Every finding on record at Carter Nursing and Rehabilitation

Based on interview, record review, and review of the facility's policy, the facility failed to ensure residents were free from verbal abuse and neglect which resulted in actual harm for 1 out of 10 sampled residents, Resident (R) 29. On 08/24/2025, Resident 29 had an incontinent episode and required the assistance of staff to help change her. However, instead of changing the resident, State Registered Nurse Aide (SRNA) 1 became verbally abusive to the resident and both, SRNA1 and SRNA11, neglected to provide the resident hygiene care to remove the feces from the resident. Instead, SRNA 1 and SRNA 11 covered the resident with a feces-covered blanket for a period of over three hours. The resident reported she was scared of SRNA1, and SRNA10 stated this upset the resident, which caused the resident psychosocial harm. The findings include:Review of the facility's policy titled, Abuse, Neglect, Misappropriation and Exploitation Policy, dated 07/01/2025, revealed abuse was the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Per the policy, abuse also included the deprivation by an individual, including a caretaker, of goods or services that were necessary to attain or maintain physical, mental, and psychosocial well-being. It included verbal abuse, sexual abuse, physical abuse, and mental abuse. The policy further revealed the facility would train care team members upon hire and annually on how to identify what constituted abuse, neglect, exploitation or misappropriation of resident property; how to recognize signs of abuse, neglect, exploitation or misappropriation of resident property; how Care Team Members should report their knowledge related to allegations without fear of reprisal; and how to recognize signs of burnout, frustration and stress, understanding behavioral symptoms of residents that could increase the risk of abuse and neglect, and how to respond. The policy stated if a Care Team Member was accused or suspected, the facility should immediately remove the Care Team Member from the facility and the schedule pending the outcome of the investigation. 1.Review of R29's admission Record revealed the facility admitted the resident on 05/29/2025 with diagnoses of chronic obstructive pulmonary disease (COPD), chronic respiratory failure, human immunodeficiency virus (HIV), muscle weakness, palliative care, and anxiety. Review of R29's admission Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 06/24/2025, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 15 out of 15. That score indicated intact cognition. The MDS further revealed R29 was always incontinent of bowel and dependent on staff for toileting hygiene.2. Review of R130's admission Record revealed the facility admitted the resident on 08/21/2025 with displaced comminuted fracture of right patella, Smith's fracture of left radius, and fracture of left ulna.Review of R130's BIMS revealed the facility assessed the resident to have a score of 15 out of 15, which indicated intact cognition. Since R130 was a new admission, the facility had not completed her admission MDS yet. During an interview on 08/26/2025 at 9:40 AM, R29 stated she had fallen on 08/24/2025 after attempting to self-transfer from bed to wheelchair to allow State Registered Nurse Aide (SRNA) 1 to remove soiled bed linen from her bed after R29 had a bowel movement in her bed. R29 stated after she fell to the floor, SRNA1 made inappropriate comments such as, I knew you would do that, and, I should have called in today. R29 stated SRNA1 also told her, You do this for attention. R29 further stated that SRNA1 and SRNA11 assisted her back to bed but did not provide hygiene care to remove the feces. She stated SRNA1 and SRNA11 failed to dress her and then covered her with a feces-covered blanket. R29 stated the SRNAs stated they would return with supplies to clean her. However, she stated, after three hours, they had not returned. R29 stated she pressed her call light for assistance and was cleaned up by SRNA10. Resident 29 stated she feared SRNA1 due to being handled roughly during care. She also stated SRNA1 routinely told her she deserved to have HIV. Resident 29 stated SRNA1 and SRNA11 treated her with no respect and had mentally, verbally, and physically abused her. R29 stated she did not tell other staff, including SRNA10 about SRNA1's inappropriate remarks, because she was scared SRNA 1 would lash out at her. During an interview on 08/26/2025 at 10:00 AM, with R29's roommate R130, she stated SRNA1 and SRNA11 treated R29 awful after she fell, explaining the staff accused R29 of falling for attention, and left R29 in feces for an extended period. R130 further stated the pungent odor of bowel movement made her sick to her stomach, and her family had to leave the facility to purchase a room spray. During an interview on 08/28/2025 at 9:17 PM with R130's Family Member (FM) 6, she stated after R29 fell, SRNA1 stated, I knew this would happen. I knew I should have called off today, and You should have had a depend on. FM6 further stated she did not believe SRNA1 or SRNA11 cleaned the feces from R29 after assisting her back to bed, as the strong and prolonged smell of bowel movement remained in the room. She stated the odor made her mother sick, and she had to leave the facility to buy a room deodorizer. FM6 stated R29 remained in the uncleaned condition for approximately three to four hours before another staff member cleaned R29. FM6 further stated when SRNA10 later cleaned R29, she overheard SRNA10 repeatedly apologizing for the condition she had been left in by SRNA1 and SRNA11. During an interview on 08/28/2025 at 11:29 PM with SRNA10, she stated R29 was upset because she had been left in feces and not been cleaned. She stated R29 explained that SRNA1 and SRNA11 told R29 they would get supplies to clean her but never returned. SRNA10 further stated the feces appeared to have been on R29 for a while before she provided cleaning. SRNA10 stated it was inappropriate for SRNA1 and SRNA11 to leave the resident in that condition.During an interview on 08/28/2025 at 9:17 PM with SRNA1, she stated she did not make inappropriate remarks to R29. She also stated she did not leave R29 soiled for three hours.The State Survey Agency (SSA) Surveyor attempted to reach SRNA11 per telephone on 08/26/2025, 08/27/2025, and 08/28/2025. However, she did not answer the telephone.During an interview on 08/28/2025 at 9:54 PM, Licensed Practical Nurse (LPN) 1 stated R29 appeared angry while she conducted a skin assessment following the fall. LPN1 further stated she believed the resident was having an anxiety attack and repeatedly told her, I'm sorry I messed on myself.During an interview on 08/28/2025 at 5:04 PM with the Administrator, she stated Resident 29 had not reported anything to her, and she had been unaware of the incident until the State Survey Agency (SSA) Surveyor brought it to her attention on 08/26/2025. She stated she was going to immediately talk with Resident 29 and left the room.During additional interview with the Administrator on 08/28/2025 at 5:24 PM, she stated she suspended SRNA1 and SRNA11, reported the incident to the Office of Inspector General (OIG) and the local police, and began the investigation on 08/26/2025. She stated R29 told her about the poor care and neglect by SRNA1 and SRNA11 but did not tell her about SRNA1's abusive remarks to her. She stated R29 requested that neither staff member provide her care in the future.

Based on interview, record review, and review of the facility's policy, State Registered Nurse Aide (SRNA) 10 failed to immediately report an allegation of staff abuse/neglect for 1 of 10 sampled residents, Resident (R) 29.SRNA10 did not notify the Administrator when R29 reported to her that SRNA1 and SRNA11 failed to provide timely hygiene care and left R29 soiled for hours after an episode of fecal incontinence on 08/24/2025. Resident 29 stated the SRNAs actions were neglectful of her care which made her scared of SRNA1, and SRNA10 reported the resident was visibly upset, causing the resident psychosocial harm.Refer to F600The findings include:Review of the facility's policy titled, Abuse, Neglect, Misappropriation and Exploitation Policy, dated 07/01/2025, revealed abuse was the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. The policy also stated abuse included the deprivation by an individual, including a caretaker, of goods or services necessary to attain or maintain physical, mental, and psychosocial well-being. It included verbal abuse, sexual abuse, physical abuse, and mental abuse. It further revealed the facility would train Care Team Members, upon hire and annually, on how to identify what constituted abuse, neglect, exploitation or misappropriation of resident property; how to recognize signs of abuse, neglect, exploitation or misappropriation of resident property; and how Care Team Members should report their knowledge related to allegations without fear of reprisal. Per the policy, all allegations of abuse, neglect, or misappropriation of resident property must be reported immediately to the Administrator and to the Department of Health, but in no event later than 24 hours from the time of the incident/allegation was made known to the Care Team Member. The policy stated if a Care Team Member was accused or suspected, the facility should immediately remove the Care Team Member from the facility and the schedule pending the outcome of the investigation. Review of R29's admission Record revealed the facility admitted the resident on 05/29/2025 with diagnoses of chronic obstructive pulmonary disease (COPD), chronic respiratory failure, human immunodeficiency virus (HIV), muscle weakness, palliative care, and anxiety. Review of R29's admission Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 06/24/2025, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 15 out of 15. That score indicated intact cognition. The MDS further revealed R29 was always incontinent of bowel and dependent on staff for toileting hygiene.During an interview on 08/26/2025 at 9:40 AM, R29 stated she fell on [DATE] after attempting to self-transfer from her bed to her wheelchair to allow SRNA1 to remove soiled bed linen from her bed after she had a bowel movement. R29 stated, after she fell to the floor and while she was still on the floor, SRNA1 made inappropriate comments such as, I knew you would do that, and, I should have called in today. R29 stated SRNA1 also told her, You do this for attention. R29 further stated SRNA1 and SRNA11 assisted her back to bed but did not provide hygiene care to remove the feces. She stated SRNA1 and SRNA11 failed to dress her and then covered her with a feces-covered blanket and told her they would return with supplies to clean her. However, she stated, after three hours, they had not returned. R29 stated she pressed her call light for assistance and was cleaned up by SRNA10. R29 stated SRNA10 repeatedly apologized for the condition R29 was left in and excused herself to get a special spray to help remove the dried feces. R29 stated she did not tell other staff, including SRNA10 about the inappropriate comments, because she was scared SRNA 1 would lash out at her. During an interview on 08/28/2025 at 9:17 PM with Family Member (FM) 6, relative of R29's roommate, she stated she was in the room when the incident happened. FM6 stated, after R29 fell, SRNA1 stated, I knew this would happen. I knew I should have called off today, and, You should have had a depend on. FM6 further reported she did not believe SRNA1 or SRNA11 cleaned the feces from R29 after assisting her back to bed, as the strong and prolonged smell of bowel movement remained in the room. She stated the odor made R29's roommate sick, and she had to leave the facility to buy a spray deodorizer. FM6 stated R29 remained in this soiled condition for approximately three to four hours before another staff member cleaned her. FM6 further stated when SRNA10 cleaned R29, she overheard SRNA10 repeatedly apologizing to R29 for the condition she had been left in by SRNA1 and SRNA11. During an interview on 08/28/2025 at 11:29 PM with SRNA10, she reported R29 was upset SRNA1 and SRNA11 had left her lying in feces for hours after they told her they would return after gathering supplies to clean her. SRNA10 stated the feces appeared to have been on R29 for a while, and it was inappropriate for SRNA1 and SRNA11 to leave R29 in that condition. SRNA10 further stated she did not report the incident because R29 frequently complained, and she did not want to say anything that might get SRNA1 and SRNA11 in trouble.During an interview on 08/28/2025 at 5:04 PM with the Administrator, she stated Resident 29 had not reported anything to her, and she had been unaware of the incident until the State Survey Agency (SSA) Surveyor brought it to her attention on 08/26/2025. She stated she was going to immediately talk with Resident 29 and left the room.During additional interview with the Administrator on 08/28/2025 at 5:24 PM, she stated she suspended SRNA1 and SRNA11, reported the incident to the Office of Inspector General (OIG) and the local police, and began the investigation on 08/26/2025. She stated R29 told her about the poor care and neglect by SRNA1 and SRNA11, and the resident requested that neither staff member provide her care in the future. She stated R29 did not tell her about SRNA1's abusive remarks to her. She also stated the facility had not yet completed an investigation of the incident.During an interview on 08/26/2025 at 6:00 PM, the Administrator stated she expected staff to always report inappropriate comments or behaviors to her.

