chest. LPN #1 took a hold of Resident #1's wrists and crossed his/her arms across his/her chest. The resident began kicking LPN #1 with his/her left leg and LPN #1 placed her left leg over Resident #1's leg and placed her knee on the resident's groin area. LPN #1 then stated We are not playing these games tonight, you're going to bed. In a few moments, LPN #1 and SRNA #1 assisted Resident #1 to a wheelchair and wheeled him/her to the nursing station for observation. Interview with KMA #2, on 11/27/18 at 2:50 PM, revealed SRNA stated he saw LPN #1 grab Resident #1's wrists, cross the resident's arms across the resident's chest and place her knee into the resident's groin. She stated she called Registered Nurse (RN) #2 at home since LPN #1 was the supervisor that night and RN #2 told her to have SRNA #1 write a statement stating what had happened. She stated RN #2 told her to place the statement in an envelope and place under her door. She further stated she was not told to send LPN #1 home that night and LPN #1 continued to work with residents until the next morning. Interview with RN #2, Supervisor, on 11/27/18 at 5:20 PM, revealed she received a phone call on Monday night (11/19/18) from KMA #2 who stated that SRNA #1 witnessed LPN #1 cross Resident #1's arms across the resident's chest and placed her knee in the resident's groin after the resident hit her in the chest. She stated she told KMA #2 to have SRNA #1 write out a statement. She further stated she did not tell KMA #2 to suspend LPN #1 and should have suspended LPN #1 immediately. Interview with the Director of Nursing (DON) on 11/17/18 at 3:20 PM revealed she received a text from RN #2 on 11/20/18 at 7:49 PM about the allegation of abuse made the previous evening. The DON stated she asked RN #2 if she called suspended LPN #1 and RN #2 stated she did not. She stated she called LPN #1 and made her aware she was suspended while the investigation was being completed.

Based on interview, record review, review of the facility investigation, and facility policy review, it was determined facility staff failed to report an allegation of abuse timely to the Administrator for one (1) of three (3) sampled residents (Resident #1). State Registered Nurse Aide (SRNA) #1 reported to Kentucky Medication Aide (KMA) #2 that Licensed Practical Nurse (LPN) #1 allegedly abused Resident #1 on 11/19/18 at approximately 9:30 PM. However, the alleged abuse was not reported to the Administrator until 11/20/18 at approximately 8:00 AN (approximately 10 hours later). The findings include: Review of the facility policy titled, Adult and Child - Abuse and Neglect, Misappropriation of Resident Property, Unexpected/Suspicious Death, Suspicion of a Crime, not dated, revealed the policy was to establish a uniform policy and procedure for reporting and responding to all abuse/neglect allegations and deaths. Further review revealed if an employee witnessed, is told of, or suspects an incident of abuse, exploitation, neglect, misappropriation of resident property, suspicious death or had a reasonable suspicion of a crime had occurred, the employee will report immediately, but no later than two (2) hours after the allegation is made. If the events that cause the allegation involve abuse or result in serious bodily injury. Record review revealed the facility admitted Resident #1 on 11/07/18 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment, dated 11/14/18, revealed the facility assessed Resident #1 was not able to completed the Brief Interview of Mental Status (BIMS) and was hie/her cognition was severely impaired. Review of the facility Self Report Incident Form, dated 11/20/18, revealed on 11/19/18 at approximately 9:30 AM, LPN #1 and SRNA #1 responded to Resident #1's call light. When they entered the room, SRNA #2 and #3 were assisting Resident #1 who was attempting to self transfer from the bed. LPN #1 asked SRNA #2 and #3 to leave the room and motioned for SRNA #1 to assist with placing Resident #1 into the bed safely. The resident was combative and continued to try to exit the bed. LPN #1 told the resident in a stern voice you are not getting out of bed. Resident #1 then struck LPN #1 across the chest. LPN #1 took a hold of Resident #1's wrists and crossed his/her arms across his/her chest. The resident began kicking LPN #1 with his/her left leg and LPN #1 placed her left leg over Resident #1's leg and placed her knee on the resident's groin area. LPN #1 then stated. We are not playing these games tonight, you're going to bed. In a few moments, LPN #1 and SRNA #1 assisted Resident #1 to a wheelchair and took him/her to the nursing station for observation. Interview with SRNA #1 on 11/27/18 at 4:30 PM, revealed on 11/19/18 around 9:30 PM, Resident #1 was trying to get out of the bed and LPN #1 grabbed the resident's shoulders and pushed him/her back on the bed and asked him to get the resident's legs. The resident then hit her across the chest. SRNA #1 stated LPN #1 then grabbed both of the resident's wrists and crossed them across the resident's chest and told the resident We're not playing these games tonight, you are going to bed. SRNA #1 stated at that point the resident kicked at LPN #1 with his/her left leg and LPN #1 crossed her left leg over the resident's and placed her knee in the resident's groin. He stated the aggressive tone in LPN #1's tone of voice was made him think she had done this deliberately. He revealed LPN #1 then held the resident in that position for a while while the resident continued struggling. SRNA #1 revealed after placing Resident #1 in wheelchair in commons area he told SRNA #2 and #3 what happened and asked what he should do since LPN #1 was the Supervisor. He stated they told him to tell KMA #2 so he told her and she called RN #2. He stated RN #2 told KMA #2 to have him write a statement and he did that. Interview with KMA #2, on 11/27/18 at 2:50 PM, revealed SRNA #1 had reported he saw LPN #1 grab Resident #1's wrists, cross the resident's arms across the resident's chest and place her knee into the resident's groin. She stated she called RN #2 at home since LPN #1 was the supervisor that night and RN #2 told her to have SRNA #1 write a statement stating what had happened. She stated RN #2 told her to place the statement in an envelope and place under her door. She further stated she did not report the allegation to the Administrator because she though RN #2 would report it. Interview with RN #2, Supervisor, on 11/27/18 at 5:20 PM, revealed she received a phone call on Monday night (11/19/18) from KMA #2 who stated that SRNA #1 witnessed LPN #1 cross Resident #1's arms across the resident's chest and placed her knee in the resident's groin after the resident hit her in the chest. She stated she told KMA #2 to have SRNA #1 write out a statement. She stated she did not call the Administrator to make him aware of the allegation of abuse per facility policy. She further stated she should have called the Administrator. Interview with the Director of Nursing (DON) on 11/17/18 at 3:20 PM revealed she received a text from RN #2 on 11/20/18 at 7:49 PM about the allegation of abuse made the previous evening. The DON stated she asked RN #2 if she called anyone and RN #2 stated she did not. She stated she immediately called the Administrator and her and the Administrator immediately began an investigation of the allegation.

Based on interview, record review, review of the facility investigation, and facility policy review, it was determined the facility failed to ensure one (1) of three (3) residents had the right to choose sleeping times (Resident #1). On 11/19/18, Resident #1 was attempting to get out of the bed per his/her choice and Licensed Practical Nurse (LPN #1) failed to honor the resident's choice which resulted in the resident becoming combative. The findings include: Review of the facility Resident Rights Document, not dated, revealed residents had the right to choose activities, schedules, and health care consistent with his/her assessments and plans of care. Record review revealed the facility admitted Resident #1 on 11/07/18 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment, dated 11/14/18, revealed the facility assessed Resident #1 was not able to completed the Brief Interview of Mental Status (BIMS) and was hie/her cognition was severely impaired. Review of the facility Self Report Incident Form, dated 11/20/18, revealed on 11/19/18 at approximately 9:30 AM, LPN #1 and State Registered Nurse Aide (SRNA) #1 responded to Resident #1's call light. When they entered the room, SRNA #2 and #3 were assisting Resident #1 who was attempting to self transfer from the bed. LPN #1 asked SRNA #2 and #3 to leave the room and motioned for SRNA #1 to assist with placing Resident #1 into the bed The resident was combative and continued to try to exit the bed. LPN #1 told the resident in a stern voice you are not getting out of bed. Resident #1 then struck LPN #1 across the chest. LPN #1 took a hold of Resident #1's wrists and crossed his/her arms across his/her chest. The resident began kicking LPN #1 with his/her left leg and LPN #1 placed her left leg over Resident #1's leg and placed her knee on the resident's groin area. LPN #1 then stated. We are not playing these games tonight, you're going to bed. In a few moments, LPN #1 and SRNA #1 assisted Resident #1 to a wheelchair and took him/her to the nursing station for observation. Interview with LPN #1 on 11/27/18 at 4:00 PM revealed looking back at the situation now she should have assisted the resident into his/her wheelchair and let him/her sit in the commons area. She stated once staff did this the resident was still cussing but was calmer and no longer combative. She stated all that was on her mind was to keep everybody safe because the resident was combative. Interview with SRNA #1 on 11/27/18 at 4:30 PM, revealed on 11/19/18 around 9:30 PM, Resident #1's call light came on and he responded. SRNA #1 stated staff would place the call light pad at the resident's hips so they would know when the resident was trying to get up. He revealed SRNA #2 and SRNA #3 were already in the room and Resident #1 was sitting on the side of the bed and trying to get up. Licensed Practical Nurse (LPN) #1 then entered the room. He stated one of the SRNA's already in the room stated the resident was trying to get up and was going to fall and LPN #1 responded he/she has the right to fall. LPN #1 then told SRNA #2 and SRNA #3 to leave the room and they would take care of the resident. He stated Resident #1 was trying to get out of the bed and LPN #1 grabbed the resident's shoulders and pushed him/her back on the bed and asked him to get the resident's legs. The resident then hit her across the chest. SRNA #1 revealed LPN #1 then grabbed both of the resident's wrists and crossed them across the resident's chest and told the resident We're not playing these games tonight, you are going to bed. SRNA #1 stated at that point the resident kicked at LPN #1 with his/her left leg and LPN #1 crossed her left leg over the resident's and placed her knee in the resident's groin. He revealed LPN #1 then held the resident in that position for a while while the resident continued struggling. At one point the resident stated, I'm going to burn you both. and LPN #1 stated something like I wish you would. SRNA #1 stated the resident continued struggling and LPN #1 finally stated forget it, let's get him/her up. SRNA #1 revealed Resident #1 had the right to get out of bed if he/she wanted to. Interview with SRNA #2 on 11/27/18 at 2:20 PM, revealed on 11/19/18 Resident #1's call light came on so she and SRNA #3 went down to his/her room and found the resident trying to get out of the bed. She stated as they were assisting the resident to get up, LPN #1 and SRNA #1 entered the room and LPN #1 told her and SRNA #3 to leave the room. SRNA #2 revealed the resident had the right to get out of bed if he/she wanted to. Interview with SRNA #3 on 11/28/18 at 12:55 PM, revealed on 11/19/18, her and SRNA #2 were attempting to help Resident #1 out of bed when LPN #1 and SRNA #1 entered the room and LPN #1 stated, it's okay we got this. SRNA #3 stated Resident #1 had the right to get out of bed if he/she wanted to. Interviews on 11/27/18 with the Director of Nursing (DON) at 3:20 PM and the Administrator at 5:45 PM revealed the resident have the right to choose if they want to go to bed or get out of bed. They stated LPN #1 should not have insisted the resident go to bed on 11/19/18 as this seemed to make him/her more combative.