Based on observation, interview, review of the U.S. Food and Drug Administration 2022 Food Code, and facility policy review, the facility failed to follow safe food handling practices, ensure food items located in dry storage were properly labeled and dated, and ensure expired food items were discarded. This had the potential to affect all 112 current residents that received food from the kitchen.The findings include:Review of the document, U.S. Food and Drug Administration 2022 Food Code, 01/18/2023 Version, in Chapter 3 Food, revealed food employees would not contact exposed, ready-to-eat food with bare hands and shall use single-use gloves. It also stated food employees shall minimize bare hand contact with exposed food not in a ready-to-eat form. Review of the facility's policy titled, Safe Food Handling, revised 02/05/2025, revealed the facility would follow safe food handling to significantly reduce the risk of foodborne illness thus strengthening the safety of the food provided to the residents. Further review revealed Care Team Members in nutrition/culinary would effectively clean their hands and keep exposed portions of their arms clean and would follow uniform standards for food safety. Review of the facility's policy titled, Handwashing-Hand Hygiene, dated 03/01/2025, revealed all Care Team Members would follow handwashing and hand hygiene to help prevent the spread of infections to other Care Team Members, residents, and visitors. Review of the facility's policy titled, Infection Prevention & Control Program, dated 12/12/2023, revealed hand hygiene shall be performed in accordance with the facility's established hand hygiene procedures. Review of the facility's policy titled, Labeling and Dating, dated 10/2018, revealed any ready-to-eat food or prepared food would be labeled with the date opened or prepared and the date of discard. Further review revealed opened packages of foods that did not require refrigeration (such as dry cereals, sugar, flour, etc.) would be dated with the opened date and the expiration date if noted by the manufacturer. Additional review revealed all foods would be used or discarded on or before any manufacturer's use by or sell by date, and all items not in their original containers would be labeled and/or easily identifiable. 1. Observation on 08/26/2025 at 12:18 PM revealed Dietary Aide (DA) 2 failed to perform hand hygiene or don (put on) gloves prior to handling fresh cabbage. Further observation revealed DA2 momentarily walked away, went to the refrigerator, pulled out a tray of desserts, handed it to another dietary staff member, and returned to the cabbage. Observations also revealed DA2 failed to perform hand hygiene at any point when she went from one task to another. During an interview with the [NAME] on 08/28/2025 at 1:51 PM, she stated she worked at the facility for over 32 years and thought what they did in the kitchen was important because food was important to the residents. The [NAME] stated kitchen staff used hand hygiene and wore gloves when they handled food like produce and meats and sanitized between activities. She further stated germs were transferred when proper hand hygiene was not used, which led to potential sickness to residents. During an interview with DA1 on 08/28/2025 at 2:03 PM, she stated she used hand hygiene and wore gloves when she handled food because it prevented foodborne illness and protected residents. An attempt was made on 08/29/2025 at 2:57 PM to contact DA2 via telephone, but the attempt was not successful. During an interview with the Dietary Manager on 08/29/2025 at 3:04 PM, she stated it was her expectation when staff handled fresh produce like cabbage, they performed hand hygiene and wore gloves. She stated the elderly were more susceptible to germs, so food safety was important for the prevention of foodborne illnesses During an interview with the Assistant Dietician (AD) on 08/29/2025 at 3:10 PM, she stated it was her expectation staff performed hand hygiene and wore gloves when they handled fresh produce, such as cabbage. The AD stated she had already re-educated DA2 and other kitchen staff on safe food handling. A second attempt to contact DA2 via telephone was made on 08/29/2025 at 3:43 PM, but the attempt was not successful. During an interview with the Infection Preventionist (IP) on 08/29/2025 at 3:46 PM, she stated she provided daily hand hygiene education with everyone in the building. She stated it was her expectation dietary staff followed the facility's infection prevention guidelines. The IP further stated it was her expectation dietary staff performed hand hygiene and donned gloves before they handled produce and when they moved from one place to another in the kitchen. The IP stated it was important dietary staff followed infection control policies and procedures, so potential germs were not spread, and residents were protected from potential illness. During an interview with the Director of Nursing (DON) on 08/29/2025 at 5:18 PM, she stated it was her expectation kitchen staff used proper hand hygiene and wore gloves when they touched food. During an interview with the Administrator on 08/29/2025 at 5:28 PM, she stated the DM oversaw the kitchen including audits and education but brought any issues needed to her attention. The Administrator stated she expected dietary staff to use hand hygiene and wear gloves if they handled produce. The Administrator stated proper infection control practices were important in the kitchen for the prevention of foodborne illnesses and resident safety. 2. Observation during a brief kitchen tour on 08/26/2025 at 9:26 AM revealed the following items found in dry storage: one opened container of cocoa dated 11/27/2024; 26 opened, undated, individual containers of dry cereal; 10 cookies in individual, undated, fold over sandwich bags; and (10) 105-ounce cans of mandarin oranges with expiration dates of 12/2023.During an interview with the [NAME] on 08/28/2025 at 1:51 PM, she stated when stock came in designated for dry storage, it was marked with the date it was received. She further stated when dry storage food items were opened, they were marked with both an opened date and a discard date. She stated everyone in the kitchen was responsible for ensuring expired foods were discarded. The [NAME] stated it was important expired foods were not served to residents because they could cause sickness. During an interview on 08/28/2025 at 2:03 PM with Dietary Aide (DA) 1, she stated she was responsible for card call during tray line and usually helped with dishes. DA1 stated she occasionally put up stock, but not often. However, she further stated she knew truck items were dated as soon as they came in, and when anything was opened, it was dated. DA1 stated it was important foods were dated when opened and discarded when expired, so residents were not served foods that could make them sick. During an interview on 08/29/2025 at 3:04 PM, the Dietary Manager stated their process for dry storage was first in and first out. She further stated all dietary staff was aware foods were dated when received, dated when opened, and discarded when expired. The DM stated it was important expired foods were not served to residents because they were a high-risk population and more susceptible to foodborne illnesses. During an interview with the Assistant Dietician (AD) on 08/29/2025 at 3:10 PM, she stated it was her expectation dietary staff disposed of any expired or undated foods because of potential harm to residents. The AD stated it was important residents were kept safe, and expired foods often caused sickness. During an interview on 08/29/2025 at 5:28 PM, the Administrator stated it was her expectation food was properly stored and dated and discarded if expired. The Administrator stated it was important dietary policies and procedures were followed because of potential negative outcomes for residents such as foodborne illnesses.

Based on observation, interview, record review, and facility policy review, the facility failed to assure that all services, as outlined by the comprehensive care plan being provided, met professional standards of quality for 1 of 6 residents reviewed for medication administration, Resident (R) 42.Review of R42's Medication Administration Record (MAR) and interviews from staff revealed the resident was administered a Zofran tablet (used to treat nausea) on 08/29/2025 at 3:54 PM by Kentucky Medication Aide (KMA) 14 without a standing order or provider's order for Zofran. The findings include:Review of the facility policy's titled, Medication Administration, dated 12/12/2023, revealed medications were administered, as ordered by the physician and in accordance with professional standards of practice.Review of R42's Face Sheet revealed the facility admitted the resident on 01/31/2018 with diagnoses of dementia, diabetes, and congestive heart failure (CHF). Review of R42's quarterly Minimum Data Set [MDS], with an Assessment Reference Date of 06/19/2025, revealed the facility assessed the resident to have a Brief Interview Mental Status [BIMS] score of three out of 15, indicating R42 was severely cognitively impaired.Review of R42's Care Plan, dated 01/18/2022, revealed an intervention to administer /medications as ordered.Observation on 08/29/2025 at 3:31 PM, while the State Survey Agency (SSA) Survey was in the South Hall medication room, a staff member came to the medication room and made Licensed Practical Nurse (LPN) 11 and KMA14 aware that R42 wanted something for nausea. KMA14 checked Point Click Care (PCC, a software program) and did not see an order. KMA14 made LPN11 aware there was no order. LPN11 then stated Zofran was a standing order (written protocols that authorize designated members of the health care team to complete certain clinical tasks without having to first obtain a physician order) and exited the medication room. Review of the facility's Standing Orders revealed Zofran was not listed as a standing order.Review of R42's Physician's Orders revealed an order for Zofran 4 milligams (mg) tablet by mouth every six hours as needed for nausea was entered on 08/29/2025 at 3:52 PM by LPN11 and under the Medical Director's name as the ordering provider. Review of R42's MAR revealed a Zofran 4 mg tablet was administered at 3:54 PM by KMA14.During an interview on 08/29/2025 at 4:22 PM with the Medical Director, she stated she thought standing orders might have been recently updated. She stated she would like to be notified if any resident was ordered and given a new medication, so she knew what the residents were receiving. She stated she did not recall Zofran being a standard order. She stated no one called her regarding Zofran for R42. She stated she would have questions about Zofran and would need to be familiar with the resident before Zofran was ordered and given.During an interview on 08/29/2025 at 5:22 PM with LPN11, she stated she was mistaken and thought Zofran was a standing order. She stated she should have obtained an order before the medication was administered. She stated she did get an order from the Nurse Practitioner (NP) on 08/29/2025 at approximately 4:50 PM and was going to correct the order that was entered to reflect the correct ordering provider. During an interview on 08/29/2025 at 5:24 PM with KMA14, she stated LPN2 pulled the Zofran from the Pyxis (an automated dispensing medication system) for her to administer to R42.However, review of a Pyxis report could not be done because the facility was unable to generate one.During an interview on 08/29/2025 at 5:27 PM with the Director of Nursing (DON), she stated it was her expectation for staff to know what was on the standing order list and an order be received before administering any medication not on that list. She stated that was important for safety reasons. During an interview on 08/29/2025 at 7:13 PM with the Administrator, she stated it was her expectation for staff to obtain a physician's order for all medications. She stated standing orders were updated annually, and staff was educated about the updates. She also stated copies of standing orders were provided to both nursing stations. She stated that was important for safety precautions for residents and was a requirement for staff to stay within their scope of practice.

Based on observation, interview, record review, review of the Centers for Disease Control and Prevention (CDC) document, and facility policy review, the facility failed to ensure a resident who had an indwelling catheter received appropriate treatment and services to prevent urinary tract infections for 1 of 2 sampled residents, Resident (R) 12. The findings include:Review of the facility's policy titled, Indwelling Catheter, dated 12/12/2023, revealed the facility would provide appropriate care for the catheter in accordance with current professional standards of practice and resident care policies and procedures. Review of the CDC's document Summary of Recommendations from the Guideline for Prevention of Catheter-Associated Urinary Tract Infections (2009), for Health Care Providers, dated 03/25/2024, revealed to keep the urine collection bag below the level of the bladder at all times. It also stated, Do not rest the bag on the floor. Review of R12's Face Sheet revealed the facility admitted the resident on 11/01/2012 with diagnoses of multiple sclerosis, dementia, and neuromuscular dysfunction of the bladder.Review of R12's Care Plan, dated 05/04/2020, revealed R12 was care planned for risk for infection/complications related to a suprapubic catheter. R12 had interventions to observe catheter tubing for kinks or twists. Observation on 08/26/2025 at 3:32 PM revealed R12's suprapubic catheter urine collection bag lying on the floor on the left side of the bed.During an interview on 08/28/2025 at 1:39 PM with State Registered Nurse Aide (SRNA) 4, she stated catheter bags should never be on the floor. She stated they should always be hooked on the bed rail or bars on the wheelchair. She stated that was important for infection control to keep it from getting germs. During an interview on 08/28/2025 at 2:05 PM with SRNA5, he stated catheter bags should hang on the side of the bed, so they did not touch the floor. He stated that was important to prevent cross-contamination and for infection control.During an interview on 08/28/2025 at 2:22 PM with SRNA6, she stated catheter bags should not be on the floor because it could get ran over and pulled and dirty.During an interview with Registered Nurse (RN) 2, she stated it was not appropriate for a catheter bag to be on the floor. She stated that was important for infection control.During an interview on 08/29/2025 at 8:53 AM with the Infection Prevention RN (IP), she stated her expectation was for the catheter bag not to touch the floor. The IP stated that was important for Infection control.During an interview on 08/29/2025 at 8:53 AM with the Director of Nursing (DON), she stated it was her expectation that catheter bags be in the proper place, whether it be the bed or wheelchair. She stated that was important, so residents did not pull or tug on them and because staff did not want anything on the floor to get on the bag and possibly cause an infection.During an interview on 08/29/2025 at 7:13 PM with the Administrator, she stated, for infection control, it was her expectation that indwelling catheter bags were never on the floor.