Based on interview, record review, and facility policy review, it was determined the facility failed to provide Cardiopulmonary Resuscitation (CPR) to one (1) of four (4) sampled residents (Resident #1). The facility admitted Resident #1 on [DATE] for Rehabilitation after sustaining a broken hip. Resident #1 and his/her responsible party signed a Directive of Care (Advanced Directive) to receive CPR if he/she ceased to have a pulse or respirations. Resident #1 had a physician's orders [REDACTED]. However, on [DATE] at approximately 6:19 AM, staff found the resident to have no respirations or pulse, but failed to provide CPR per facility policy. The facility's failure to provide Resident #1 CPR has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) was identified on [DATE] and determined to exist on [DATE], An acceptable Credible Allegation of Compliance (A[NAME]), was received on [DATE], The State Survey Agency validated the AoC and determined Immediate Jeopardy was removed on [DATE]. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy titled, CPR/DNR (do not resuscitate), last reviewed [DATE] revealed the facility offered CPR twenty-four (24) hours a day by certified staff. CPR is initiated for any resident who has a cardiopulmonary arrest (cease breathing/no pulse) while in the facility, unless a decision has been previously made and properly recorded. Every resident and their responsible party is afforded the opportunity to communicate their decision regarding CPR. The resident or responsible party has the right to change that decision at any time. Closed record review revealed the facility admitted Resident #1 with diagnoses, which included Non-displaced Intertrochanteric Fracture; and, pain right hip, to receive rehabilitation services. Review of Resident #1's Directive of Care (Advanced Directive) dated [DATE] revealed the resident chose to receive CPR in the event of cardiac or respiratory arrest (no pulse or respirations) and both the resident and responsible party signed it. Review of the physician's orders [REDACTED].#1 was a Full Code. Review of Resident #1's Progress Notes revealed on [DATE] at 2:32 PM, Physical Therapy reported the resident's oxygen saturation (O2 sat) dropped with activity between ,[DATE]%, and was 91% when resting (admission: 97%). In addition, the resident's pulse (P.) was irregular with activity at 80 to 104 (admission: 82). Blood pressure (B/P) was ,[DATE] (admission: ,[DATE]) and slight wheezing was noted. Resident #1's Physician was notified with orders received to obtain a chest x-ray and laboratory work. At 6:30 PM, the Physician was called with results of the chest x-ray with new order received to administer [MEDICATION NAME] (diuretic) 40 milligrams (mg) intramuscularly (IM) times one dose and start [MEDICATION NAME] 20 mg by mouth daily on [DATE]. Further review revealed orders to check Blood Metabolic Panel (BMP) on Monday, set up outpatient echo, and consult with Cardiology in AM. If condition worsens, send to hospital emergency room . At 7:30 PM, [MEDICATION NAME] 40 mg IM was given. Further review of the Nursing Progress Notes revealed on [DATE] at 3:40 AM Resident #1 was extremely confused talking to people that were not there The resident's vitals were B/P: ,[DATE], R: 20, P:99 and O2 sat: 91% on room air. Review of a Late Entry Nursing Progress Note dated [DATE] at 7:45 AM for 4:00 AM, revealed Resident #1 was resting quietly in bed and responded when name called, O2 sat: 91%. Review of a Late Entry Nursing Note, dated [DATE] at 5:15 AM, revealed around 5:00 AM-5:15 AM, Licensed Practical Nurse (LPN) #4 entered Resident #1's room to administer medication to the resident's roommate. Resident #1 responded to a question the nurse had asked of his/her roommate and then laid his/her head down and went back to sleep. Review of the facility's video recording revealed on [DATE] at 5:12 AM, Resident #1's and his/her roommate's room call light over the door began flashing. LPN #4 was observed to enter Resident #1's room and exited at 5:14 AM with the light still flashing. Further review revealed the light continued to flash until State Registered Nurse Aide (SRNA) #1 entered Resident #1's room at 6:19 AM (approximately one (1) hour later). SRNA #1 then exited the room swiftly going down the hall towards the nursing station. Then SRNA #1, LPN #1, LPN #4 and Registered Nurse (RN) #1 walked up the hall and entered Resident #1's room. Review of a Late Entry Nursing Progress Note, dated [DATE] at 8:05 AM for 6:00 AM (approximately one (1) hour after resident was seen in bed awake) revealed SRNA #1 notified the nurse she thought the resident had passed away and the resident needed to be examined. The nurse examined the resident and the resident felt cold to touch, eyes were staring straight ahead at the ceiling, and there were no cardinal signs of life (no blood pressure, pulse, temperature or heart rate). The Coroner, Physician, Director of Nursing (DON), Administrator and Responsible Party were notified. Interview with SRNA #1 on [DATE] at 2:25 PM revealed on [DATE] she arrived at work at 6:00 AM to work day shift and identified there were two (2) call lights going off at the end of the hall. She stated she and her orientee went to the first room and assisted a resident to the commode, and then she went to the second room (Resident #1's room). She stated it was dark but Resident #1 was laying sideways across the bed with his/her feet hanging off the bed. She stated she turned on the light and saw the resident was staring towards the ceiling and did not respond. SRNA #1 stated she touched the resident to get him/her to respond and the resident was not warm to touch as normal but was not cold to touch either; she stated she did not want to use the word lukewarm. She stated she immediately ran down the hallway hollering for the nurse. Continued interview revealed the nurse came to the room with two (2) other nurses, and other staff arrived so she left the room. SRNA #1 stated she was CPR certified and she should have started CPR on the resident and called for the nurse. She stated at the time she did not know the resident was a full code and did not know what the blue dot next to the resident's name outside the door meant. She stated from 5:,[DATE]:00 AM was the time the aides would get the residents up for the day. SRNA #1 stated the nurse at the nurses' desk usually answered the call lights when staff were in residents' rooms. Interview with LPN #4 on [DATE] at 9:55 AM revealed when she came on duty on [DATE], Resident #1 had received [MEDICATION NAME] IM due to his/her O2 sats dropping and heart rate becoming irregular with activity. She stated she and staff checked on the resident often throughout the night because the resident was seeing people that were not there and was constantly pushing his/her light. LPN #4 stated the last time she saw the resident was around 5:15 AM and the resident spoke to her then laid his/her head back down. She stated she must have forgotten to turn the call light off when she entered the room. The LPN stated she usually answers the call lights when the aides were in the rooms, but she did not answer Resident #1's room call light after 5:15 AM. She stated at approximately 6:00 AM, while she was giving report to the day shift nurse (RN #1), SRNA #1 came running down the hall stating she needed a nurse. LPN #4 stated she went to Resident #1's room and the resident was laying across the bed as if he/she had tried to get up. She stated she assessed the resident to be blue, cold and with no heart rate or breath sounds LPN #4 stated she was in shock and went to the nurses' station to call the Administrator, Director of Nursing, Coroner and family. She stated she was aware the resident was a full code because she had admitted the resident. LPN #4 stated none of the staff in the room brought up starting CPR. She further stated she should have began CPR immediately and had someone call Emergency Medical Services (EMS). LPN #4 stated she wished she could do that night over again. Interview with LPN #1 on [DATE] at 2:15 PM, revealed she had heard and seen SRNA #1 running down the hall calling for a nurse on [DATE] at approximately 6:00 AM. She stated she went down to Resident #1's room and LPN #4 and RN #1 walked in right behind her. She stated LPN #4 immediately began to assess the resident so she left the room. Interview with RN #1 on [DATE] at 2:50 PM revealed she worked days and had just came on duty when the day shift SRNA came down the hall to get the nurse. She stated she went down and there were three (3) SRNAs, LPN #1, and LPN #4 in the room. She stated she did not know if Resident #1 was a full code or not as she had not worked with the resident before and she did not look at the door. RN #1 stated she asked LPN #4 if the resident was a full code and LPN #4 stated yes so she asked LPN #4 what she was going to do, and LPN #4 did not respond. She stated she, the other two (2) nurses and the SRNA were wrong and they should have began CPR immediately, called EMS, and continued CPR until EMS arrived and took over. Interview with the LPN/CPR Instructor on [DATE] at 12:48 PM revealed the staff should have immediately started CPR on Resident #1, called EMS, and continued CPR until the resident was revived or EMS arrived to take over care. Interview with the Director of Nursing (DON) on [DATE] at 4:19 PM revealed she immediately conducted an investigation on [DATE]. She stated she determined SRNA #1, LPN #1, LPN #4 and RN #1 failed to provide CPR per the facility's policy, She stated all staff were CPR Certified and educated to start CPR immediately if a full code resident was found with no respirations/pulse. The DON stated someone should have called EMS and staff should continue CPR until the resident revives or EMS arrives to take over care. She stated she determined there was a blue dot next to the resident's name outside of the room. Interview with Resident #1's Physician/Facility Medical Director, on [DATE] at 1:45 PM revealed Resident #1 was admitted to the facility for rehabilitation (rehab). He stated he had not seen the resident yet but on [DATE], he was notified Resident #1 experienced shortness of breath with a decrease in O2 sats during rehab activity. He stated he ordered a chest x-ray with some labs and determined the resident had Mild [MEDICAL CONDITION] and was not on a diuretic so he ordered a one time dose of IM [MEDICATION NAME] and a daily dose of [MEDICATION NAME] beginning the next day. The physician stated he was going to see the resident the next day but was notified the resident had passed away the next morning. He stated the staff did not tell him the resident was a full code and staff had not provided CPR. Further interview revealed the staff should have called EMS and immediately began CPR if the resident was a full code. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. The DON verbally reeducated SRNA #1, RN #1, LPN #1, and LPN #4 on [DATE] on the facility's CPR policy which included that CPR should be started immediately by staff if the resident is a full code and must continue until EMS arrives and takes over. The DON issued Final Warnings of employment, to SRNA #1, RN #1, LPN #1, and LPN #4. 2. The Administrator removed Charge Nurse, LPN #4, from employment on [DATE]. 3. The LPN/Educational Coordinator and LPN/Restorative Nursing Supervisor revised the facility's CPR policy to include steps to identify code status, administering CPR, duration of CPR, when to begin, and appropriate cessation. 4. The facility's Administrator educated all staff on the new CPR policy on [DATE] and tested on understanding of the CPR policy. Staff members not present will be provided the new policy upon arrival to work for immediate review and tested for understanding by the Charge Nurse or Administrator. 5. The CPR policy education will be provided to all new hires by the LPN/CPR Instructor during New Hire Orientation and will be reviewed annually with all employees. The facility's Licensed Nurse Orientation form and the SRNA Orientation form were updated by the LPN/Education Coordinator, on [DATE] to include the CPR policy. 6. On [DATE], the RN Supervisor and the LPN-Education Coordinator, revised the Policy for Baseline Care plans to include that the Social Worker was responsible to include code status entry. A printed copy of the baseline care plan will be provided to care givers. 7. On [DATE], the RN Supervisor, the LPN-Education Coordinator, and the LPN/Minimum Data Set (MDS) Nurse, updated the Comprehensive Care Plan policy procedures to ensure continued disclosure of code status for residents as entered by the Social Worker. 8. On [DATE], the LPN/Educational Coordinator, updated the Nurse Aide Kardex, plan of care information to include code status. 9. On [DATE], the Social Worker reviewed all the residents' electronic charts and verified there were physician orders [REDACTED]. In addition, on [DATE] and [DATE], the Social Worker reviewed each resident's Comprehensive Care Plan via electronic record to assure all resident comprehensive care plans clearly disclosed appropriate Code Status. 10. On [DATE], the Social Worker visually verified, comparing physician orders [REDACTED]. She also verified that all full code residents had the appropriate identifying blue line under the bed light above the resident's bed. 11. On [DATE], the Performance Improvement Plan (PIP) was developed by the LPN/Educational Coordinator, The PIP verification of understanding of the CPR policy will include mock drills weekly, one on each shift, for the next quarter. Upon conclusion of the PIP, the PIP team will recommend the frequently for future mock CPR drills. The LPN/CPR Instructor will conduct the mock drills and evaluate staff performance. 12. The PIP will monitor understanding by giving ten (10) written questions exam per week by the RN/Charge Nurse and LPN/Medication Nurse regarding code status and how to perform CPR and grade for correct responses for the next quarter. 13. PIP Team members (2 {two} SRNAs) will visually review all Kardex files for appropriate code status weekly for the next quarter. 14. PIP Team members from Dietary and Housekeeping will visually check name plates and above bed lights for appropriate Code Status designation from all residents' Code Status list for next quarter. 15. RN/Charge Nurse will monitor all Comprehensive Care Plans weekly for Code Status by Physician order [REDACTED]. **The State Survey Agency validated the corrective action taken by the facility as follows: 1. Review of Incident/Employee Noncompliance with facility policy forms dated [DATE], revealed SRNA #1's, LPN #1's, LPN #4's and RN #1's final warning and education due to failing to start CPR on a full code resident when found cool to touch and no signs of life. The staff were educated that CPR should be started immediately on a resident that is a full code and must continue until EMS arrives to take over. The forms were signed by each staff and the DON. Interviews on [DATE] with SRNA #1 at 2:25 PM, LPN #1 at 2:15 PM, RN #1 at 2:55 PM; and interview on [DATE] at 9:55 AM with LPN #4, revealed they received education and a final warning on [DATE] due to their failure to provide CPR when Resident #1, who was a full code, was found with no respirations or pulse. 2. Review of a Office Memo form revealed LPN #4 was terminated on [DATE] and it was signed by the Administrator. Review of the Employee Timecard Report revealed LPN #4's last day worked was [DATE]. 3. Review of the CPR Policy last revised [DATE], revealed the policy was revised to include the steps to identify code status, administering CPR, duration of CPR, when to begin, and appropriate cessation. Interview with the Staff Coordinator on [DATE] at 11:57 AM, revealed she helped revise the care plan to ensure it included the steps to identify code status, administering CPR, duration of CPR, when to begin, and appropriate cessation. 4. Review of he Employee Emergency Contact Report revealed all but eleven employees names were crossed off indicating the had received education and testing related to CPR on [DATE]. The eleven (11) employees names not crossed off were either PRN (as needed), on vacation or on medical leave. Further review revealed the tests the staff had completed at the time of education. Interviews on [DATE] with SRNA #6 at 8:55 AM, SRNA #7 at 9:02 AM, SRNA #8 at 9:06 AM, Kentucky Medication Aide (KMA) #2 at 9:11 AM, Nurse Aide (NA) #1 at 9:18 AM, LPN #5 at 9:34 AM, the Housekeeping Supervisor at 9:40 AM, Maintenance Assistant at 9:45 AM, Dietary Aide #1 at 9:51 AM, LPN #1 at 9:33 AM, Physical Therapy Assistant #1 at 9:57 AM, SRNA #9 at 1:50 PM, SRNA #10 at 1:55 PM, SRNA #11 at 2:00 PM, SRNA #12 at 2:05 PM, and KMA #3 at 2:06 PM revealed they were inserviced on the revised CPR policy which included the steps to identify code status, administering CPR, duration of CPR, when to begin, and appropriate cessation. They stated they also had to take a test after the inservice. Interview with the Administrator on [DATE] at 10:30 AM, revealed the eleven (11) staff who did not receive the education or test would be educated and tested prior to working the floor when they returned to work. 5. Review of the Licensed Nurse Orientation and SRNA Orientation Checklists revealed the CPR procedure to include equipment, full code indicators, where to find full codes, and the CPR policy were added to the checklists on [DATE]. Interview with the Staff Coordinator on [DATE] at 11:AM revealed she assisted with adding the CPR information to the Orientation check lists. Interview with the facility's LPN/CPR Instructor on [DATE] at 12:48 PM, revealed she added more details in the orientation education to include how to tell if a resident was full code; CPR equipment; and, location of the equipment. 6. Review of the Baseline Care Plan policy last revised [DATE] revealed it was revised to include the Social Worker will enter code status on baseline care plan. Interview with the Staff Coordinator on [DATE] at 11:57 AM revealed she revised the Baseline Care Plan policy to include that the Social Worker will enter code status on the baseline care plan. 7. Review of the Care Plan-Comprehensive Person-Centered policy, last revised [DATE], revealed it was revised to include that the Social Worker will enter code status on the resident's comprehensive care plan. Interview with the Staff Coordinator on [DATE] at 11:57 AM revealed she revised the Comprehensive Care Plan policy to include that the Social Worker will enter the resident's code status on the Comprehensive Care Plan. 8. Interview with the Staff Coordinator on [DATE] at 11:57 AM, revealed she went into the computer Point Click Program and added an area for the Code status to be addressed on the Nurse Aide Kardexes and completed a mass printing of the kardexes. 9. Review of the Point Click System on [DATE], for each resident revealed each resident's code status was on the physician's orders [REDACTED].>Interview with the Social Worker on [DATE] at 12:09 PM revealed she went into the electronic records and ensured each resident's physician's orders [REDACTED]. 10. Interview with the Social Worker on [DATE] at 12:09 PM revealed she ensured all residents that were a full code had a blue dot on the name plates next to their names outside of their door and a blue strip under the light over their bed. 11. Interview with the Medical Director on [DATE] at 2:10 PM revealed he was aware and involved with the plan put in place to correct the deficient practice related to staff not providing CPR to a full code resident. He stated he thought the plan the facility put in place would be effective to ensure this would not happen again. Review of the Mock Survey Form revealed CPR drills were conducted on [DATE], by the LPN/CPR Instructor on the East Wing at 3:00 PM and on the West Wing at 1:45 PM and again on [DATE], on night shift with education provided by the LPN/CPR instructor. Interview with the CPR Instructor on [DATE] at 12:48 PM, revealed she was conducting mock drills on each shift once a week. She stated she was also providing education to the staff at the time of the mock drills. Interviews on [DATE] with SRNA #6 at 8:55 AM, SRNA #8 at 9:06 AM, and LPN #1 at 9:33 AM revealed they had participated in a mock drill in the last week. 12. Interview with LPN #1 on [DATE] at 9:33 AM revealed she was on the PIP Team and she provided the questions to staff and reviewed them to ensure staff were aware of what to do if a resident was a full code and was found with no respirations and pulse. She stated this would be completed with ten (10) staff, once a week. 13. Interview with SRNA #12 on [DATE] at 2:05 PM, revealed she checked to ensure all Kardex files had the appropriate code status. She stated this would be completed weekly. Review of the Point Click System on [DATE], for each resident revealed each resident's code status was on the Nurse Aide Kardex. 14. Interview with Dietary Aide #2 on [DATE] at 12:23 PM revealed she was added to the PIP Team and would be monitoring once a week to ensure a blue dot was next to the name of the resident outside his/her room door; and, blue tape was over the bed under the light, if the resident was a full code. Tour of the facility on [DATE] revealed all full code residents had a blue dot next to their name on the name plate just outside the room door and a strip of blue tape was below the light above the resident's bed. 15. Interview with the Staff Coordinator and PIP Leader on [DATE] at 12:09 PM, revealed the RN Charge Nurse was responsible for reviewing the Comprehensive Care Plans and the LPN Restorative Nurse was responsible for reviewing the Baseline Care Plans. This was being done once a week to ensure the care plans contained the resident's code status. Review of the Point Click System on [DATE], for each resident revealed each resident's code status was on the Comprehensive Care Plan/Baseline Care Plans.