Based on observation, interview, record review, review of the website accuweather.com, and review of the facility's policies, it was determined the facility failed to have an effective system to address an ongoing problem with its cooling system by ensuring the room temperatures were safely maintained between seventy-one (71) degrees Fahrenheit (F) and eighty-one (81) degrees F. The facility also failed to ensure a safe, comfortable and homelike environment was provided to residents for ten (10) of fifty (50) sampled residents (residents that had room temperatures taken), Resident #23, #34, #47, #77, #81, #86, #94, #101, #108, and #118. Interviews with staff from two (2) Heating, Ventilation, and Air Conditioning (HVAC) companies revealed they had been involved with repairing the air conditioning (a/c) system numerous times. Review of estimates from the two (2) HVAC companies revealed on 04/17/2023, an estimate for the replacement of two (2) a/c units was given; on 04/19/2023, an estimate of compressor replacement was given; and on 04/26/2023, another estimate of compressor replacement was given. Review of the invoices from the two (2) HVAC companies revealed on 05/26/2023, the North Unit a/c had a new leak repaired, and it took five (5) days for repair; and on 06/24/2023, the a/c unit on the South Unit was not working, and it took three (3) days for repair. Resident #101, with a diagnosis of Chronic Obstructive Lung Disease (COPD), was observed on 07/05/2023 sitting in bed with a reddened face and beads of sweat on his/her upper lip. Resident #101 stated he/she was having difficulty breathing. Resident #101's room, room [ROOM NUMBER], on 07/05/2023 at approximately 4:48 PM had a temperature of 85.4 degrees F; on 07/05/2023 at 6:16 PM, the room had a temperature near the hallway of 88.7 degrees F, and by the window the temperature was 91.3 degrees F. This was also Resident #81's room. Resident #23, with diagnoses of Multiple Sclerosis and Diabetes, was observed on 07/05/2023 sitting in a motorized wheelchair on the South Unit. The resident was slumped over, and his/her face was red. The resident stated his/her room, room [ROOM NUMBER], was on the North Unit, but it was too hot to be in the room. Resident #23's room, on 07/05/2023 at approximately 4:50 PM, had a temperature 82.7 degrees F. This was also Resident #34's room. Resident #94, with diagnoses of Alzheimer's Disease and Stroke, resided in room [ROOM NUMBER]. The resident's daughter stated, in an interview on 07/05/2023, she had recently bought a portable cooling unit for the resident's room because it was so hot. She stated she reported her concern with the hot temperatures to the Executive Director on 04/08/2023. Resident #77 and #108 both resided in room [ROOM NUMBER]. The residents' room, on 07/05/2023 at approximately 4:49 PM, had a temperature of 83.3 degrees F. Resident #86 and #47 both resided in room [ROOM NUMBER]. The residents' room, on 07/05/2023 at approximately 4:44 PM, had a temperature of 83.3 degrees F. Resident #118 resided in room [ROOM NUMBER]. The resident's room, on 07/05/2023 at approximately 4:40 PM, had a temperature of 81.3 degrees F. The facility's failure to have an effective system to ensure a safe, comfortable homelike environment for the residents, and the facility's failure to ensure room temperatures were safely maintained between seventy-one (71) degrees F and (81) degrees F, is likely to cause serious injury, serious harm, serious impairment, or death to residents. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) was identified on 07/05/2023 and was determined to exist on 04/17/2023 in the area of 42 CFR 483.10 Resident Rights F584 at a Scope and Severity (S/S) of a K. The facility was notified of the Immediate Jeopardy on 07/06/2023. The facility provided an acceptable IJ Removal Plan on 07/14/2023 alleging removal of the IJ on 07/08/2023. The State Survey Agency (SSA) validated removal of the IJ as alleged on 07/17/2023, prior to exit which lowered the scope and severity (S/S) to an E at 42 CFR 483.10 Resident Rights F584, while the facility develops and implements a Plan of Correction (PoC) and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's policy titled, Safe and Homelike Environment, dated 2023, revealed the facility would maintain comfortable and safe temperature levels. Per the policy, the facility should strive to keep the temperature in common resident areas between seventy-one (71) and eighty-one (81) degrees Fahrenheit (F). Review of the facility's policy titled, Resident Rights Policy, revised 12/2016, revealed residents had the right to be free from abuse, neglect, misappropriation of property, and exploitation. Review of the facility's policy, Resident Abuse Prevention, dated 2019, revealed neglect was the failure to care for a person in a manner which would avoid harm and pain or failure to react to a situation which might be harmful. Per the policy, neglect meant failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Review of an HVAC company estimate, dated 04/17/2023, revealed an estimate was given for Squirrel Cage replacement of (two) 2 units. Review of an HVAC company estimate, dated 04/19/2023, revealed an estimate for a compressor replacement. Review of the website, accuweather.com, revealed the highest outside temperature on 07/05/2023 was ninety-two (92) degrees F for the facility's location. The temperatures were taken by one (1) State Survey Agency surveyor using a digital infrared thermometer provided by the Office of Inspector General. 1. Review of Resident #101's medical record revealed the facility admitted the resident, on 04/23/2023, with diagnoses of Chronic Obstructive Lung Disease (COPD) and History of Tracheostomy. Review of Resident #101's Quarterly MDS Assessment, dated 03/22/2023, revealed the facility assessed the resident to have a BIMS score of fifteen (15) of fifteen (15), indicating the resident was cognitively intact. Observation of Resident #101 on 07/05/2023 at 5:16 PM, revealed the resident was in his/her room (room [ROOM NUMBER]A)sitting in the bed. The resident's face was red, and he/she had beads of sweat on his/her upper lip. During interview with Resident #101 on 07/05/2023 at 5:16 PM, the resident reported he/she was having difficulty breathing due to the heat. 2. Review of Resident #81's medical record revealed the facility admitted the resident, on 11/10/2019, with diagnoses to include Dementia, Depression and Muscle Weakness. Review of Resident #81's Quarterly MDS Assessment, dated 05/08/2023, revealed the facility assessed the resident to have a BIMS score of eight (8) of fifteen (15), indicating the resident had moderate cognitive impairment. Observation of Resident #81 on 07/05/2023 at 5:18 PM, revealed the resident was lying in bed, clean and groomed. The resident was wearing a short sleeved gown and had a sheet over the lower extremities. Interview with Resident #81 on 07/05/2023 at 5:18 PM was attempted, but was not successful. The resident was asleep and did not wake when his/her name was called twice. The temperature of room [ROOM NUMBER], where Resident #101 and #81 resided, 07/05/2023 at 4:48 PM was 85.4 degrees F near the hallway and Resident #101's bed. However, the temperature of Resident #81's room area, whose bed was next to the window, on 07/05/2023 at 4:48 PM was 91.0 degrees F. The temperature of room [ROOM NUMBER], where Resident #101 and #81 resided, on 07/05/2023 at 6:16 PM, was 88.7 degrees F near the hallway, and by the window, the temperature was 91.3 degrees F. 3. Review of Resident #23's medical record revealed the facility admitted the resident, on 12/13/2022, with diagnoses of Multiple Sclerosis and Diabetes. Review of Resident #23's Quarterly Minimum Data Set (MDS) Assessment, dated 06/07/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fifteen (15) of fifteen (15), indicating the resident was cognitively intact. Observation of Resident #23 on 07/05/2023 at 5:07 PM, revealed the resident was sitting in a motorized wheelchair on the South Unit. The resident was slumped over, and his/her face was red. During interview with Resident #23 on 07/05/2023 at 5:07 PM, the resident stated he/she had an autoimmune disease, and the heat made it terrible. The resident stated his/her room was on the North Unit, but it was too hot to be in his/her room. Further, the resident stated the staff had been putting ice in a double garbage bag, then in a pillowcase, and placing it around his/her neck. Resident #23 stated the excessive heat had been going on for a couple of months. 4. Review of Resident #34's medical record revealed the facility admitted the resident, on 07/29/2016, with diagnoses to include Alzheimer's Disease and Depression. Review of Resident #34's Quarterly MDS Assessment, dated 05/25/2023, revealed the facility assessed the resident to have a BIMS score of 6 (six) of fifteen (15), indicating the resident had severe cognitive impairment. The temperature of room [ROOM NUMBER], where Resident #23 and #34 resided, on 07/05/2023 at 4:55 PM, was 82.7 degrees F. 5. Review of Resident #94's medical record revealed the facility admitted the resident, on 07/13/2021, with diagnoses of Alzheimer's Disease, Renal Failure, and Stroke. Review of Resident #94's Quarterly MDS Assessment, dated 05/24/2023, revealed the facility assessed the resident to have a BIMS score of three (3) of fifteen (15), indicating severe cognitive impairment. During interview with Resident #94's (resided in room [ROOM NUMBER]) daughter on 07/05/2023 at 5:30 PM, she stated she recently bought a portable cooling unit for his/her room because it was so hot, and they tried to keep the door closed to keep the room cool. She stated she reported her concern with the hot temperatures to the Executive Director on 04/08/2023. 6. Review of Resident #77's medical record revealed the facility admitted the resident, on 06/13/2022, with diagnoses to include Right Hip Joint Replacement, Polymyalgia Rheumatica, and Kidney Failure. Review of Resident #77's Admission MDS Assessment, dated 06/11/2023, revealed the facility assessed the resident to have a BIMS score of twelve (12) of fifteen (15), indicating moderate cognitive impairment. 7. Review of Resident #108's medical record revealed the facility admitted the resident, on 01/27/2023, with diagnoses to include Dementia and Heart Failure. Review of Resident #108's Quarterly MDS Assessment, dated 04/17/2023, revealed the facility assessed the resident to have a BIMS score of six (6) of fifteen (15), indicating severe cognitive impairment. The temperature of room [ROOM NUMBER] where Resident #77 and #108 resided, on 07/05/2023 at 4:50 PM, was 83.3 degrees F. 8. Review of Resident #86's medical record revealed the facility admitted the resident, on 03/10/2022, with diagnoses to include Heart Failure and Arthritis. Review of Resident #86's Quarterly MDS Assessment, dated 04/28/2023, revealed the facility assessed the resident to have a BIMS score of fifteen (15) of fifteen (15), indicating intact cognition. 9. Review of Resident #47's medical record revealed the facility admitted the resident, on 04/13/2022, with diagnoses to include Schizophrenia, Age Related Physical Debility, and Polyneuropathy. Review of Resident #47's Annual MDS Assessment, dated 05/22/2023, revealed the facility assessed the resident to have a BIMS score of fifteen (15) of fifteen (15), indicating intact cognition. The temperature of room [ROOM NUMBER], where Resident #86 and #47 resided, on 07/05/2023 at 4:46 PM, was 83.3 degrees F. 10. Review of Resident #118's medical record revealed the facility admitted the resident, on 06/28/2023, with diagnoses to include Stroke and Diabetes. Review of Resident #118's Five (5) Day MDS Assessment, dated 07/05/2023, revealed the facility assessed the resident to have a BIMS score of fifteen (15) of fifteen (15), indicating intact cognition. The temperature of room [ROOM NUMBER], where Resident #118 resided, on 07/05/2023 at approximately 4:40 PM, was 81.3 degrees F. Observations on 07/05/2023 at approximately 5:00 PM revealed facility staff to be sweating with sweat beads to their foreheads During interview with State Registered Nurse Aide (SRNA) #13 on 07/13/2023 at 3:08 PM, she stated it had been hotter in the facility lately. She reported the facility would fix the air, and it would get better and then get worse again. She stated there were days when Resident #101 was sweating, and his/her face was red. She also stated Resident #64 told her he/she was hot and did not want the sheet to cover him/her. During interview with the North Unit Manager on 07/06/2023 at 2:38 PM, she stated she had been at the facility since 2009. She reported the air conditioner had gone out and would not work on both the North Unit and the South Unit at least once this year. She stated, to assist the residents when the air conditioner was not working, she had offered to move the residents, and she made sure the residents had plenty of water and ice. She stated she checked on the residents herself to make sure they had drinks and were not having any issues. During interview with the HVAC Account Manager on 07/07/2023 at 10:55 AM, he reported he had done maintenance on approximately ten (10) of the facility's a/c units in the past. During interview with the owner of another HVAC company on 07/07/2023 at 11:40 AM, he reported he had been contracted with the facility for about a month and a half. He stated the facility called him on 05/20/2023 due to an a/c problem. He stated he came to the facility on [DATE] and repaired the ten (10) ton unit that serviced Rooms 1 through 14 on the North Unit. He stated the a/c unit was not working from about 05/20/2023 to 05/26/2023. During further interview, he stated the a/c unit on the South Unit went out on 06/24/2023, and he finished the job on 06/27/2023. He stated an a/c unit usually lasted about twenty (20) years. During interview with the Director of Nursing (DON) on 07/06/2023 at 2:14 PM, she reported when the air conditioner was not working on the North Unit, on 07/04/2023, she offered to move the residents, but they declined. She stated a while back the air conditioner went out on the North Unit and was repaired the following day. The DON stated she did not do any training with the staff on how to assist the residents when the air conditioner was not working. She stated the air conditioner had gone out in the past few years. She stated the Executive Director (ED) talked with the Corporate Office about getting air conditioner units for the rooms without air conditioning, if the air conditioner did not get repaired. During interview with the ED, on 07/06/2023 at 3:00 PM, he stated he had been at the facility for ten (10) years. He stated the facility had experienced issues with air conditioning units every year since he had been at the facility. He stated he dreaded every year because there could be a problem with the air conditioner. He stated this year one (1) air conditioning unit was known to need replacement. He stated there were twelve (12) to fourteen (14) different air conditioner units. He stated some of the residents' rooms had air conditioner units in the wall. Further, he reported the temperatures increased in the facility as the day progressed. He stated he sent an email to the Regional Maintenance Directors, on 07/04/2023, when the air conditioner went out and stopped working. Further, he reported there were currently two (2) air conditioners not working, one (1) for the front lobby and one (1) for Rooms 14-28 on the North Unit. He stated maintenance personnel came on 07/05/2023, and it was expected the repairs would be completed by 07/05/2023. He stated additional fans were utilized on the morning of 07/05/2023. After he put the fans out, he stated, he and the DON checked on the residents. The ED stated he did not have a plan if the contracted company could not complete the repair other than to provide fans for the residents and hydration. Further, he reported he did not educate staff on hyperthermia. The facility provided an acceptable IJ Removal Plan on 07/14/2023 alleging removal of the IJ on 07/08/2023 as follows: 1. a) Resident #101, #23, and #94 were assessed for signs and symptoms of distress and heat exhaustion on 07/04/2023 by the Director of Nursing (DON) with documentation to include temperature, oxygen saturation, lung sounds, and current respiratory status. Assessment findings were negative for these residents. Respiratory assessments were completed for Resident #101, #23, and #94 twice by a Licensed Nurse on 07/05/2023, three (3) times by a Licensed Nurse on 07/06/2023, and once on 07/07/2023. All assessment findings were within normal limits (WNL) for these residents. The respiratory assessments consisted of body temperature, oxygen saturation, lung sounds, labored breathing, cough, respiratory symptoms, and gastrointestinal (GI) symptoms. All assessments from 07/04/2023 to 07/07/2023 were documented in the residents' Electronic Medical Record (EMR). Respiratory assessments were completed for the other residents that resided on the North 2 Unit, Rooms 14 to 28 by a Licensed Nurse on 07/04/2023 through 07/06/2023. No issues or concerns were noted for any resident residing on the North 2 Unit. Respiratory assessments were documented in each resident's electronic medical record. The respiratory therapist assessed each resident receiving oxygen or nebulizer treatments on the North 2 Unit on 07/05/2023. The respiratory therapist's observations revealed no residents with any noted distress, no residents with any increased need for oxygen supplementation or nebulizer treatments, and no noted changes in the residents' overall health status. b) Resident #101 and #23 were offered a room change by the DON on 07/04/2023 and 07/05/2023, and the residents declined. Resident #94 was not offered a room change by the DON because the resident's room already had a portable a/c unit in place. On 07/04/2023 and 07/05/2023, the DON offered temporary room changes to the all residents on the North 2 Unit, Rooms 14 to 28. Only one (1) resident accepted the room change. c) Review of Resident #101's, #23's, and #94's voiding patterns was completed on 07/04/2023 to 07/06/2023 by the Executive Director (ED). The review revealed the residents voided each shift on 07/04/2023, 07/05/2023, and 07/06/2023. These findings were similar to the residents' baseline voiding patterns. Resident #101, #23, and #94 had no signs or symptoms of dehydration. The ED the DON reviewed all other residents residing on the North 2 Unit, on 07/04/2023 to 07/06/2023, for their voiding patterns. No concerns were noted, and the voiding patterns were noted to be similar to the residents' baseline voiding patterns. d) Resident #101, #23, and #94 verbalized no complaints or concerns to the ED or DON, who followed up with these residents on 07/04/2023, 07/05/2023, 07/06/2023, and 07/07/2023. e) The Executive Director and Director of Nursing reviewed the residents' activities participation record for 07/04/2023, 07/05/2023, and 07/06/2023 revealing a normal activities pattern for residents. f) The ED, DON, Licensed Nurses, and State Registered Nurse Aides (SRNA), for residents on the North 2 Unit, from 07/04/2023 to 07/06/2023, encouraged fluids, offered to close blinds in rooms, dressed residents in light clothing, and checked residents for appropriate/light bed linen. g) The plan of care was reviewed and revised for each resident that resided in Resident Rooms 14 to 28 for 07/04/2023 through 07/06/2023. 2. a) Each resident in Rooms 14 to 28 were provided with a fan on the afternoon of 07/04/2023. On the morning of 07/05/2023 at approximately 11:30 AM, the ED purchased additional fans to ensure that each resident had a fan. b) On 07/04/2023 at approximately 6:40 PM, the DON made rounds and assessed residents in Rooms 14 to 28 on the North 2 Unit, where the a/c unit required repairs and was not working. No residents were noted with any distress. All resident rooms had fans in place. In addition, the DON completed a temperature check of the hallway and resident room temperatures, with all being noted in the 75 to 76 degree F range. c) Temperature checks were obtained from 07/04/2023 through 07/06/2023 of the North 2 Hall and Resident Rooms 14 to 28 beginning at 6:40 PM on 07/04/2023, and again at 10:00 PM on 07/04/2023. Temperature checks were obtained on 07/05/2023 at 7:40 AM, 8:56 AM, 9:42 AM, 10:36 AM, 11:50 AM, 1:10 PM, 2:40 PM, 3:50 PM, 4:25 PM, 6:10 PM, 8:30 PM, and 10:15 PM. On 07/06/2023 were done at 12:30 AM, 7:20 AM, 12:05 PM, 4:00 PM, and 10:05 PM. d) On 07/04/2023 at approximately 9:40 PM, the Maintenance Supervisor contacted a contractor specializing in heating and cooling (HVAC) related to family concerns about a resident's room temperature. The ED emailed the Regional Maintenance Supervisors, on 07/04/2023 at approximately 11:29 PM, informing them of the current a/c issues and inquiring about obtaining mobile cooling units in the event repairs could not be made timely. On 07/04/2023, the HVAC contractor recommended to turn off the heating/air unit as he thought it might be freezing. This action was completed by the DON, at approximately 10:00 PM. The contractor stated to turn the unit on again at 3:00 AM, after a few hours being off. This was done by the Charge Nurse on duty. e) On the morning of 07/05/2023 at approximately 7:40 AM, the North 2 Hallway and random room temperatures were obtained by the ED, which ranged from 74 to 77 degrees F. The ED determined that the a/c was still functioning below capacity, notified the HVAC representative, and was informed the company would be onsite on 07/05/2023 to diagnose and make repairs. f) On 07/05/2023 at approximately 11:00 AM, HVAC technicians arrived at the facility and began repairs. On 07/05/2023 at approximately 6:45 PM, the ED was notified by the HVAC company that the a/c repair would not be able to be finished today as previously stated and that the repairs would be finished on 07/06/2023. The delay was because the company could not obtain the amount of refrigerant needed for the repair. The facility's plan to purchase air conditioner (a/c) units for each room was then activated. The DON purchased twelve (12) window a/c units at approximately 8:00 PM, and each resident on the North 2-Unit was offered a window a/c unit. The residents in room [ROOM NUMBER] declined the a/c unit. g) The affected a/c unit was repaired (affecting Rooms 14 to 28) on 07/06/2023 at approximately 4:00 PM. All a/c units in the facility were inspected by the HVAC contractor on 07/05/2023 and 07/06/2023 with no other affected units identified. 3. A Resident Council meeting was held on 07/05/2023 with no concerns/issues noted related to the a/c unit requiring repair or facility temperatures (Resident Rooms 14 to 28). 4. a) All care team members including nursing, contracted therapy, housekeeping/laundry, and dietary were educated on 07/07/2023 on the Emergency Operations plans, with loss of cooling, residents rights, signs and symptoms of hyperthermia, dehydration, heat exhaustion, safe/homelike environment, acceptable temperatures (temperatures between 71-81 degrees F) for the facility, and grievances. The education was given by the ED, DON, the Assistant Director of Nursing (ADON), or the Infection Preventionist. No care team member would be permitted to work until education was completed. Staff members on vacation could receive the education over the phone, and department managers were notified on 07/06/2023 to review work schedules and schedule education for those staff members not currently working on 07/06/2023 or 07/07/2023. All new hire care team members would receive the education described above in orientation. The Maintenance Director was educated by the ED on 07/07/2023 to complete temperature checks on all areas of the facility including hallways and resident rooms daily for two (2) weeks. The ED and/or DON could assist with temperature monitoring. b) Routine HVAC service checks would be completed monthly on all units by an HVAC company beginning August 2023. c) Resident room temperatures would be emphasized/discussed in the daily (Monday-Friday) Magic Moment program (facility internal program utilization for quality improvement purposes by the Interdisciplinary Team, consisting of the ED, DON, ADON, Infection Preventionist/Staff Development Coordinator (IPSD), Dietary Manager, Social Services Director, MDS Coordinator, Maintenance Supervisor, Medical Records Coordinator, and Registered Nurse (RN) Unit Managers. d) Post tests would be conducted for care team members on Emergency Operations plans with loss of cooling, resident rights, signs and symptoms of hyperthermia, dehydration, heat exhaustion, safe/homelike environment, and grievances. The IPSD would conduct the post tests weekly for one (1) month and then monthly for three (3) months to ensure retention of the education. The IPSD/ADON would forward the post tests the Quality Assurance Committee for review by Executive Director or Director of Nursing. The Quality Assurance Performance Improvement (QAPI) Committee consisted of the ED, DON, ADON, IPSD, Social Services, Dietary Manager, RN Unit Managers, MDS Coordinators, Maintenance Supervisor, Medical Records Coordinator, and the Medical Director. 5. a) An ad hoc QAPI Committee meeting was held on 07/07/2023 with the ED, DON, Medical Director, Regional [NAME] President, Director of Social Services, ADON, IPSD, and MDS Coordinator present. The meeting reviewed a plan of action, education, audit tools being performed by the facility regard the alleged deficiencies. An ad hoc QAPI meeting would be held weekly for four (4) weeks by the ED and the DON. b) After the initial daily air temperature monitoring for two (2) weeks, air temperatures of random resident rooms, hallways, and other areas of the facility would be conducted weekly for one (1) month and then monthly for three (3) months by the ED, the DON, or the Maintenance Supervisor. Emergency Preparedness drills, specifically loss of cooling, would be completed weekly for one (1) month and then monthly for three (3) months. The results would be forwarded to the QAPI committee by the Maintenance Director or the ED. The State Survey Agency (SSA) validated removal of the IJ on 07/08/2023, as alleged by the facility, as follows: 1. a) Review of respiratory assessment forms for Resident #101, #23, and #94 revealed there was documentation that indicated assessments were completed for 07/04/2023, 07/05/2023, 07/06/2023, and 07/07/2023 regarding signs and symptoms of distress and heat exhaustion. The assessments included temperature values, oxygen saturation, lung sounds, and current respiratory status. No abnormal assessment values were noted. Review of respiratory assessment forms for the residents that resided in Rooms 14 to 28 revealed lungs clear, no shortness of breath, and oxygen levels WNL, except for residents residing in room [ROOM NUMBER]B, room [ROOM NUMBER]A, and room [ROOM NUMBER]B, who refused an assessment but had no signs/symptoms of distress. Observations on 07/06/2023 initiated at 10:10 AM of Residents #46, #38, #101, and #23, all residents of North 2 Unit, Rooms 14 to 28, revealed no respiratory distress. Review of resident assessment forms done on 07/05/2023 and 07/06/2023, revealed there were no concerns noted per documentation for residents residing in Rooms 14A, 14B, 15A, 15B, 16A, 16B-EMPTY, 17A, 17B, 18A, 18B EMPTY, 19A, 19B, 20A, 20B, 21A, 21B, 22A, 22B, 23A, 23B, 24A, 24B, 25A, 25B, 26A, 26B, 27A, 27B, 28A EMPTY, and 28B. Review of an attestation letter, undated and signed by the ED and the DON with no signature date, revealed no resident declines were reported on 07/04/2023, 07/05/2023, and 07/06/2023. Review of a signed statement from the Respiratory Therapist, dated 07/06/2023, attested no residents were in any distress or had an increased need for oxygen, and there were no changes in their health status. Observations on 7/05/2023 initiated at approximately 9:00 AM, revealed residents in Rooms 9, 19, 23, and 27 had oxygen therapy and appeared in no distress. b) Review of an attestation letter dated 7/04/2023 at 5:10 PM, confirmed the DON offered residents room changes on 07/04/2023, including Resident #101, #23, and #94. Further review revealed Resident #101, #23, and #94 declined the offer. In an interview with the DON on 07/06/2023 at 2:14 PM, she verified room changes were offered. In an interview with the ED on 07/06/2023 at 3:00 PM, he stated room changes were offered to residents but they had declined. In an interview with Resident #101 on 07/05/2023 at 4:48 PM, the resident stated he/she was offered a room change on 07/04/2023 and 07/05/2023 and declined offer the offer. Resident #46 stated in an interview on 07/07/2023 at 10:37 AM, that a room change was offered, but he/she declined. c) Review of resident output records revealed Resident #101's, #23's, and #94's assessment by the ED of their voiding patterns was completed on 07/04/2023, 07/05/2023, 07/06/2023, with no signs or symptoms of dehydration noted. Review of resident output records revealed voiding pattern assessments for the other residents on the North 2 Unit, on 07/04/2023, 07/05/2023, and 07/06/2023 and done by the ED and DON, showed no concerns for dehydration. d) In an interview with Resident #101 on 07/06/2023 at 9:45 AM, the stated an a/c unit had been placed last night and the temperature was better now. Observation during the interview revealed the resident had drinks at the bedside on the overbed table, and an a/c unit was in the window. Review of a written statement/follow-up on Resident #23 on 07/04/2023, 07/05/2023 and 07/06/2023 revealed the follow-up was performed by the ED and the DON. The statement revealed Resident #23 had no complaints or concerns for air temperatures. In an interview with Resident #23 on 07/06/2023 at 10:00 AM, he/she stated the room temperature was adequate. The resident also stated he/she had experienced no declines and did not report the room temperature being hot. Observation, during the interview, revealed Resident #23 was covered in a blanket. In an interview with Resident #94's daughter, on 07/05/2023 at 5:50 PM, she stated the family had purchased an a/c unit about three (3) weeks ago. She also stated the resident had not experienced any decline in health. Observation of Resident #94's room temperature on 07/05/2023 at 5:40 PM, revealed it was within the acceptable temperature range of 71 degrees F and 81 degrees F. and the daughter reported no health declines of her mother. e) Review of Resident #101's Activity Participation Record for 07/04/2023, 07/05/2023, and 07/06/2023 revealed Resident #101 attended activities on both 07/05/2023 and 07/06/2023. On 07/05/2023, the resident attended Current Events and Tablet, Laptop Technology at 11:01 AM. On 07/06/2023, the resident attended the Social at 12:25 PM and Family/Friends Visit at 5:39 PM. Review of activities records for Resident #23 per a notation on the Legend Report, revealed Resident #23 had refused, or was out of the facility, for activities from 07/04/2023 through 07/06/2023. Review of Resident #94's Activity Participation Record for 07/04/2023, 07/05/2023, and 07/06/2023 revealed Resident #94 attended activities on both 07/05/2023 and 07/06/2023. On 07/05/2023, the resident attended Music/Singing/Dance/Memory and Social at 11:00 AM, Reminiscing/Life Reflection at 3:51 PM, and Family/Friends Visit at 7:47 PM. On 07/06/2023, Resident #94 attended the Social at