Based on interview, record review and review of the American Red Cross (ARC) (YEAR) Cardiopulmonary Resuscitation (CPR) Guidelines, it was determined the facility failed to provide CPR per professional standards of practice for one (1) of four (4) sampled residents. Resident #1 had a Care Directive to receive CPR if found without pulse/respirations on [DATE]. However, the staff who were CPR certified failed to provide CPR per professional standards of practice on [DATE] at approximately 6:19 AM when the resident was found with no pulse and not breathing. The facility's failure to ensure Resident #1 was provided CPR per professional standards of practice has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) was identified on [DATE] and determined to exist on [DATE], An acceptable Credible Allegation of Compliance (A[NAME]), was received on [DATE]. The State Survey Agency validated the AoC and determined Immediate Jeopardy was removed on [DATE]. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the CPR Certification Headquarters Online CPR Certification and Training Center (YEAR) American Red Cross (ARC) CPR Guidelines revealed to have the best chance of recovering from a [MEDICAL CONDITION] the ARC advises that individuals should follow the Cardiac Chain of Survival. The chain starts with early recognition of [MEDICAL CONDITION] and immediately upon recognition activation of Emergency Medical Services with a rapid response from them. The second link in the chain is CPR provided by those on scene with the victim immediately at the time of collapse. The third link is early defibrillation, when appropriate, by quick use of an AED (Automated External Defibrillator) by bystanders. The final link is early advanced care as provided by Emergency Medical Services (EMS) and then a hospital with the capability of correcting the problem which led to the [MEDICAL CONDITION]. Review of American Red Cross Certificates of Completion revealed Registered Nurse (RN) #1 received his/her CPR Certification on [DATE]; Licensed Practical Nurse (LPN) #1 on [DATE]; LPN #4 on [DATE]; and, State Registered Nurse Aide (SRNA) #1 on [DATE]. Further review revealed the certifications were valid for two (2) years. Closed record review revealed the facility admitted Resident #1 on [DATE] for Rehabilitation Services with [DIAGNOSES REDACTED]. Review of the Resident #1's Directive of Care dated [DATE], revealed the resident chose to receive CPR in the event of cardiac or respiratory arrest and both the resident and responsible party signed it. Review of the facility's video recording revealed on [DATE] at 5:12 AM the light above Resident #1's door was flashing and LPN #4 entered Resident #1's room and exited at 5:15 AM. The call light above door continued to flash until SRNA #1 was observed to enter Resident #1's room at 6:19 AM. SRNA #1 then exited the room swiftly going down the hall towards the nursing station. Then SRNA #1, LPN #1, LPN #4 and Registered Nurse (RN) #1 walked up the hall and entered Resident #1's room. Review of Resident #1's Progress Note dated [DATE] at 6:00 AM, revealed SRNA #1 notified the nurse she thought Resident #1 had passed away and the resident needed to be examined. The nurse examined the resident and the resident felt cold to touch, eyes were staring straight ahead at ceiling, and there were no cardinal signs of life (no blood pressure, pulse). However, the staff did not initiate CPR, call EMS and continue CPR until the resident was revived or EMS arrived and took over care, per professional standards of practice. Interviews on [DATE] with SRNA #1 at 2:25 PM, LPN #1 at 2:15 PM, and RN #1 at 2:50 PM; and interview on [DATE] with LPN #4 at 9:55 AM revealed they were CPR certified and they should have initiated CPR on Resident #1, called EMS, and continued CPR until the resident was revived or EMS arrived to take over care. LPN #1 stated she left the room after LPN #4 and RN #1 entered behind her. RN #1 stated LPN #4 was the Charge Nurse on duty and it was her call. LPN #4 stated she was in shock and once she identified the resident was deceased she went to the nurses' desk to call the coroner. Interview with the facility's LPN/CPR Instructor on [DATE] at 12:48 PM revealed the staff should have immediately started CPR on Resident #1 since he/she was a full code and called EMS. She stated then they should have continued CPR until the resident was revived or EMS arrived to take over care. Interview with the Director of Nursing (DON) on [DATE] at 4:19 PM revealed she determined SRNA #1, LPN #1, LPN #4 and RN #1 failed to provide CPR per professional standards of practice. She stated all staff were CPR Certified and were educated to immediately start CPR if a full code resident was found with no respirations/pulse. She stated someone should have called EMS and then staff should have continued CPR until the resident was revived or EMS arrived to take over care. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. The DON verbally reeducated SRNA #1, RN #1, LPN #1, and LPN #4 on [DATE] on the facility's CPR policy which included that CPR should be started immediately by staff if the resident is a full code and must continue until EMS arrives and takes over. The DON issued Final Warnings of employment, to SRNA #1, RN #1, LPN #1, and LPN #4. 2. The Administrator removed Charge Nurse, LPN #4, from employment on [DATE]. 3. The LPN/Educational Coordinator and LPN/Restorative Nursing Supervisor revised the facility's CPR policy to include steps to identify code status, administering CPR, duration of CPR, when to begin, and appropriate cessation. 4. The facility's Administrator educated all staff on the new CPR policy on [DATE] and tested on understanding of the CPR policy. Staff members not present will be provided the new policy upon arrival to work for immediate review and tested for understanding by the Charge Nurse or Administrator. 5. The CPR policy education will be provided to all new hires by the LPN/CPR Instructor during New Hire Orientation and will be reviewed annually with all employees. The facility's Licensed Nurse Orientation form and the SRNA Orientation form were updated by the LPN/Education Coordinator, on [DATE] to include the CPR policy. 6. On [DATE], the RN Supervisor and the LPN-Education Coordinator, revised the Policy for Baseline Care plans to include that the Social Worker was responsible to include code status entry. A printed copy of the baseline care plan will be provided to care givers. 7. On [DATE], the RN Supervisor, the LPN-Education Coordinator, and the LPN/Minimum Data Set (MDS) Nurse, updated the Comprehensive Care Plan policy procedures to ensure continued disclosure of code status for residents as entered by the Social Worker. 8. On [DATE], the LPN/Educational Coordinator, updated the Nurse Aide Kardex, plan of care information to include code status. 9. On [DATE], the Social Worker reviewed all the residents' electronic charts and verified there were physician orders [REDACTED]. In addition, on [DATE] and [DATE], the Social Worker reviewed each resident's Comprehensive Care Plan via electronic record to assure all resident comprehensive care plans clearly disclosed appropriate Code Status. 10. On [DATE], the Social Worker visually verified, comparing physician orders [REDACTED]. She also verified that all full code residents had the appropriate identifying blue line under the bed light above the resident's bed. 11. On [DATE], the Performance Improvement Plan (PIP) was developed by the LPN/Educational Coordinator, The PIP verification of understanding of the CPR policy will include mock drills weekly, one on each shift, for the next quarter. Upon conclusion of the PIP, the PIP team will recommend the frequently for future mock CPR drills. The LPN/CPR Instructor will conduct the mock drills and evaluate staff performance. 12. The PIP will monitor understanding by giving ten (10) written questions exam per week by the RN/Charge Nurse and LPN/Medication Nurse regarding code status and how to perform CPR and grade for correct responses for the next quarter. 13. PIP Team members (2 {two} SRNAs) will visually review all Kardex files for appropriate code status weekly for the next quarter. 14. PIP Team members from Dietary and Housekeeping will visually check name plates and above bed lights for appropriate Code Status designation from all residents' Code Status list for next quarter. 15. RN/Charge Nurse will monitor all Comprehensive Care Plans weekly for Code Status by Physician order [REDACTED]. **The State Survey Agency validated the corrective action taken by the facility as follows: 1. Review of Incident/Employee Noncompliance with facility policy forms dated [DATE], revealed SRNA #1's, LPN #1's, LPN #4's and RN #1's final warning and education due to failing to start CPR on a full code resident when found cool to touch and no signs of life. The staff were educated that CPR should be started immediately on a resident that is a full code and must continue until EMS arrives to take over. The forms were signed by each staff and the DON. Interviews on [DATE] with SRNA #1 at 2:25 PM, LPN #1 at 2:15 PM, RN #1 at 2:55 PM; and interview on [DATE] at 9:55 AM with LPN #4, revealed they received education and a final warning on [DATE] due to their failure to provide CPR when Resident #1, who was a full code, was found with no respirations or pulse. 2. Review of a Office Memo form revealed LPN #4 was terminated on [DATE] and it was signed by the Administrator. Review of the Employee Timecard Report revealed LPN #4's last day worked was [DATE]. 3. Review of the CPR Policy last revised [DATE], revealed the policy was revised to include the steps to identify code status, administering CPR, duration of CPR, when to begin, and appropriate cessation. Interview with the Staff Coordinator on [DATE] at 11:57 AM, revealed she helped revise the care plan to ensure it included the steps to identify code status, administering CPR, duration of CPR, when to begin, and appropriate cessation. 4. Review of he Employee Emergency Contact Report revealed all but eleven employees names were crossed off indicating the had received education and testing related to CPR on [DATE]. The eleven (11) employees names not crossed off were either PRN (as needed), on vacation or on medical leave. Further review revealed the tests the staff had completed at the time of education. Interviews on [DATE] with SRNA #6 at 8:55 AM, SRNA #7 at 9:02 AM, SRNA #8 at 9:06 AM, Kentucky Medication Aide (KMA) #2 at 9:11 AM, Nurse Aide (NA) #1 at 9:18 AM, LPN #5 at 9:34 AM, the Housekeeping Supervisor at 9:40 AM, Maintenance Assistant at 9:45 AM, Dietary Aide #1 at 9:51 AM, LPN #1 at 9:33 AM, Physical Therapy Assistant #1 at 9:57 AM, SRNA #9 at 1:50 PM, SRNA #10 at 1:55 PM, SRNA #11 at 2:00 PM, SRNA #12 at 2:05 PM, and KMA #3 at 2:06 PM revealed they were inserviced on the revised CPR policy which included the steps to identify code status, administering CPR, duration of CPR, when to begin, and appropriate cessation. They stated they also had to take a test after the inservice. Interview with the Administrator on [DATE] at 10:30 AM, revealed the eleven (11) staff who did not receive the education or test would be educated and tested prior to working the floor when they returned to work. 5. Review of the Licensed Nurse Orientation and SRNA Orientation Checklists revealed the CPR procedure to include equipment, full code indicators, where to find full codes, and the CPR policy were added to the checklists on [DATE]. Interview with the Staff Coordinator on [DATE] at 11:AM revealed she assisted with adding the CPR information to the Orientation check lists. Interview with the facility's LPN/CPR Instructor on [DATE] at 12:48 PM, revealed she added more details in the orientation education to include how to tell if a resident was full code; CPR equipment; and, location of the equipment. 6. Review of the Baseline Care Plan policy last revised [DATE] revealed it was revised to include the Social Worker will enter code status on baseline care plan. Interview with the Staff Coordinator on [DATE] at 11:57 AM revealed she revised the Baseline Care Plan policy to include that the Social Worker will enter code status on the baseline care plan. 7. Review of the Care Plan-Comprehensive Person-Centered policy, last revised [DATE], revealed it was revised to include that the Social Worker will enter code status on the resident's comprehensive care plan. Interview with the Staff Coordinator on [DATE] at 11:57 AM revealed she revised the Comprehensive Care Plan policy to include that the Social Worker will enter the resident's code status on the Comprehensive Care Plan. 8. Interview with the Staff Coordinator on [DATE] at 11:57 AM, revealed she went into the computer Point Click Program and added an area for the Code status to be addressed on the Nurse Aide Kardexes and completed a mass printing of the kardexes. 9. Review of the Point Click System on [DATE], for each resident revealed each resident's code status was on the physician's orders [REDACTED].>Interview with the Social Worker on [DATE] at 12:09 PM revealed she went into the electronic records and ensured each resident's physician's orders [REDACTED]. 10. Interview with the Social Worker on [DATE] at 12:09 PM revealed she ensured all residents that were a full code had a blue dot on the name plates next to their names outside of their door and a blue strip under the light over their bed. 11. Interview with the Medical Director on [DATE] at 2:10 PM revealed he was aware and involved with the plan put in place to correct the deficient practice related to staff not providing CPR to a full code resident. He stated he thought the plan the facility put in place would be effective to ensure this would not happen again. Review of the Mock Survey Form revealed CPR drills were conducted on [DATE], by the LPN/CPR Instructor on the East Wing at 3:00 PM and on the West Wing at 1:45 PM and again on [DATE], on night shift with education provided by the LPN/CPR instructor. Interview with the CPR Instructor on [DATE] at 12:48 PM, revealed she was conducting mock drills on each shift once a week. She stated she was also providing education to the staff at the time of the mock drills. Interviews on [DATE] with SRNA #6 at 8:55 AM, SRNA #8 at 9:06 AM, and LPN #1 at 9:33 AM revealed they had participated in a mock drill in the last week. 12. Interview with LPN #1 on [DATE] at 9:33 AM revealed she was on the PIP Team and she provided the questions to staff and reviewed them to ensure staff were aware of what to do if a resident was a full code and was found with no respirations and pulse. She stated this would be completed with ten (10) staff, once a week. 13. Interview with SRNA #12 on [DATE] at 2:05 PM, revealed she checked to ensure all Kardex files had the appropriate code status. She stated this would be completed weekly. Review of the Point Click System on [DATE], for each resident revealed each resident's code status was on the Nurse Aide Kardex. 14. Interview with Dietary Aide #2 on [DATE] at 12:23 PM revealed she was added to the PIP Team and would be monitoring once a week to ensure a blue dot was next to the name of the resident outside his/her room door; and, blue tape was over the bed under the light, if the resident was a full code. Tour of the facility on [DATE] revealed all full code residents had a blue dot next to their name on the name plate just outside the room door and a strip of blue tape was below the light above the resident's bed. 15. Interview with the Staff Coordinator and PIP Leader on [DATE] at 12:09 PM, revealed the RN Charge Nurse was responsible for reviewing the Comprehensive Care Plans and the LPN Restorative Nurse was responsible for reviewing the Baseline Care Plans. This was being done once a week to ensure the care plans contained the resident's code status. Review of the Point Click System on [DATE], for each resident revealed each resident's code status was on the Comprehensive Care Plan/Baseline Care Plans.