Based on observation, record review, review of the facility's documents, and review of the facility's policy, it was determined the facility failed to ensure the residents' environment remained free of accident hazards related to water temperatures outside the acceptable range for thirty-two (32) of one hundred ten (110) residents (Resident #94, #64, #98, #25, #16, #46, #90, #69, #108, #77, #60, #107, #95, #85, #414, #53, #99, #68, #34, #36, #54, #15, #73, #71, #100, #26, #21, #70, #31, #91, #9, and #164). Observation of water temperature checks on 07/10/2023 beginning at 4:43 PM, revealed water temperatures in Rooms 14, 15, 16, 19, 20, 23, 29, 48, 49, and 50 were not within the acceptable parameters for ensuring resident safety. The water temperatures ranged between one hundred twelve (112) degrees Fahrenheit (F) and one hundred twenty (120) degrees F. The water temperatures were taken utilizing a metal Bi-Therm hand held thermometer with a dial gauge. In an interview with the Maintenance Director (MD) on 07/10/2023 at 6:10 PM, he stated water temperatures were checked weekly in showers and random rooms; the thermostat was broken; and he was going to replace it with a dial type thermostat. However, during an interview with the Maintenance Director on 07/11/2023 at 6:12 PM, he stated the thermostat had not been replaced. In an interview with the Executive Director (ED) on 07/11/2023 at 7:25 PM, he stated he was made aware of problems with water temperatures on the evening of 07/10/2023. He stated a resident could be burned if the water temperature was too hot. The facility's failure to ensure water temperatures remained at safe levels is likely to cause serious injury, serious harm, serious impairment, or death to residents. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) was identified on 07/11/2023 and was determined to exist on 07/10/2023 in the area of 42 CFR 483.25 Quality of Care F689 at a Scope and Severity (S/S) of a K. The facility was notified of the Immediate Jeopardy on 07/11/2023. The facility provided an acceptable IJ Removal Plan on 07/14/2023 alleging removal of the IJ on 07/13/2023. However, on 07/13/2023 some water temperature readings were above the acceptable level. The SSA validated removal of the IJ on 07/14/2023, prior to exit on 07/17/2023, which lowered the scope and severity (S/S) to an E at 42 CFR 483.25 Quality of Care F689, while the facility develops and implements a Plan of Correction (PoC) and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. In addition, observation of staff using a sit-to-stand lift for one (1) of forty-four (44) sampled residents, Resident #1, on 07/10/2023, revealed the facility failed to provide a safe environment by staff using one (1) of the four (4) lifts that had an improperly maintained and crooked footplate. The findings include: 1. Review of the facility's policy titled, Safe Water Temperatures, dated February 2023, revealed the facility was to maintain appropriate water temperatures in resident care areas. The policy stated direct care staff would monitor residents' prolonged exposure to warm or hot water for any signs or symptoms of burns and respond appropriately. It stated staff members were to be educated on safe water temperatures, and thermometers would be available as needed by staff. Continued review revealed staff would report any abnormal findings such as complaints of water being too cold or too hot, burns, or redness. Per the policy, additional problems for staff to report were reddened areas to the residents' skin that were painful to the touch. The policy stated these abnormal findings were to be reported to the supervisor or maintenance supervisor. Continued review revealed water temperatures were to be no more than one hundred ten (110) degrees F or the state's allowable maximum water temperature. Per the policy, maintenance staff would check water temperature controls and the temperatures of tap water in all hot water circuits weekly and as needed. Additional review revealed documentation of testing would be kept for three (3) years and kept in the maintenance office. Observation on 07/10/2023 at 4:36 PM, revealed the hot water in Resident room [ROOM NUMBER] felt painfully hot to the touch. Observation on 07/10/2023 at 4:43 PM, revealed the hot water temperature in Resident room [ROOM NUMBER] measured 118 degrees F. Continued observations on 07/10/2023 for water temperature checks initiated at 6:07 PM, revealed water temperatures were between 112 degrees F to 120 degrees F for Resident Rooms 14, 15, 16, 19, 20, 23, 29, 47, 48, and 50. Additional observations for water temperatures on 07/12/2023 with checks initiated at 9:05 AM, revealed water temperatures were between 98 degrees F to 116 degrees F for Resident Rooms 14, 15, 16, 19, 20, 23, 29, 47, 48, and 50. Continued observations on 07/13/2023 for water temperature checks initiated at 2:36 PM, revealed water temperatures were between 112 degrees F and 120 degrees F for Resident Rooms 29, 47, 48, 50. There was no hot water for Resident Rooms 14, 15, 16, 20, and 23. Observations initiated at 2:20 PM on 07/14/2023 revealed water temperatures were between 92 degrees F and 98 degrees F for Resident rooms [ROOM NUMBER]. There was no hot water for Resident Rooms 14, 15, 16, 19, 20, and 29. Observations initiated at 4:00 PM on 07/15/2023 for Resident Rooms 14, 15, 16, 19, 20, 23, 29, 47, 48, and 50 revealed water temperature ranges between 94 degrees F and 110 degrees F. Continued observations for water temperatures on 07/16/2023 initiated at 9:12 AM, revealed water temperatures between 96 degrees F and 106 degrees F for Resident Rooms 14, 15, 16, 19, 20, 29, 47, 48, and 50. In an interview on 07/10/2023 at 4:36 PM, Resident #26 (lived in room [ROOM NUMBER]) stated he/she knew to turn some cold water on with the hot water when he/she washed hands to prevent getting burned. In an interview with the Maintenance Director on 07/05/2023 at 6:10 PM, he stated he had been the director for about (two) 2 years, and he was responsible for six (6) other buildings. He stated there were no other maintenance personnel for this facility. In another interview with the Maintenance Director on 07/10/2023 at 6:10 PM, he stated water temperatures were checked weekly in the showers and random rooms. He stated his expectation was for water temperatures to be maintained at 110 degrees F per State regulations. In a continued interview with the Maintenance Director on 07/10/2023 at 6:25 PM, he stated water temperatures were checked weekly and when complaints were reported to him. However, no complaints had been reported. He stated the process he followed was when complaints occurred, he adjusted the water temperature for the hot water tanks located in the mechanical room; waited about ten (10) minutes; and, rechecked the water temperatures again. In an additional interview with the Maintenance Director on 07/11/2023 at 6:12 PM, he stated the thermostat that controlled the hot water tanks for the North Hall, located in the mechanical room, was in disrepair. He stated the plan was to replace the thermostat with equipment already purchased. However, he stated, as of yet, he had not had time to install a new thermostat because he was the only maintenance staff at the facility. Observation of the North Hall hot water tank thermostat in the mechanical room on 07/11/2023 at 6:12 PM, revealed the thermostat was lying horizontally with what appeared to be a mercury looking substance split in half which placed the substance at each end of the thermostat and not in center. Because of this, reading a temperature could not be done with the broken thermostat. In an interview with the Maintenance Director at the time of the observation on 07/11/2023 at 6:12 PM, he stated the North Hall thermostat should not be like that, it should be vertical. He stated he thought the hot temperature in the mechanical room had caused the breakage of the mercury appearing substance. When asked how long the thermostat had been like that, he stated for a while now, but he was unable to give the exact date or timeline. He stated he would replace it with a dial like thermostat, and it should be done as soon as possible. The Maintenance Director stated the thermostats were checked two (2) times weekly for accuracy, but he did not state what method was used for the checks. He stated the maintenance guidance he received from the Corporate Office was for the hot water tanks to be drained monthly. He stated this task was performed last month, June 2023, and he thought the hot water system was about two (2) to three (3) years old. In an interview with the Executive Director (ED) on 07/11/2023 at 7:25 PM, he stated he was not aware of any problems with water temperatures. He stated he was first made aware last night, on 07/10/2023, and had not received any reports from residents or staff of water temperatures being too hot. He stated he was not aware of any residents getting burned, but a resident could be burned if the water temperatures were too hot. The ED stated to prevent elevated water temperatures, he reviewed the maintenance records two (2) to three (3) times a week, in addition a report was e-mailed to him each Sunday. He stated if there was an issue, he would report it to the Quality Assurance and Performance Improvement (QAPI) Committee. He added he relied upon the maintenance staff to report any elevated water temperatures. In another interview with the ED on 07/17/2023 at 11:22 AM, he stated his job was to provide oversight on a day-to-day basis for the facility and ensure regulations were followed. 46710 2. The State Survey Agency (SSA) Surveyor, on 07/15/2023, requested the facility's policies on safety and supervision of residents, as well as a policy on the use of mechanical lifts. However, the facility did not provide those policies. Review of the facility's maintenance logs revealed the Maintenance Director inspected the EZ Way Sit-to-Stand lift (brand of lift that assist residents to stand) on 05/18/2023 and 06/21/2023, but marked the section, Check foot platform assembly pins on sit to stand to assure they have to pushed in and still engage into base, as NA, or not applicable. Review of Resident #1's Admission Record revealed the facility admitted the resident, on 11/01/2012, with diagnoses including Multiple Sclerosis, Diabetes with Diabetic Neuropathy, and Anxiety Disorder. Review of Resident #1's Annual Minimum Data Set Assessment, dated 05/12/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fifteen (15) of fifteen (15), which indicated the resident was cognitively intact. Further review revealed the facility assessed the resident as requiring extensive assistance of a two (2) person physical assistance for transferring from wheelchair to bed. Review of Resident #1's care plan, revised 07/07/2023, revealed the facility assessed Resident #1 to require a sit-to-stand lift with at least one (1) staff assist to transfer. Observation on 07/10/2023 at 4:15 PM, revealed State Registered Nurse Aide (SRNA) #4 and SRNA #8 using a sit-to-stand lift to transfer Resident #1 from his/her wheelchair to his/her bed. Further observation revealed the footplate of the lift was crooked, with the right side of the footplate lower than the left side. In an interview on 07/10/2023 at 4:25 PM, SRNA #4 stated she had not noticed that the footpad of the lift was crooked. She stated she would place an out of order sign on the lift so it would not be used with another resident because it might be unsafe. SRNA #4 stated inspection of the lifts was performed by the Maintenance Director. However, she did not know how often the inspections were performed. The SSA was unable to interview the Maintenance Director, as the facility had terminated his employment during the survey. In an interview on 07/16/2023 at 10:21 AM, the Assistant Director of Nursing (ADON) stated she expected staff not to use a lift that appeared to be in disrepair and to notify management immediately. In an interview on 07/17/2023 at 3:15 PM, the Director of Nursing (DON) stated she expected staff to inspect mechanical lifts before use with a resident to ensure the lift was in good working order and place an out of order sign on the lift if it was not. She stated staff should put the lift out of order on the lift. The DON stated it was important because if there was a problem residents could be hurt if parts of the lift were loose or not in the correct placement. The DON stated she had personally inspected the sit-to-stand lift that SRNA #4 had shown her with the crooked footplate. She explained that the footplate was designed to come off the lift for cleaning and had pins that held it in place. Per interview, the DON stated she inserted the pins in the correct slots and ensured all pieces were in working order before returning the lift to service. The DON stated the Maintenance Director inspected mechanical lifts once per month. She stated she could not explain why the Maintenance Director had marked NA for inspecting the pins of the footplate in the inspections completed on 05/18/2023 and 06/21/2023. In an interview on 07/17/2023 at 5:06 PM, the Executive Director (ED) stated it was his expectation that staff would place a mechanical lift with a loose piece, out of order, because using equipment in poor condition could hurt a resident. The facility provided an acceptable IJ Removal Plan on 07/14/2023 alleging removal of the IJ on 07/13/2023 as follows: 1. a) A new thermostat was placed on the affected hot water heater on 07/11/2023 at approximately 9:40 PM by the Maintenance Director. Water temperatures were checked and documented in every resident room, sink, and shower room in the facility on the evening of 07/11/2023 at approximately 10:00 PM by the Maintenance Director and ED. b) A body audit was completed on every resident by the DON, Assistant Director of Nursing (ADON), or Infection Preventionist/Staff Development Coordinator (IPSD) on 07/11/2023 with no skin issues related to water temperatures. Resident interviews were also conducted for each resident able to communicate, and had a Brief Interview for Mental Status of eight (8) and higher regarding water temperatures. No resident reported any uncomfortable water temperatures. 