Based on interview, record review, and facility policy review it was determined the facility failed to develop a baseline care plan that included the Physician order [REDACTED].#1). Resident #1 was admitted to the facility on [DATE] with Physician order [REDACTED].{CPR} if found with no pulse or respirations). However, review of the Baseline Care Plan, dated [DATE], revealed the care plan did not address the resident's code status. On [DATE], staff found Resident #1 with no respirations or pulse and failed to provide CPR. The facility's failure to include Resident #1's code status on the baseline care plan has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) was identified on [DATE] and determined to exist on [DATE], An acceptable Credible Allegation of Compliance (A[NAME]), was received on [DATE]. The State Survey Agency validated the AoC and determined Immediate Jeopardy was removed on [DATE]. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy titled, Care Plans, not dated revealed staff should assess the resident upon admission and initiate a temporary plan of care, for the key problems or possible problems identified. Closed record review revealed the facility admitted Resident #1 on [DATE] with diagnoses, which included Non-displaced Intertrochanteric Fracture; and, pain right hip, to receive rehabilitation services. Review of Resident #1's Directive of Care dated [DATE], revealed the resident chose to receive CPR in the event of cardiac or respiratory arrest (Full Code) and both the resident and responsible party signed it. In addition, review of the physician's orders [REDACTED].#1 was a Full Code. However, review of Resident #1's Baseline Care Plan initiated [DATE], revealed the care plan did not address the resident's code status. Review of a Nursing Progress Note dated [DATE] at 6:00 AM, and interviews on [DATE] with State Registered Nurse Aide (SRNA) #1 at 2:25 PM, Licensed Practical Nurse (LPN) #1 at 2:15 PM, and Registered Nurse (RN) #1 at 2:50 PM; and on [DATE] with LPN #4 at 9:55 AM revealed SRNA #1 found Resident #1 laying across the bed on his/her back with his/her eyes staring at the ceiling and unresponsive. SRNA #1 ran up the hall calling for the nurse. SRNA #1, LPN #1, LPN #4 and RN #1 entered the room and LPN #4 assessed the resident and determined the resident had no respirations or pulse and was cold to touch. However; SRNA #1, LPN #1, LPN #4 and RN #1 failed to initiate CPR per the resident's Code Status. Interview with the Minimum Data Set (MDS) Coordinator on [DATE] at 12:58 PM, revealed it was the Social Worker's responsibility to ensure the resident's code status was on the Baseline Care Plan. Interview with the Social Worker (SW) on [DATE] at 10:20 PM revealed Resident #1's Code Status had not been placed on the Baseline care plan because he/she had only been at the facility for thirty-six (36) hours. She stated it was her responsibility to place the code status on the care plan. Interview with the Director of Nursing (DON) on [DATE] at 4:19 PM revealed Resident #1's code status should have been on the baseline care plan. She stated the code status should have been placed on the baseline care plan right away. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. The DON verbally reeducated SRNA #1, RN #1, LPN #1, and LPN #4 on [DATE] on the facility's CPR policy which included that CPR should be started immediately by staff if the resident is a full code and must continue until EMS arrives and takes over. The DON issued Final Warnings of employment, to SRNA #1, RN #1, LPN #1, and LPN #4. 2. The Administrator removed Charge Nurse, LPN #4, from employment on [DATE]. 3. The LPN/Educational Coordinator and LPN/Restorative Nursing Supervisor revised the facility's CPR policy to include steps to identify code status, administering CPR, duration of CPR, when to begin, and appropriate cessation. 4. The facility's Administrator educated all staff on the new CPR policy on [DATE] and tested on understanding of the CPR policy. Staff members not present will be provided the new policy upon arrival to work for immediate review and tested for understanding by the Charge Nurse or Administrator. 5. The CPR policy education will be provided to all new hires by the LPN/CPR Instructor during New Hire Orientation and will be reviewed annually with all employees. The facility's Licensed Nurse Orientation form and the SRNA Orientation form were updated by the LPN/Education Coordinator, on [DATE] to include the CPR policy. 6. On [DATE], the RN Supervisor and the LPN-Education Coordinator, revised the Policy for Baseline Care plans to include that the Social Worker was responsible to include code status entry. A printed copy of the baseline care plan will be provided to care givers. 7. On [DATE], the RN Supervisor, the LPN-Education Coordinator, and the LPN/Minimum Data Set (MDS) Nurse, updated the Comprehensive Care Plan policy procedures to ensure continued disclosure of code status for residents as entered by the Social Worker. 8. On [DATE], the LPN/Educational Coordinator, updated the Nurse Aide Kardex, plan of care information to include code status. 9. On [DATE], the Social Worker reviewed all the residents' electronic charts and verified there were physician orders [REDACTED]. In addition, on [DATE] and [DATE], the Social Worker reviewed each resident's Comprehensive Care Plan via electronic record to assure all resident comprehensive care plans clearly disclosed appropriate Code Status. 10. On [DATE], the Social Worker visually verified, comparing physician orders [REDACTED]. She also verified that all full code residents had the appropriate identifying blue line under the bed light above the resident's bed. 11. On [DATE], the Performance Improvement Plan (PIP) was developed by the LPN/Educational Coordinator, The PIP verification of understanding of the CPR policy will include mock drills weekly, one on each shift, for the next quarter. Upon conclusion of the PIP, the PIP team will recommend the frequently for future mock CPR drills. The LPN/CPR Instructor will conduct the mock drills and evaluate staff performance. 12. The PIP will monitor understanding by giving ten (10) written questions exam per week by the RN/Charge Nurse and LPN/Medication Nurse regarding code status and how to perform CPR and grade for correct responses for the next quarter. 13. PIP Team members (2 {two} SRNAs) will visually review all Kardex files for appropriate code status weekly for the next quarter. 14. PIP Team members from Dietary and Housekeeping will visually check name plates and above bed lights for appropriate Code Status designation from all residents' Code Status list for next quarter. 15. RN/Charge Nurse will monitor all Comprehensive Care Plans weekly for Code Status by Physician order [REDACTED]. **The State Survey Agency validated the corrective action taken by the facility as follows: 1. Review of Incident/Employee Noncompliance with facility policy forms dated [DATE], revealed SRNA #1's, LPN #1's, LPN #4's and RN #1's final warning and education due to failing to start CPR on a full code resident when found cool to touch and no signs of life. The staff were educated that CPR should be started immediately on a resident that is a full code and must continue until EMS arrives to take over. The forms were signed by each staff and the DON. Interviews on [DATE] with SRNA #1 at 2:25 PM, LPN #1 at 2:15 PM, RN #1 at 2:55 PM; and interview on [DATE] at 9:55 AM with LPN #4, revealed they received education and a final warning on [DATE] due to their failure to provide CPR when Resident #1, who was a full code, was found with no respirations or pulse. 2. Review of a Office Memo form revealed LPN #4 was terminated on [DATE] and it was signed by the Administrator. Review of the Employee Timecard Report revealed LPN #4's last day worked was [DATE]. 3. Review of the CPR Policy last revised [DATE], revealed the policy was revised to include the steps to identify code status, administering CPR, duration of CPR, when to begin, and appropriate cessation. Interview with the Staff Coordinator on [DATE] at 11:57 AM, revealed she helped revise the care plan to ensure it included the steps to identify code status, administering CPR, duration of CPR, when to begin, and appropriate cessation. 4. Review of he Employee Emergency Contact Report revealed all but eleven employees names were crossed off indicating the had received education and testing related to CPR on [DATE]. The eleven (11) employees names not crossed off were either PRN (as needed), on vacation or on medical leave. Further review revealed the tests the staff had completed at the time of education. Interviews on [DATE] with SRNA #6 at 8:55 AM, SRNA #7 at 9:02 AM, SRNA #8 at 9:06 AM, Kentucky Medication Aide (KMA) #2 at 9:11 AM, Nurse Aide (NA) #1 at 9:18 AM, LPN #5 at 9:34 AM, the Housekeeping Supervisor at 9:40 AM, Maintenance Assistant at 9:45 AM, Dietary Aide #1 at 9:51 AM, LPN #1 at 9:33 AM, Physical Therapy Assistant #1 at 9:57 AM, SRNA #9 at 1:50 PM, SRNA #10 at 1:55 PM, SRNA #11 at 2:00 PM, SRNA #12 at 2:05 PM, and KMA #3 at 2:06 PM revealed they were inserviced on the revised CPR policy which included the steps to identify code status, administering CPR, duration of CPR, when to begin, and appropriate cessation. They stated they also had to take a test after the inservice. Interview with the Administrator on [DATE] at 10:30 AM, revealed the eleven (11) staff who did not receive the education or test would be educated and tested prior to working the floor when they returned to work. 5. Review of the Licensed Nurse Orientation and SRNA Orientation Checklists revealed the CPR procedure to include equipment, full code indicators, where to find full codes, and the CPR policy were added to the checklists on [DATE]. Interview with the Staff Coordinator on [DATE] at 11:AM revealed she assisted with adding the CPR information to the Orientation check lists. Interview with the facility's LPN/CPR Instructor on [DATE] at 12:48 PM, revealed she added more details in the orientation education to include how to tell if a resident was full code; CPR equipment; and, location of the equipment. 6. Review of the Baseline Care Plan policy last revised [DATE] revealed it was revised to include the Social Worker will enter code status on baseline care plan. Interview with the Staff Coordinator on [DATE] at 11:57 AM revealed she revised the Baseline Care Plan policy to include that the Social Worker will enter code status on the baseline care plan. 7. Review of the Care Plan-Comprehensive Person-Centered policy, last revised [DATE], revealed it was revised to include that the Social Worker will enter code status on the resident's comprehensive care plan. Interview with the Staff Coordinator on [DATE] at 11:57 AM revealed she revised the Comprehensive Care Plan policy to include that the Social Worker will enter the resident's code status on the Comprehensive Care Plan. 8. Interview with the Staff Coordinator on [DATE] at 11:57 AM, revealed she went into the computer Point Click Program and added an area for the Code status to be addressed on the Nurse Aide Kardexes and completed a mass printing of the kardexes. 9. Review of the Point Click System on [DATE], for each resident revealed each resident's code status was on the physician's orders [REDACTED].>Interview with the Social Worker on [DATE] at 12:09 PM revealed she went into the electronic records and ensured each resident's physician's orders [REDACTED]. 10. Interview with the Social Worker on [DATE] at 12:09 PM revealed she ensured all residents that were a full code had a blue dot on the name plates next to their names outside of their door and a blue strip under the light over their bed. 11. Interview with the Medical Director on [DATE] at 2:10 PM revealed he was aware and involved with the plan put in place to correct the deficient practice related to staff not providing CPR to a full code resident. He stated he thought the plan the facility put in place would be effective to ensure this would not happen again. Review of the Mock Survey Form revealed CPR drills were conducted on [DATE], by the LPN/CPR Instructor on the East Wing at 3:00 PM and on the West Wing at 1:45 PM and again on [DATE], on night shift with education provided by the LPN/CPR instructor. Interview with the CPR Instructor on [DATE] at 12:48 PM, revealed she was conducting mock drills on each shift once a week. She stated she was also providing education to the staff at the time of the mock drills. Interviews on [DATE] with SRNA #6 at 8:55 AM, SRNA #8 at 9:06 AM, and LPN #1 at 9:33 AM revealed they had participated in a mock drill in the last week. 12. Interview with LPN #1 on [DATE] at 9:33 AM revealed she was on the PIP Team and she provided the questions to staff and reviewed them to ensure staff were aware of what to do if a resident was a full code and was found with no respirations and pulse. She stated this would be completed with ten (10) staff, once a week. 13. Interview with SRNA #12 on [DATE] at 2:05 PM, revealed she checked to ensure all Kardex files had the appropriate code status. She stated this would be completed weekly. Review of the Point Click System on [DATE], for each resident revealed each resident's code status was on the Nurse Aide Kardex. 14. Interview with Dietary Aide #2 on [DATE] at 12:23 PM revealed she was added to the PIP Team and would be monitoring once a week to ensure a blue dot was next to the name of the resident outside his/her room door; and, blue tape was over the bed under the light, if the resident was a full code. Tour of the facility on [DATE] revealed all full code residents had a blue dot next to their name on the name plate just outside the room door and a strip of blue tape was below the light above the resident's bed. 15. Interview with the Staff Coordinator and PIP Leader on [DATE] at 12:09 PM, revealed the RN Charge Nurse was responsible for reviewing the Comprehensive Care Plans and the LPN Restorative Nurse was responsible for reviewing the Baseline Care Plans. This was being done once a week to ensure the care plans contained the resident's code status. Review of the Point Click System on [DATE], for each resident revealed each resident's code status was on the Comprehensive Care Plan/Baseline Care Plans.