2. a) All staff including nursing, contracted therapy, housekeeping/laundry, and dietary would be educated by the DON, ADON, or IPSD regarding the facility's policy on Safe Water Temperatures, with acceptable water temperature ranges (not to exceed 110 degrees F). The education would also include actions to complete if the water felt hot to the touch, such as using the facility provided digital thermometer available at each nurses' station to immediately take the water temperature. Education began on 07/11/2023 with no care team member being permitted to begin working prior to completing education. All new hire staff would receive the education described above in orientation prior to working. b) The Maintenance Director received individual one-to-one (1:1) education on 07/11/2023 by the ED regarding the facility's policy on Safe Water Temperatures, with acceptable water temperature ranges (not to exceed 110 degrees F). He was also educated on immediate actions to complete if any water temperature was found out of range or any equipment needed repair, as well as immediately communicating this to the ED. c) Water temperatures for the last thirty (30) days in four (4) resident rooms on each of the two hallways in the facility was completed by the ED on 07/11/2023. No water temperatures exceeding 110 degrees F or out of range temperatures were found. d) An Ad Hoc QAPI (Quality Assurance Performance Improvement) meeting was held on 07/11/2023 with the ED, DON, MDS Coordinator, Central Supply/Scheduler, Maintenance Director, Director of Medical Records, and Director of Social Services. The meeting reviewed actions, education, and audit tools being used by the facility regarding the alleged deficiency. e) A contracted plumbing service inspected all water heaters/thermostats to ensure they were in good working order and provided any additional repairs as needed on 07/12/2023. f) A follow-up Resident Council meeting would be held on 07/12/2023 where participants would discuss the Safe Water Temperatures policy. The meeting would update the participants on the recent repairs to the hot water management system. 3. a) Water temperatures would be checked daily in four (4) resident rooms on each of the two hallways in the facility for one (1) week beginning on 07/11/2023, then moved to three (3) times per week for one (1) month, if no out of range temperatures reported. b) Post test questionnaires would be completed to ensure that the education provided was effective. Five (5) questionnaires/interviews would be completed daily (Monday-Friday) for one (1) month; then two (2) times a week for two (2) weeks; and then monthly for two (2) months. The post test questionnaire would be given by the Assistant Director of Nursing, Infection Preventionist/Staff Development, Director of Social Services or Director of Nursing who would forward results to the Quality Assurance Committee for review. This would begin on 07/11/2023. c) Water temperatures would be discussed at the monthly Resident Council meeting beginning August 2023. d) An ad hoc QAPI meeting would be held weekly for four (4) weeks, starting 07/07/2023. The State Survey Agency validated the IJ Removal Plan. The validation verified that the immediacy was removed on 07/14/2023, instead of 07/13/2023 as alleged. The water temperatures on 07/13/2023 remained elevated above acceptable levels. 1. a) Review of a signed statement, undated, from the ED revealed a new hot water heater thermostat was placed on the North Unit water heater, on 07/11/2023 at approximately 9:40 PM, by the Maintenance Director. Observation of the North Unit water heater's new thermostat was made on 07/17/2023 at 5:47 PM. Review of the water temperature log dated 07/11/2023 at 9:55 PM, revealed the facility had the water temperatures recorded for all residents' room's sinks and showers. The log revealed the water temperatures ranged from 103 degrees F to 110 degrees F, in the acceptable range. In an interview on 07/17/2023 at 2:11 PM with the ED, he confirmed he was with the Maintenance Director on 07/11/2023 and checked water temperatures in all residents' rooms and shower rooms. b) Review of the body audit skin assessments conducted by the DON and the ADON on all residents in the facility, dated 07/11/2023, revealed there were no skin issues related to water temperatures. Review of the Resident Roster list, dated 07/11/2023, revealed Brief Interview for Mental Status (BIMS) scores of all residents. All residents with a BIMS' score of eight (8) to fifteen (15) and were interviewable were interviewed on 07/11/2023 with their statements recorded. The statements revealed no reports of uncomfortable water temperatures mentioned by the residents. Review of a signed statement from the ED, undated, revealed residents with a BIMS' score of eight (8) to fifteen (15) were interviewed by him on 07/11/2023 regarding water temperature. No resident had reported any uncomfortable water temperatures. During an interview on 07/17/2023 at 2:11 PM, the ED stated he interviewed all residents with a BIMS' score of eight (8) to fifteen (15), and there were no reports of uncomfortable water temperatures. 2. a) Review of a staff roster sheet titled,Water Temperature Education, dated 07/10/2023, revealed all staff were listed and checked as receiving education on 07/10/2023 and 07/11/2023. Any new staff will be educated before starting work. A document titled, Education was attached to the staff roster with the education topics listed, including acceptable water temperatures of 110 Fahrenheit or below; and actions to complete if the water felt hot to the touch, such as keeping residents safe by removing them from the area if applicable; testing the water temperature with a facility provided thermometer; turning off the water under the sink if the temperature exceeded 110 degrees Fahrenheit, and notifying the supervisor on duty immediately so maintenance staff and the ED could be notified. In an interview on 07/17/2023 at 8:39 AM with the DON, she confirmed she assisted the ADON and the IPSD with providing water temperature education to all staff before they began their shifts. All staff members, including agency staff, were provided education before their shifts began. In an interview on 07/17/2023 at 10:06 AM, Licensed Practical Nurse (LPN) #11 stated the DON provided her education regarding water temperatures, water thermometers, and to whom to report abnormal water temperatures. In an interview on 07/17/2023 at 1:19 PM, Housekeeper #1 stated last week, before she started work, she had training on water temperatures, what to do if they were too hot, and to whom to report too hot water temperatures. In an interview on 07/17/2023 at 1:32 PM, Registered Nurse (RN) #1 stated she had a training on water temperatures last week before she could begin work. She stated the training included the safe water temperature range, and the thermometer at the nurses' station would be used to check water temperatures. RN #1 stated she was educated, if the water was too hot, to turn off the water. She stated she also learned to whom she was to notify about the water being too hot. In an interview on 07/17/2023 at 10:00 AM, State Registered Nurse Aide (SRNA) #28 stated she was provided safe water temperature education from the ADON last week before she could begin her shift at work. She stated she learned if the water temperature felt too hot in the resident's room, she would turn it off and report it immediately to the supervisor. In an interview on 07/17/2023 at 2:11 PM, the ED stated all new staff members would receive training and education regarding safe water temperatures in orientation before the start of their shift. b) Review of a statement, dated 07/11/2023 and signed by the Executive Director, revealed the statement documented the Maintenance Director received one-to-one (1:1) education regarding the facility's policy on safe water temperatures. The ED stated the educational content was acceptable water temperatures were not to exceed 110 degrees F. The educational content also included immediate actions to complete if any temperatures were found out of range or any equipment needed repair, as well as communicating this to the ED. c) Review of the Logbook Documentation Water Temps, dated 06/07/2023, revealed water temperatures on the North Hall room [ROOM NUMBER] at 110 degrees F; North Hall room [ROOM NUMBER] at 110 degrees F; North Hall room [ROOM NUMBER] at 109 degrees F; and North Hall room [ROOM NUMBER] at 109 degrees F. Further review revealed South Hall water temperatures for room [ROOM NUMBER] at 109 degrees F; South Hall room [ROOM NUMBER] at 109 degrees F; South Hall room [ROOM NUMBER] at 109 degrees F; and South Hall room [ROOM NUMBER] at 109 degrees F. Review of the Logbook Documentation Water Temps, dated 06/15/2023, revealed water temperatures on North Hall room [ROOM NUMBER] at 110 degrees F; North Hall room [ROOM NUMBER] at 110 degrees F; North Hall room [ROOM NUMBER] at 108 degrees F; and North Hall room [ROOM NUMBER] at 109 degrees F. Further review revealed the South Hall water temperatures for room [ROOM NUMBER] at 110 degrees F; South Hall room [ROOM NUMBER] at 110 degrees F; South Hall room [ROOM NUMBER] at 109 degrees F; and South Hall room [ROOM NUMBER] at 109 degrees F. Review of the Logbook Documentation Water Temps, dated 06/22/2023, revealed water temperatures on the North Hall room [ROOM NUMBER] at 109 degrees F; North Hall room [ROOM NUMBER] at 110 degrees F; North Hall room [ROOM NUMBER] at 108 degrees F; and North Hall room [ROOM NUMBER] at 108 degrees F. Further review revealed the South Hall water temperatures for room [ROOM NUMBER] at 108 degrees F; South Hall room [ROOM NUMBER] at 109 degrees F; South Hall room [ROOM NUMBER] at 108 degrees F; and South Hall room [ROOM NUMBER] at 109 degrees F. Review of the Logbook Documentation Water Temps, dated 06/29/2023, revealed water temperatures on the North Hall Rooms #1, #10, #19, #28 were all within the normal temperature range. Further review revealed the South Hall water temperatures for Rooms #29 at 110 degrees F; South Hall room [ROOM NUMBER], #47 and #56 were all within the normal range. Review of the Logbook Documentation Water Temps, dated 07/04/2023, revealed water temperatures on the North Hall Rooms #1, #10, #19, #28 were within normal range. Further review revealed the South Hall water temperatures for Rooms #29, #38, #47 at 110, #56 were within the normal range. d) Review of the Ad hoc QAPI Meeting Attendance Form, Discussed IJ Removal Plan for F689 Quality of Care, dated 07/11/2023, revealed the ED, DON, Minimum Data Set Coordinator, Central Supply/Scheduler, Maintenance Director, Director of Medical Records, and the Director of Social Services, attended the meeting. Further review revealed an education sheet regarding safe water temperatures, actions to take for unsafe water temperatures, and audit tools used to include temperature logs and performed by the facility regarding the alleged deficiency. e) Review of a receipt from a plumbing company, dated 07/12/2023, revealed the job detail of hot water was too hot, and the facility wanted water heaters inspected and to also check the mixing valves. In an interview on 07/17/2023 at 2:11 PM with the ED, he confirmed the contracted plumbing company did inspect all water heaters and thermostats on 07/12/2023. He stated the contracted plumbing company ensured the thermostats were in good working order and provided any repairs that were needed. f) Review of the Resident Council meeting minutes, dated 07/12/2023, revealed Residents #41, #1, #4, #29, #18, #59, #42, #15, #49, #91, and #31 attended. Further review revealed the residents that attended were updated on the current hot water situation, safe water temperatures, and recent repairs to the hot water management system. 3. a) Review of Water Temperature Observations, dated 07/12/2023, revealed all resident room water temperatures were recorded at 9:40 AM. The temperatures ranged from 96 degrees F to 110 degrees F. Review of the Water Temperature Observations, dated 07/13/2023, revealed all residents' room water temperatures were recorded at 7:30 AM. The temperatures ranged from 100 degrees F to 109 degrees F. Review of theWater Temperature Observations, dated 07/14/2023, revealed all resident room water temperatures were recorded at 7:20 AM. The temperatures ranged from 102 degrees F to 109 degrees F. Review of the Logbook Documentation Water Temps, dated 07/15/2023, 07/16/2023 and 07/17/2023 revealed water temperatures for taken for the North Hall and South Hall rooms were within normal range. Observation on 07/17/2023 at 4:28 PM of the ED, revealed he was checking water temperatures in resident rooms. Review of a binder containing post tests, revealed post tests regarding safe water temperature were given to five (5) different staff members on 07/11/2023, 07/12/2023, 07/13/2023, 07/14/2023, and 07/17/2023. In an interview on 07/17/2023 at 8:39 AM, the DON stated that she administered the post test questionnaire to staff and forwarded the results to the QAPI Committee for review. She stated she reviewed them immediately with staff to address any questions or concerns.