Based on observation, interview, record review, and review of the facility's policy/procedure, it was determined the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for two (2) residents (#7 and #11), in the selected sample of nineteen (19) residents. The facility assessed Resident #7 at high risk for falls requiring a chair pad alarm when up in the wheelchair. Resident #7 sustained a fall, on 07/31/12, resulting in a left intertrochanteric femur fracture requiring surgical intervention. It was determined the residents' chair pad alarm was not in place at the time of the fall but the facility failed to complete a thorough investigation of the fall and develop an action plan to correct the identified concerns. In addition, the facility failed to ensure a construction area in the facility was supervised to prevent residents from being injured. Resident #11 wheeled self into the construction area and caused a ceiling tile to fall and hit him/her in the shin causing a 13.5 centimeters (cm.) by 4 cm. skin tear. Findings include: 1. A review of the Resident Falls Policy/Procedure, undated, revealed after the resident had been carefully assessed for fall risk factors, interventions would be implemented that were individualized, according to the resident's needs. A record review revealed Resident #7 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the initial Minimum Data Set (MDS) assessment, dated 12/27/11, revealed the facility assessed the resident as cognitively intact with a BIMS score of 13 and required extensive assistance with ambulation and transfer. A review of the Fall Risk Assessment, dated 06/06/12, revealed the facility assessed the resident at high risk for falls. A review of the Comprehensive Care Plan and the Nurse Assistant Assignment sheet, dated 06/06/12, revealed staff should place a chair pad alarm to the wheelchair, as a safety intervention from a previous fall. A review of the Fall Investigation Form, dated 07/31/12 at 11:00 AM, revealed Resident #7 sustained a fall in the dining room resulting in left hip pain. Review of the Safety/Alarm Check sheet, dated 07/31/12, revealed Certified Nurse Aide (CNA) #1 initialed she checked the resident's chair pad alarm at 7:30 AM and again at 9:30 AM. An interview with CNA #1, on 03/22/13 at 10:20 AM, revealed the chair pad alarm was in the wheelchair the morning of 07/31/12 per her documentation; however, further review of the fall investigation revealed the chair pad alarm was not in the resident's wheelchair at the time of the fall. An interview with the Dietary Aide, on 03/22/13 at 11:15 AM and 12:50 AM, revealed she witnessed the fall involving Resident #7 on 07/31/12. She was in the kitchen area preparing to serve lunch when she looked up and saw the resident standing behind another resident's wheelchair, attempting to push it; however, she revealed there was no alarm sounding. She stated it was just a few seconds and the resident had fallen in the floor; however, she was unaware of how long he/she had been standing prior to the fall. An interview with the Business Manager, on 03/22/13 at 1:45 PM, revealed her office was directly across from the dining room. She was in her office on 07/31/12 and vaguely remembered when Resident #7 fell . She stated that she would have responded if an alarm sounded; however, she verified there was no alarm sounding prior to the fall. An interview with Licensed Practical Nurse (LPN) #1, on 03/22/13 at 10:30 AM and 1:35 PM, revealed she was the nurse for Resident #7 on 07/31/12. She completed the Fall Investigation Form and documented the chair pad alarm was not in the wheelchair at the time of the fall. Although she could not remember details of the incident, she verified if it was documented, it was true. She revealed the CNAs were supposed to ensure the alarms were in the chair when getting a resident out of bed. She was responsible for monitoring staff to ensure alarms were in place and functioning; however, she "apparently" did not check the resident's alarm on 07/31/12, or would have questioned why it was not in place. An interview with the Director of Nursing (DON), on 03/22/13 at 2:50 PM, revealed while the CNA was responsible for documentation of the alarm, it was also the nurse's responsibility to monitor placement and functioning of alarms. A review of the Nurse's Note, dated 07/31/12 at 11:30 AM, revealed the resident was transported to the emergency room for evaluation and treatment. A review of the emergency room Record, dated 07/31/12 at 12:06 PM, revealed the clinical impression in the emergency room included acute pain with a left intertrochanteric hip fracture and left femoral neck hip fracture. A review of the Radiology Report, dated 07/31/12, revealed the x-ray of the left hip and femur indicated a minimally displaced left femoral intertrochanteric fracture. Review of the Surgical Department Report, dated 08/02/12, revealed the resident had an open reduction and internal fixation of the intertrochanteric femur fracture. A record review revealed the resident was readmitted to the facility on [DATE]. A review of the Resident Falls Policy/Procedure, undated, revealed as soon as possible, a complete and thorough investigation would be completed to determine contributory causes for the fall and what other actions needed to be completed to minimize the potential for a future fall. Further review of the Fall Investigation Form, dated 07/31/12, revealed the facility failed to complete a thorough investigation of the fall involving Resident #7 on 07/31/12 at 11:00 AM. The investigation indicated the chair pad alarm was not in the resident's wheelchair at the time; however, did not indicate an action plan to correct the identified concern. The investigation did not indicate a root cause of the resident's fall. An interview with LPN #2, on 03/22/13 at 2:15 PM, revealed she was responsible for reviewing the fall investigation reports for completion and accuracy. She verified there was no documented interviews of the CNAs working on the unit with Resident #7 on 07/31/12. She was aware the chair pad alarm did not sound during the fall; however, she could not provide any documented evidence this was discussed at the time of the fall. She revealed an in-service was scheduled to discuss alarms. A review of the Mandatory Nursing Staff Meeting, dated 08/10/12, revealed "Alarms" were discussed during the meeting, ten days after the fall; however, it did not detail the content of the meeting. An interview with the Registered Nurse (RN) Unit Manager, on 03/22/13 at 2:00 PM, revealed she was not aware, but should have been notified about the resident's missing chair pad alarm on 07/31/12. She stated she would have educated the staff at that time; however, did not have the information. She did not review the fall investigation report as it was the responsibility of LPN #2. An interview with the DON, on 03/22/13 at 2:50 PM, revealed she was not aware of the issue with the chair pad alarm at the time of the fall. She stated "Honestly, I did not know for awhile." She expected the nurse to make her aware of the situation so the staff involved could be educated immediately. She could not provide content of the mandatory meeting on 08/10/12, related to alarm use. She further revealed LPN #2 was responsible for ensuring the fall investigations were completed accurately, including interviews with all staff or residents involved; however, she verified the fall investigation for Resident #7 was not thorough. 2. A review of the facility's policy for Safe Environment, undated, revealed "All work areas should be secure with safety equipment to assure the protection of employees, contractors,visitors and residents". A record review revealed Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the quarterly MDS assessment, dated 03/18/13, revealed the facility had assessed Resident #11 with a BIMS score of 3 revealing severe cognitive impairment and he/she required extensive assistance with transfers and activities of daily living and was nonambulatory. Observation on 03/19/13 at 3:05 PM and on 03/20/13 at 9:30 AM, 10:30 AM, 11:30 AM and 1:45 PM revealed the resident was in the hall area and/or dining room seated in a Broda chair with an alarming seatbelt. No reliable information could be obtained from Resident #11 due to the resident's impaired cognitive status. A review of the Nurse's Note, dated 10/12/12 at 1:50 PM, revealed Resident #11 propelled self in Broda chair into a construction area. A ceiling tile fell hitting the resident on the left shin causing a 13.5 cm by 4 cm skin tear. A review of an accident/incident report, dated 10/12/12 at 1:50 PM, revealed the resident had propelled self into construction area at nursing station and a ceiling tile fell and hit the resident's left shin. The section of the accident/incident report, titled "Results of Investigation" revealed "Someone is to be monitoring all construction areas". An interview with LPN #3, on 03/20/13 at 2:40 PM, revealed she was on duty on 10/12/12 and remembered when the ceiling tile fell and injured Resident #11's leg. She stated a telephone man had been installing a line or something and the area was not secured as he did not rope off the area. She stated the injury looked bad and the telephone man felt terrible. An interview with the DON, on 03/21/13 at 1:30 PM, revealed that outside contractors were to check in with maintenance so work could be monitored for resident safety but she did not recall what the circumstances were at the time of the incident. An interview with Maintenance Director, on 03/22/13 at 9:30 AM, revealed the contractors usually stopped and checked in at the front door; however, he was not familiar with the incident involving Resident #11. An interview with a Unit Manager, on 03/21/13 at 4:40 PM, revealed she recalled Resident #11 had wheeled self into the ladder the contractor was using and the ceiling tile that was sitting on the ladder fell and hit him/her on the leg. An interview with the Administrator, on 03/21/13 at 1:50 PM, revealed staff was made aware on more than one occasion that someone was to help secure any area where work was going on and that area should have been secured and was not.