Based on interview, record review, review of the facility's investigation reports, and review of the facility's policy, it was determined the facility failed to protect residents from resident-to-resident abuse which affected eleven (11) of fifty (50) sampled residents (Residents #1, #38, #40, #70, #89, #99, #264, #364, #365, #367, and #416). Resident #70, on 08/27/2022, threw coffee on Resident #264's chest area while the resident was sitting in his/her doorway, leaving a reddened area on Resident #264's chest. Resident #89, on 11/17/2022, hit Resident #1's arm which caused a bruise because Resident #1 closed the window blinds. Resident #364 was involved in the following: on 10/07/2021, he/she entered Resident #38's room and struck the resident; on 11/07/2021, he/she entered Resident #40's room and struck the resident; on 02/07/2022, he/she entered Resident #367's room and struck the resident leaving a red mark on the bridge of the nose; and on 02/24/2022, he/she struck Resident #365 in the face while in the hallway. Resident #99, on 12/27/2022, entered Resident #416's room and hit the resident on the head with a reacher (an assistive device for grabbing objects). The findings include: Review of the facility's policy titled, Abuse, Neglect, and Exploitation, dated 04/2023, revealed the policy prohibited abuse of residents. Per the policy, abuse meant the willful infliction of injury, including physical abuse with examples to include hitting, slapping, pinching, and kicking. Continued review of the policy revealed prevention measures included that knowing every resident might be at risk for abuse, and wandering behaviors increased the risk of abuse. It stated those identified at risk would have care planned interventions designed to reduce the threat of abuse or neglect. Further review revealed Care Team members would have ongoing training to include how to report abuse to the Executive Director (ED). 1. Review of the facility's investigation, dated 09/01/2022, revealed, on 08/27/2022, Resident #70 had thrown coffee on Resident #264. Further review of the facility's Self-Reported Incident Form Final Report, no date given, revealed SRNA (State Registered Nurse Aide) #29 was assisting a resident with lunch when she heard Resident #264 yell. The report revealed SRNA #29 checked on Resident #264, and he/she was sitting in the doorway of Resident #70's room with the front of his/her shirt wet with what appeared to be coffee. The report stated SRNA #29 asked Resident #70 if he/she had thrown coffee on Resident #264, and Resident #70 replied, I sure did. Per the report, SRNA #29 immediately reported the incident to Licensed Practical Nurse (LPN) #5. Review of Resident #70's Admission Record revealed the facility initially admitted the resident on 10/01/2021 and readmitted the resident on 10/13/2021, with diagnoses that included Alcohol Abuse, Anxiety Disorder, and Depressive Disorder. Review of Resident #70's Annual MDS Assessment, dated 10/31/2022, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fourteen (14) of fifteen (15), which indicated the resident was cognitively intact. Review of Resident #70's care plan, dated and revised on 10/12/2021, revealed a focus that the resident exhibited signs of cognitive impairment related to confusion and memory deficit. Interventions placed on 10/12/2021 included to encourage Resident #70 to use the call light to alert staff for assistance if other residents entered his/her room. Also, an intervention placed on 08/27/2022 was to place a stop sign across the resident's doorway to discourage/prevent other residents from entering the room. No additional revisions or updates were noted. Review of Resident #264's Admission Record revealed the facility initially admitted the resident on 06/22/2022 and readmitted him/her on 11/28/2022, with diagnoses that included Altered Mental Status, Chronic Obstructive Pulmonary Disease (COPD), and Alzheimer's Disease. Review of Resident #264's Admission MDS Assessment, dated 06/29/2022, revealed the facility assessed the resident to have a BIMS' score of zero (0) of fifteen (15), which indicated the resident had severe cognitive impairment. Review of Resident #264's care plan, dated 06/29/2022, revealed a focus that the resident exhibited behaviors that included wandering with interventions placed on 07/14/2022. The interventions included to provide the resident with redirection and remove him/her from the situation. No other revisions were noted after the 08/27/2022 incident. Review of Resident #264's wandering assessment tool, dated 12/05/2022, revealed a score of twelve (12), which indicated the resident was a high risk for wandering. Review of the facility's Progress Notes, dated 08/27/2022 at 1:12 PM by Licensed Practical Nurse (LPN) #5, revealed she had been notified by SRNA #29 that Resident #70 threw hot coffee on Resident #264. Per the note, LPN #5 had instructed Resident #70, after the incident, to use his/her call light, and Resident #70 stated, I will do what I want. Further review of the Progress Notes revealed Resident #264 was removed from Resident #70's room, assessed, and a cold compress was placed on his/her chest, with Silvadene ointment (a topical antimicrobial drug used to treat burns) applied. Review of Resident #264's skin assessment, dated 08/27/2022 and performed by the DON, revealed no apparent injury and no signs or symptoms of a burn. The assessment stated the nurse applied Silvadene, and the chest area was circled on the skin assessment body audit. In an interview with Resident #70 on 07/13/2023 at 4:15 PM, the resident stated he/she felt safe at the facility and had not had any trouble with any staff or residents. The resident added no one had mistreated him/her in any way and did not recall any incident with another resident. Resident #70 stated there were times when other residents would wander in his/her room but not many since the stop sign had been put on the door. In an interview with SRNA #29 on 07/15/2023 at 8:11 PM, she stated she was assisting another resident at mealtime in a nearby room and heard someone holler. She stated she immediately went to that area and found Resident #264 sitting in the doorway of Resident #70's room, and Resident #70 had a coffee cup in his/her hand. She added Resident #264's shirt was wet with coffee. The SRNA stated she asked Resident #70 what had happened, and the resident told her he/she had thrown coffee on Resident #264. SRNA #29 stated she immediately got the nurse and took Resident #264 to his/her room. She added Resident #264's shirt was removed, and she observed his/her chest area and upper belly was reddened. However, she stated there were no blisters, and Resident#264 voiced no complaints of pain. She stated she could not recall Resident #70 having any physical aggression toward others, but the resident was verbally abusive to other residents and staff at times. She stated the verbal abuse would come on very quickly like flipping a light switch on and off. In an interview with Registered Nurse (RN) #1 on 07/14/2023 at 1:55 PM, she stated, to the best of her memory, Resident #70 had always had verbal behaviors since being a resident at the facility. She stated some of the behaviors noted were screaming at his/her son and other residents and calling one resident a midget. In an interview with the DON on 07/16/2023 at 10:40 AM, she stated she was made aware of Resident #70 throwing coffee on Resident #264's chest area, and a skin assessment was performed and Silvadene ointment was applied to the area. However, she stated there were no indications of a burn only, some redness. She stated she knew Resident #264 had been removed from Resident #70's doorway and taken to his/her room immediately. She stated staff knew to watch Resident #264 to prevent him/her from entering other residents' rooms since he/she at times would wheel himself/herself around. The DON stated she felt there were no other interventions to be developed since staff had been trained and retrained on resident altercations. In an interview with the Executive Director (ED) on 07/18/2023 at 11:22 AM, he stated he was made aware that Resident #70 threw coffee on Resident #264 by the nurse. He stated to the best of his memory it happened on a weekend. The ED stated he had not been made aware of any behaviors of Resident #70, but he knew Resident #264 had a history of wandering. 2. Review of the facility's investigation, dated 11/23/2022, revealed Resident #1 reported Resident #89 hit his/her left arm on 11/17/2022. Further review of the facility's Self-Reported Incident Form Final Report, no date given, revealed Resident #1 reported to the ADON that Resident #89 hit him/her on the left mid-forearm and left upper arm while the resident attempted to open the window blinds. Review of Resident #1's Admission Record revealed the facility admitted the resident, on 11/01/2012, with diagnoses that included Diabetes, Anxiety, and Morbid Obesity. Review of Resident #1's Quarterly MDS Assessment, dated 12/16/2022, revealed the facility assessed the resident to have a BIMS' score of twelve (12) of fifteen (15), indicating the resident had moderate cognitive impairment. Review of Resident #1's care plan, dated 08/15/2022, revealed a focus that the resident exhibited behavior symptoms of combativeness, such as slapping and hitting, with interventions placed to re-direct as needed and remove the resident from the situation. Review of Resident #89's Admission Record revealed the facility admitted the resident, on 09/01/2021, with diagnoses to include Vascular Dementia and Psychotic Disorder. Review of Resident #89's Quarterly MDS Assessment, dated 11/28/2022, revealed the facility assessed the resident to have a BIMS' score of zero (0) of fifteen (15), indicating the resident had severe cognitive impairment. Review of Resident # 89's care plan, dated 11/02/2022, revealed behavior symptoms of yelling, cursing, refusing care, smacking/ hitting staff, and during care, refusing to answer assessment questions and telling staff to leave me alone, don't touch me, I'm not talking to you. Further review revealed interventions placed on 11/02/2022 included to provide re-direction and remove the resident from the situation. No revisions were noted after the 11/17/2022 incident. Review of Resident #1's skin assessment, dated 11/17/2022, revealed a bruise to the left forearm measuring two (2) inches by one (1) inch and circled on the facility's body audit tool. Review of Resident #89's skin assessment, dated 11/17/2022, revealed no apparent injuries. In an interview with Resident #1 on 07/14/2023 at 4:45 PM, he/she stated he/she felt safe at the facility, and no one had hurt him/her including another resident. Interview with Resident #89 was attempted on 07/14/2023 at 5:00 PM, but could not be done due to the resident's low BIMS score. Also, when spoken to, the resident yelled get out. In an interview with Registered Nurse (RN) #1 on 07/14/2023 at 1:55 PM, she stated to the best of her memory she had heard Resident #1 scream, and upon entering the room of Resident #1 and Resident #89, who were roommates, she found Resident #89 hitting the window shades. She stated she thought she remembered a bruise to Resident #1 arm. She stated Resident #89 had been at the facility for awhile, and he/she exhibited paranoid behavior at times. However, she did not give an example. She stated Resident #89 was moved to another room but was unsure of the date. In an interview with the ADON (Assistant Director of Nursing) on 07/14/2023 at 2:45 PM, she stated Resident #1 had come to the front desk and reported the incident of Resident #89 hitting his/her arm, but there had been no witnesses. She stated she did a skin assessment on Resident #1, and she found a reddened area to the left arm which did look fresh. The ADON stated she had no reports of behavior like that from Resident #89. She stated the only report she had received was Resident #89's refusal of care, and the resident had never been violent to her knowledge. In an interview with the DON (Director of Nursing (DON) on 07/15/2023 at 10:40 AM, she stated she received a report that Resident #1 and Resident #89 had gotten into an argument over the window blinds, and Resident #1 held onto Resident #89's wheelchair to prevent the window blinds from being opened. The DON stated there were no witnesses, but Resident #1 did have a bruise on his/her arm. In an interview with the ED on 07/17/2023 at 11:22 AM, he stated Resident #1 had reported the incident to the ADON, but he had not witnessed the incident and had not seen Resident #1's arm. The ED stated there had been no reports of any altercations between the residents before. 