Based on observation, interview, record review, and review of the facility's policy/procedure, it was determined the facility failed to ensure services were provided by qualified persons in accordance with each resident's written plan of care for two (2) residents (#7 and #11), in the selected sample of nineteen (19) residents. Resident #7 was care planned for a chair pad alarm to the wheelchair as a safety intervention from a previous fall. The resident sustained [REDACTED]. It was determined the chair pad alarm was not in place at the time of the fall to alert staff Resident #7 was attempting to rise. Resident #11 was care planned to have skin sleeves applied to the upper extremities while in the chair; however, observations revealed this intervention was not implemented. Findings include: A review of the Resident Falls Policy/Procedure, undated, revealed once a resident had been identified as being at risk for falling and interventions implemented to minimize the risk, everything would be documented in the resident's chart. The resident's care plan would list all interventions that were used to minimize the potential for a fall. All direct care staff would need to know what interventions were needed to prevent an occurrence. A written assignment sheet was implemented monthly to alert direct care staff. A record review revealed Resident #7 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the initial Minimum Data Set (MDS) assessment, dated 12/27/11, revealed the facility assessed Resident #7 with a BIMS score of 13 revealing he/she was cognitively intact and required extensive assistance with ambulation and transfer. A review of the Fall Incident Investigation, dated 03/22/12, revealed the facility assessed the resident as needing a chair pad alarm to the wheelchair after a fall in the dining room. A review of the Fall Risk Assessment, dated 06/06/12, revealed the facility assessed the resident at high risk for falls. A review of the Comprehensive Care Plan and Nurse Assistant Assignment sheet, dated 06/06/12, revealed staff should place a chair pad alarm to the wheelchair. A review of the Fall Investigation Form, dated 07/31/12 at 11:00 AM, revealed Resident #7 sustained a fall in the dining room resulting in left hip pain. Review of the Safety/Alarm Check sheet, dated 07/31/12, revealed Certified Nurse Aides (CNA) #1 initialed she checked the resident's chair pad alarm at 7:30 AM and again at 9:30 AM. An interview with CNA #1, on 03/22/13 at 10:20 AM, revealed the chair pad alarm was in the wheelchair the morning of 07/31/12 per her documentation; however, further review of the fall investigation revealed the chair pad alarm was not in the resident's wheelchair at the time of the fall. An interview with the Dietary Aide, on 03/22/13 at 11:15 AM and 12:50 AM, revealed she witnessed the fall involving Resident #7 on 07/31/12. She was in the kitchen area preparing to serve lunch when she looked up and saw the resident standing behind another resident's wheelchair, attempting to push it; however, she revealed there was no alarm sounding. She stated it was just a few seconds and the resident had fallen in the floor; however, she was unaware of how long he/she had been standing prior to the fall. An interview with the Business Manager, on 03/22/13 at 1:45 PM, revealed her office was directly across from the dining room. She was in her office on 07/31/12 and vaguely remembered when Resident #7 fell . She stated that she would have responded if an alarm sounded; however, she verified there was no alarm sounding prior to the fall. An interview with Licensed Practical Nurse (LPN) #1, on 03/22/13 at 10:30 AM and 1:35 PM, revealed she was the nurse for Resident #7 on 07/31/12. She completed the Fall Investigation Form and documented the chair pad alarm was not in the wheelchair at the time of the fall. Although she could not remember details of the incident, she verified if it was documented, it was true. She revealed the CNAs were supposed to ensure the alarms were in the chair when getting a resident out of bed. She was responsible for monitoring staff to ensure alarms were in place and functioning; however, she "apparently" did not check the resident's alarm on 07/31/12, or would have questioned why it was not in place. An interview with the Director of Nursing (DON), on 03/22/13 at 2:50 PM, revealed while the CNA was responsible for documentation of the alarm, it was also the nurse's responsibility to monitor placement and functioning of alarms. She expected the CNA to follow the resident's care plan to ensure the chair pad alarm was in place and functioning. A review of the Nurse's Note, dated 07/31/12 at 11:30 AM, revealed the resident was transported to the emergency room for evaluation and treatment. A review of the emergency room Record, dated 07/31/12 at 12:06 PM, revealed the clinical impression in the emergency room included acute pain with a left intertrochanteric [MEDICAL CONDITION] and left femoral neck [MEDICAL CONDITION]. A review of the Radiology Report, dated 07/31/12, revealed the x-ray of the left hip and femur indicated a minimally displaced left femoral intertrochanteric fracture. Review of the Surgical Department Report, dated 08/02/12, revealed the resident had an open reduction and internal fixation of the intertrochanteric femur fracture. A record review revealed the resident was readmitted to the facility on [DATE]. 2. A record review revealed Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the quarterly MDS assessment, dated 03/18/13, revealed the facility had assessed Resident #11 with a BIMS score of 3 revealing severe cognitive impairment and he/she required extensive assistance with transfers and activities of daily living and was nonambulatory. A review of Resident #11's Comprehensive Care Plan, titled "Potential for Alteration in Skin Integrity", dated 01/03/13, revealed an intervention for staff to apply skin sleeves to the upper extremities when the resident was in the chair. A review of the Nurse's Assistant Assignment sheet, dated 03/01/13, revealed Resident #11 was to have protective skin sleeves while up in the Broda chair. Observations on 03/19/13 at 3:05 PM and on 03/20/13 at 9:30 AM, 10:30 AM, 11:30 AM and 1:45 PM revealed the resident in the hall area and/or dining room seated in a Broda chair. The resident's bilateral forearms were visible as there were no protective sleeves on the resident's arms. There were multiple discolored areas that were visible on the resident's right forearm. Interview was attempted with each observation; however, due to the resident's impaired cognitive status, he/she could not provide any reliable information. Observation on 03/20/13 at 2:30 PM, during a skin assessment performed by LPN #3 and Registered Nurse (RN) #2 revealed Resident #11 had two areas of bruising to the right forearm. One area was 6 centimeters (cm) by 4 cm and was purple and red with yellow around the perimeter. The other area was irregular shaped with a 3 cm by 3 cm by 2.7 cm and was purple and blue. An interview with Certified Nurse Aide (CNA) #4, on 03/20/13 at 1:45 PM revealed she was providing care for Resident #11 on this date and revealed she had not put protective sleeves on Resident #11 and had not seen the resident with protective sleeves in a long time. CNA #4 verified an intervention on the Nurse Assistant Assignment sheet included "Skin Sleeve on upper extremities while up in Broda chair". An interview with CNA #5, on 03/20/13 at 1:50 PM, revealed she was not aware the resident was to have protective sleeves on the arms. An interview and observation on 03/20/13 at 2:30 PM with the DON verified Resident #11 did not have the protective sleeves in place and she expected the staff to ensure those protective sleeves were in place as per the resident's care plan. Furthermore, she stated it was the Nurses' responsibility to ensure placement.

Based on observation, interview, record review and review of the facility's policy and procedure, it was determined the facility failed to ensure eight (8) residents (#2, #5, #8, #9, #10, #12, #14, and #16), in the selected sample of seventeen (17) residents, were provided sufficient fluid intake to maintain proper hydration. Additionally, the facility failed to monitor the 24 hour total fluids ingested and intervene prior to Resident #8 being hospitalized for [REDACTED]. The resident was admitted to the hospital, on 12/12/11, with [DIAGNOSES REDACTED]. However, even after returning from the hospital with these diagnoses, the facility failed to monitor the 24 hour fluid intake and ensure the requirements were met. Findings include: A review of the facility's policy and procedure, "Hydration Fluid Intake Policy," dated 08/05/09, revealed each resident's fluid requirement would have been determined at the time of admission by the Dietary Supervisor or the physician order. Fluid intake would have been documented each 24 hour period and totaled to include meals, snacks, medication pass, and activity functions. Staff members were to be alert for signs and symptoms to immediately report, such as decreased or absent urine output, decreased tears or complaints of dry eyes, dry chapped lips, tongue dryness, substantial muscle wasting, and sunken eyes or [MEDICAL CONDITION]. Expected outcomes, in providing adequate hydration, included decreased infections, decreased constipation and decreased acute confusion. 1. A record review revealed the facility admitted Resident #8 on 10/06/11, and was re-admitted on [DATE], with [DIAGNOSES REDACTED]. Upon the resident's first admission to the facility, the resident's lab values, which determined kidney function, were within normal limits, and blood tests revealed a test for Blood, Urea, Nitrogen (BUN) of 15 (normal value 7-18 mg/dl) and a Creatinine level of 0.8 (normal value 0.8-1.4 mg/dl.) On 12/12/11, the facility transferred Resident #8 to the local hospital having symptoms of confusion, weakness and difficulty responding to verbal and tactile stimuli. The BUN, at the hospital, was 59 mg/dl and Creatinine level was 1.69 mg/dl. The resident was diagnosed with [REDACTED]. Intravenous fluids (IVFs) were administered and the resident returned to the facility on [DATE]. Observations of the resident, on 05/08/12 at 9:30 AM, 3:30 PM, and 05/09/12 ,at 9:15 AM and 11:15 AM, revealed the resident was propelling independently around the facility and sitting in the lobby, in the dining area and sometimes in the room. The water pitcher in the room remained full and was kept at the sink area. An interview with State Registered Nurse Aide (SRNA) #9, on 05/10/12 at 2:55 PM, revealed the SRNAs were suppose to document the amount of fluids consumed on the Dietary Intake Records and the Extra Fluid Sheets, but was unaware of exactly how much fluid the resident required, as this was not written on the SRNA's assignment sheet or the SRNA care plan. She stated the resident was difficult to understand and was not sure if he/she would ask for a drink or say if he/she was thirsty. The SRNA checked the water pitcher in the resident's room and stated it was full and the resident probably did not drink from the pitcher. The SRNA was unsure if the resident was able to hold the pitcher or pour a drink into a cup. A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident as moderately cognitively impaired and required the extensive assistance of two staff members with dressing, hygiene and bathing and the extensive assistance of one staff member for transfers. A review of the care plan for the potential fluid volume deficit, related to the decreased sense of thirst, dated 10/22/11, revealed the resident was to be provided adequate fluids every shift and staff members to encourage fluid intake between meals and throughout the shift. A review of the Monthly Nutrition at Risk Review, dated 11/01/11, and review of the Medical Nutritional Therapy Assessment, dated 10/11/11, revealed the Registered Dietician/Licensed Dietician (RDLD) required the resident to have 2400-2800 mls of fluid every day. A review of the Dietary Intake Records and the Extra Fluids Sheets, dated December 2011, revealed there was no evidence the fluids were totaled during the 24 hour periods and on the Extra Fluid Sheets, there were no fluids administered on Saturday or Sunday. A review of the meal ticket, distributed on the resident's tray every shift, did not mention the required fluid needs. A review of the Nurse Aide Assignment Sheets revealed the SRNAs were to provide adequate fluids every shift and monitor the fluid intake at meals; however, there was no evidence of the required daily fluid needs. The physician's orders [REDACTED]. A review of the hospital History and Profile, from the hospital, just prior to the resident's admission to the facility, on 10/06/11, revealed the resident "had a tendency to not drink enough adequate fluids." An interview with Licensed Practical Nurse (LPN) #6, on 05/09/12 at 1:18 PM, revealed the Dietary Manager and the hydration nurse were responsible for totaling up the daily fluid needs and informing the charge nurse know if there was a problem. An interview with the RDLD, on 05/10/12 at 11:20 PM, revealed the Dietician recommended Resident #8 to require between 2400 and 2800 mls of fluid per day, based on the resident's weight and height and body mass index. After returning from the hospital and on the dietician's next visit, on 12/27/11, it was determined the resident required 2520 mls and this was increased again, on 03/12/12, to 2670 mls every day. However, the dietician stated it was the Dietary Manager's job to compile the 24 hour totals for each resident, the Dietary Department's job to provide the fluids, and the charge nurses' job to let the Dietician know when changes needed to be made and fluids needs were not being met. An interview with the Dietary Manager (DM) and review of the Dietary Intake Records and the Extra Fluid Sheets, on 05/10/12 at 3:05 PM, revealed the DM did not write the 24 hour totals on any of the paperwork and stated he knew the residents were getting enough fluids, but did not have any documentation to prove this, as they were always in groups and activities and fluids were passed several times a day. He also stated he had problems for some time in getting the SRNAs, on the wings, to fill out the Extra Fluids Sheets and stated "they were just not made to do it." The DM stated he was aware of the [DIAGNOSES REDACTED]. An interview with LPN #7, on 05/10/12 at 3:50 PM, revealed the nurse stated when she was the midnight nurse, she used to total up all the 24 hour fluid totals and keep them on a clipboard and the DM and the Dietician were suppose to review them. Since she went to work on the day shift, she thought the DM was keeping up with this. An interview with Registered Nurse (RN) #1, on 05/11/12 at 11:00 AM, revealed after the resident was readmitted to the facility from the hospital, with the [DIAGNOSES REDACTED]. There were no changes to the resident's care plan, the resident was not placed on alert charting or increased monitoring to ensure the resident received the required fluids, and the consumption records were still not totaled at the end of the 24 hours. The RN stated "everyone was responsible to ensure the recommendations of the dietician was carried out." The RN stated she thought once the resident received IVFs at the hospital, the problem with Dehydration "was taken care of." An interview with the Director of Nursing (DON), on 05/10/12 at 11:40 AM, revealed "whoever gave fluids to a resident" was suppose to document the amount on the Dietary Intake Records and the Extra Fluid Sheets. The Extra Fluid Sheet was a new form that was created, approximately four or five months ago, to ensure fluids, at other times of the day, besides the mealtimes, were being monitored. The DON stated it was the charge nurses' responsibility to ensure this form was being filled out. The required daily amount of fluids required should have been spelled out on the care plan and the physician's orders [REDACTED]. An interview with Physician #1, on 05/10/12 at 5:15 PM, revealed the physician was unaware of any infection or other condition that would have caused the Acute [MEDICAL CONDITION], outside of [MEDICAL CONDITION] would have caused the resident trouble eating, swallowing or talking and would cause the resident to be less likely to be compliant with the fluid requirements. 2. A record review revealed the facility admitted Resident #2 on 01/16/12, with a re-admission date of [DATE]. [DIAGNOSES REDACTED]. A review of the quarterly MDS, dated [DATE], revealed the facility assessed the resident as cognitively intact and could eat independently with tray setup. A review of the Dehydration Risk Assessment, dated 04/09/12, revealed Resident #2 had the following conditions that increased the resident's risk for dehydration: [MEDICAL CONDITION], Depression, age greater than [AGE] years old, female gender, physical immobility, recent changes in the ability to carry out activities of daily living, urinary incontinence, falling episodes, lethargy/weakness, greater than four medications, and diuretic use. A review of the Dietary Intake Record, dated April 2012, revealed the resident received fluids daily, ranging from (480-1110 ml) in April. A review of the Resident Care Plan, dated 05/03/12, revealed the resident had a potential for fluid volume deficit related to diuretic use and decreased fluid intake. Interventions included to provide adequate fluids of 1790 ml daily. 3. A record review revealed the facility admitted Resident #9 on 04/20/12 with [DIAGNOSES REDACTED]. A review of the Dehydration Risk Assessment, dated 04/29/12, revealed Resident #9 had the following conditions that increased the resident's risk for dehydration: Dementia, age greater than [AGE] years old, female gender, lack of understanding about fluid needs, and the lack of understanding about the causes of dehydration. A review of the Dietary Intake Record, dated April 2012, revealed the resident received fluids daily, ranging from (270-1140 ml) in April. A review of the Resident Care Plan, dated 05/03/12, revealed the resident had a potential for fluid volume deficit. Interventions included to provide adequate fluids of 1500 ml daily. 4. A record review revealed the facility admitted Resident #14 on 04/20/12 with [DIAGNOSES REDACTED]. A review of the admission MDS, dated [DATE], revealed the facility identified the resident as cognitively intact and could eat independently with tray setup. A review of the Dehydration Risk Assessment, undated, revealed Resident #14 had the following conditions that increased the resident's risk for dehydration: Female gender, physical immobility, falling episodes, and urinary incontinence. A review of the Dietary Intake Record, dated April 2012, revealed the resident received fluids daily, ranging from (240-1440 ml) in April. A review of the Resident Care Plan, dated 05/03/12, revealed the resident had the potential for fluid volume deficit. Interventions included to provide adequate fluids of 1893 ml daily. 5. A record review revealed the facility admitted Resident #10 on 10/12/09 with [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]." A review of the Dehydration Risk Assessment, dated 03/05/12, revealed to encourage fluids each shift. A review of the resident's care plan, dated 03/15/12, revealed staff was to provide 1740 ml fluids daily to the resident. A review of the Dietary Intake Record, dated May 2012, revealed Resident #10 consumed 1620 ml of fluid on 05/01/12, 1375 ml of fluid on 05/02/12, 1425 ml of fluid on 05/03/12, and 945 ml of fluid on 05/04/12. Further review of the fluid intake recorded between 05/01/12 and 05/04/12 was below 1740 ml. An interview with State Registered Nurse Aide (SRNA#1) on 05/09/12 at 2:45 PM, revealed "When I give a resident a drink out of the water pitcher I just "guesstimate" on what they get because I'm not really sure on how much they are really getting as there no real way to measure the fluid I give them." An interview with SRNA #3, on 05/09/12 at 2:55 PM, revealed "I tell my medication nurse when I give a resident a drink, so she can record it with her medication pass. Dietary is in charge of totaling the daily fluid intake, they should be able to tell how much a resident has received for each shift." An interview with Licensed Practical Nurse (LPN #1), on 05/09/12 at 2:48 PM, revealed "I record all fluids with the medication pass on the extra fluid sheet, all fluids are recorded on the consumption sheet where the resident eats their main meal at and the extra fluid sheet is kept at the nurse's station." 6. A record review revealed the facility admitted Resident #5 on 04/03/12 with [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]." A review of the Resident Care Plan, dated 04/19/12, revealed the staff was to provide 2460 ml daily. A review of the facility's Dietary Intake Record, dated April 2012 and May 2012, revealed Resident #5 consumed 1990 ml of fluid on 04/18/12 and 05/04/12. On 05/08/12, Resident #4 consumed 1830 ml of fluid, and the fluid intake recorded on 04/15/12, 04/19/12, and 04/24/12 was 1800 ml. The fluid intake recorded on 04/07/12, 04/09/12 through 04/14/12, 04/16/12 through 04/17/12, 04/20/12 through 04/23/12, 04/25/12 through 05/03/12, and 05/05/12 through 05/07/12, revealed the daily intake records was at or below 1770 ml each day. The minimum fluid intake recorded for Resident #5 was 1020 ml consumed on 04/08/12. A review of lab values for Resident #5, collected on 04/04/12, revealed a BUN of 25 with the lab normal reference range of 9-23, and the Creatinine level of 1.40 with the lab normal reference range of 0.5 - 1.1. 7. A record review revealed the facility admitted Resident #12 on 03/22/11 with [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]." A review of the Resident Care Plan, dated 04/19/12, and updated on 05/07/12, revealed the staff was to provide 1560 ml daily. A review of the facility's Dietary Intake Record, dated April 2012 and May 2012, revealed Resident #12 consumed 1220 ml of fluid on 04/18/12, and on 05/03/12 Resident #12 consumed 1160 ml of fluid. Fluid intake recorded on 04/24/12 and 04/25/12 was 1020 ml. The fluid intake recorded on 04/01/12 through 04/03/12, 04/07/12 through 04/09/12, 04/11/12, 04/14/12 through 04/17/12, 04/21/12 through 04/23/12, 04/26/12, 04/28/12 through 04/29/12, 05/05/12, and 05/08/12, revealed the daily intake records was below 500 ml each day. Resident #12 consumed between 500 ml and 1000 ml on 04/04/12 through 04/06/12, 04/10/12, 04/12/12 through 04/13/12, 04/19/12 through 04/20/12, 04/27/12, 04/30/12 through 05/02/12, 05/04/12, 05/06/12 through 05/07/12, and 05/09/12. The minimum fluid intake recorded for Resident #12 was 220 ml on 04/22/12. 8. A closed record review revealed the facility admitted Resident #16 on 02/27/12 with [DIAGNOSES REDACTED]. A review of the Resident Care Plan, dated 03/15/12, revealed the staff was to provide 1500 ml daily. A review of the facility's Dietary Intake Record, dated March 2012, revealed Resident #16 consumed the maximum fluid intake of 1200 ml on 03/16/12. A review of lab values for Resident #16, collected on 03/05/12, revealed a BUN of 30 with the lab normal reference range of 9-23. Interview with the West Wing Unit Supervisor, on 05/09/12 at 2:40 PM, revealed she completed the Dehydration Risk Assessment for each resident on the west wing. "Monitoring" meant the nursing staff who fed the resident each day entered the fluid intake information into the Dietary Intake Record and the kitchen documented the fluid intake each shift and totaled it. Interview with LPN # 8, on 05/09/12 at 2:45 PM, revealed anyone who witnessed consumption from the bedside water pitcher documented the fluid intake on the Dietary Intake Record. An interview with SRNA #9, on 05/09/12 at 2:55 PM, revealed she documented fluids consumed during meals and in between meals by the residents on the facility's Consumption Record. SRNA #9 stated water at the bedside was documented on the Consumption Record and was a "guesstimate" according to information provided by each resident. Interview with the Hydration Dietary Aide, on 05/09/12 at 3:15 PM, revealed she filled the water pitchers at the bedside of each resident. She stated there was no process to record the fluid consumed from the bedside water pitcher. An interview with LPN #6, on 05/10/12 at 9:50 AM, revealed the process for fluid intake documentation in the Dietary Intake Record was completed by the nurse aide when the meal tray was picked up. She stated the Hydration/ Dietary Aide provided refilled the bedside water pitcher and entered the fluid consumption into the Extra Fluids sheet at the nurse's desk. The Hydration/ Dietary Aide also provided and recorded the intake from snacks. She stated if nursing staff provided a refill of the bedside water pitcher, the fluid intake would be documented on the Extra Fluids sheet. Interview with the Registered Dietician/Licensed Dietician and the Dietary Manager, on 05/09/12 at 3:25 PM, revealed the Dietician determined the amount of fluid intake for each resident based on the individual body weight and she completed quarterly nutrition assessments to include calculation totals of the fluid intake records. The Dietician stated the bedside water pitchers were filled twice each day, but nursing refilled and documented what was consumed on the Dietary Intake Record. The Dietary Manager stated the residents wear getting adequate fluids, but it was not documented properly. He stated he also monitored the resident's labs and nursing assessments for indications of dehydration, but did not document the reviews. The Dietician and the Dietary Manager revealed there was a problem with the process of ensuring the resident's fluid intake goal was met.