46710 3. Review of Resident #364's Admission Record revealed the facility admitted the resident, on 09/14/2021, with diagnoses of Encephalopathy and Sequelae of Infectious Diseases. Further review revealed the facility added Psychotic Disorder with Delusions to Resident #364's diagnoses on 09/27/2021. Review of Resident #364's Admission Minimum Data Set (MDS) Assessment, dated 09/21/2021, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of zero (0) of fifteen (15), which indicated severe cognitive impairment. Further review revealed the facility assessed the resident as requiring supervision when walking in the corridor, and on or off the unit. Continued review revealed the facility identified Resident #364 as having behaviors of wandering one (1) to three (3) days during the look back period. Review of Resident #364's care plan, dated 09/26/2021, revealed the facility identified the resident as exhibiting signs of cognitive impairment and dementia and included interventions such as, being alert to nonverbal cues of unmet needs and intervening as indicated. Further review revealed, on 10/07/2021, the facility added providing redirection if the resident was noted wandering into other residents' rooms and placing large print signage on Resident #364's door to assist the resident in finding his/her room. a) Review of the facility's investigation revealed, on 10/07/2021, Resident #364 entered Resident #38's room and struck him/her with a plastic coffee cup. Further review revealed State Registered Nurse Aide (SRNA) #24 wrote a statement that she heard Resident #38 yelling and went to his/her room. Per review, Resident #368 stated he/she witnessed Resident #364 strike Resident #38. Review of Resident #38's Admission Record revealed the facility admitted the resident, on 08/14/2020, with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD), Rheumatoid Arthritis, and Anxiety. Review of Resident #38's Quarterly Minimum Data Set (MDS) Assessment, dated 04/17/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fifteen (15) of fifteen (15), which indicated the resident was cognitively intact. In an interview on 07/11/2023 at 11:10 AM, Resident #38 stated Resident #364 came into his/her room and hit him/her with a plastic coffee cup. Resident #38 stated he/she yelled for help to get Resident #364 out of his/her room. Resident #38 further stated a staff member came and redirected Resident #364 back to his/her room after the incident. Per the interview, Resident #38 stated he/she felt angry that the facility failed to keep Resident #364 out of his/her room and subsequently striking him/her. In an interview on 07/15/2023 at 1:51 PM, SRNA #24 stated she recalled Resident #364 going into Resident #38's room, but did not recall the altercation between the residents. In an interview on 07/17/2023 at 8:16 AM, SRNA #13 stated she was working on 10/07/2021 and Resident #38 told her that Resident #364 hit him/her with a plastic coffee cup. SRNA #13 stated she saw a small amount of spilled coffee, but she did not see any sign of injury on Resident #38. In an interview on 07/16/2023 at 5:34 PM, the current Infection Preventionist and Staff Development (IPSD) Coordinator, who was the Charge Nurse on 10/07/2021, stated she came to Resident #38's room right after the altercation with Resident #364. She stated Resident #38 told her Resident #364 had been in his/her room and hit him/her with a plastic coffee cup. The IPSD stated she believed Resident #364 was confused and startled when Resident #38 yelled at him/her to get out of his/her room, Resident #364 struck Resident #38 as a result. In further interview, she stated it was her expectation that staff members remained aware residents that wandered and kept them out of other residents' rooms. In an interview on 07/17/2023 at 3:15 PM, the Director of Nursing (DON) stated she and the Executive Director (ED) investigated the altercation between Resident #364 and Resident #38. Per the interview, she stated the facility determined the cause of the altercation was that Resident #364 wandered into Resident #38's room. The DON stated their investigation revealed Resident #364 struck Resident #38 with a plastic coffee cup when Resident #38 yelled at Resident #364 to get out of his/her room. The DON also stated Resident #364 was not receiving constant one-to-one (1:1) supervision but stated staff, including management, knew to keep an eye on him/her and keep him/her occupied because Resident #364 wandered into other residents' rooms. In further interview, the DON stated her expectations were for staff to redirect residents that wandered out of other residents' rooms and ensure the safety of all residents. In an interview on 07/17/2023 at 5:06 PM, the Executive Director (ED) stated Resident #38 reported to him on 10/07/2021 that Resident #364 hit him/her with a coffee cup. Per the interview, the ED stated he initiated an investigation, interviewed witnesses, and determined the incident had occurred. The ED also stated he sat with Resident #364 on 10/07/2021 for a while after the altercation to ensure the safety of the residents. In further interview, the ED stated it was his expectation that staff kept residents that wandered occupied as much as possible to decrease wandering and monitored them to keep all residents safe. b) Review of the facility's investigation revealed, on 11/07/2021, Resident #364 wandered into Resident #40's room, sat on his/her bed, and struck him/her in the face when Resident #40 yelled at Resident #364 to get out of his/her room. Further review revealed SRNA #23 heard Resident #40 yelling and came to the room to redirect Resident #364 back to his/her room. Further review revealed staff found a red mark on the bridge of Resident #40's nose. Review of Resident #40's Admission Record revealed the facility admitted the resident, on 03/28/2017, with diagnoses that included Schizophrenia, Bipolar Disorder, and Unspecified Intellectual Disabilities. Review of Resident #40's Quarterly MDS Assessment, dated 07/10/2023, revealed the facility assessed the resident to have a BIMS' score of twelve (12) of fifteen (15), which indicated the resident was moderately cognitively impaired. In an interview on 07/13/2023 at 4:02 PM, Resident #40 stated a long time ago a resident came into his/her room, sat on his/her bed, and hit him/her in the head. Resident #40 further stated he/she yelled for help, and an SRNA came and took the person out of his/her room. In an interview on 07/17/2023 at 9:02 AM, Resident #2, Resident #40's roommate, stated a long time ago a resident came into his/her room, sat on his/her roommate's bed, and hit the roommate. In further interview, Resident #2 stated there had not been a further incident since the facility placed a mesh stop sign across the door to his/her room. In an interview on 07/16/2023 at 6:17 PM, SRNA #23 stated he came to Resident #40's room when he heard yelling on 11/07/2021 and saw Resident #364 strike Resident #40 in the face. SRNA #23 stated he immediately separated the residents, redirected Resident #364 back to his/her room, provided him/her with a snack, and reported the incident to the nurse. In an interview on 07/16/2023 at 5:34 PM, the current IPSD, who was the Charge Nurse on 11/07/2021, stated SRNA #23 and Resident #40 told her Resident #364 struck Resident #40 in the face. The IPSD further stated she assessed Resident #40 and noted a small red mark on the bridge of Resident #40's nose. In an interview on 07/17/2023 at 3:15 PM, the DON stated she was in the facility at the time of the altercation between Resident #364 and Resident #40 and began investigating it immediately. She stated her investigation revealed SRNA #23 was in the room next door to Resident #40's room, heard Resident #40 call out, and responded immediately to remove Resident #364 from the situation. Per the interview, no staff witnessed Resident #364 enter Resident #40's room. In further interview, the DON stated the facility placed Resident #364 on fifteen (15) minute checks for a few days following this altercation for his/her safety, as well as the safety of other residents. In an interview on 07/17/2023 at 5:06 PM, the ED stated his recollection of the altercation between Resident #364 and Resident #40 was that Resident #364 wandered, unwitnessed, into Resident #40's room, sat on his/her bed, and struck Resident #40 in the face when he/she waved his/her arms to try to shoo Resident #364 out of the room. Per the interview, the ED stated Resident #40 had a small red mark on his/her nose, but no further injuries. The ED stated it was his expectation that residents with a history of physical violence resulting in harm to themselves or others would be monitored closely with one-to-one (1:1) supervision or fifteen (15) minute checks. The ED stated the facility placed Resident #364 on one-to-one (1:1) supervision while the investigation was ongoing. However, he stated it was not the facility's practice to sustain one-to-one (1:1) supervision because a resident had the right to move about the facility freely. c) Review of the facility's investigation revealed, on 02/07/2022, Resident #367 reported Resident #364 entered Resident #367's room and struck him/her on the head. Further review revealed Licensed Practical Nurse (LPN) #10 heard Resident #367 state, Get out of here!, and saw Resident #364 walk out of Resident #367's room. Continued review revealed Resident #364 entered the room behind LPN #10 when she brought medicine to Resident #367. Per the investigation, when LPN #10 left, she failed to redirect Resident #364 back out of Resident #367's room. Review of the facility's document ,Incident Note, dated 02/07/2022, revealed LPN #10 wrote she heard Resident #367 say Get out of here! and went to check on the resident. Further review revealed Resident #367 told LPN #10 another resident hit him/her in the head. Continued review revealed LPN #10 assessed Resident #367 for injuries or skin discoloration and found none. Review of Resident #367's Admission Record revealed the facility admitted the resident, on 01/13/2022, with diagnoses including Malignant Neoplasm of the Right Lung (lung cancer), Parkinson's Disease, and Depression. Review of Resident #367's Admission MDS Assessment, dated 01/20/2022, revealed the facility assessed the resident to have a BIMS' score of eleven (11) of fifteen (15), indicating moderate cognitive impairment. Further review revealed the facility assessed Resident #367 as requiring one (1) person physical assist for bed mobility, as well as for walking in his/her room and/or the corridor. Interview not conducted with Resident #367 due to the resident's discharge from the facility. In an interview on 07/16/2023 at 1:32 PM, LPN #10 stated she recalled hearing Resident #367 call out, and she went to the resident's room to check on him/her. LPN #10 further stated she saw Resident #364 leave the room. Per the interview, Resident #367 told LPN #10 that Resident #364 had hit him/her on the head. LPN #10 stated she did not see any injuries on Resident #367. LPN #10 stated she did not recall leaving Resident #364 in Resident #367's room unsupervised and did not believe she would have done so because she knew Resident #364 had a history of striking other residents. In an interview on 07/17/2023 at 3:15 PM, the DON stated her investigation into the altercation between Resident #364 and Resident #367 revealed LPN #10 left Resident #364 in Resident #367's room unsupervised, which was not acceptable practice, due to Resident #364's known history of resident-to-resident abuse. In an interview on 07/17/2023 at 5:06 PM, the ED stated the facility's investigation revealed Resident #367 stated Resident #364 entered his/her room with LPN #10, but LPN #10 failed to redirect Resident #364 out of the room when she left. The ED stated Resident #364 struck Resident #367 on the head after LPN #10 left the room. d) Review of the facility's investigation revealed, on 02/24/2022, Resident #364 was going through binders at the nurses' station, and Resident #365 told him/her to stay out of the binders. The investigation stated both residents wandered away from the nurses' station, and LPN #10 witnessed Resident #364 strike Resident #365 in the face with an open hand. Review of Resident #365's Admission Record revealed the facility admitted the resident, on 10/12/2021, with diagnoses including Congestive Heart Failure, Chronic Respiratory Failure, and Alzheimer's Disease. Review of Resident #365's Quarterly MDS Assessment, dated 06/20/2022, revealed the facility assessed the resident to have a BIMS score of six (6) of fifteen (15), indicating severe cognitive impairment. Further review revealed the facility assessed the resident as requiring supervision with a one (1) person physical assist while walking in the corridor. Continued review revealed the facility assessed the resident as having behaviors of wandering one (1) to three (3) days during the look-back period. Review of Resident #365's care plan, dated 10/25/2021, revealed the facility assessed the resident as having wandering behaviors and included interventions such as redirecting the resident when wandering and observing the resident for unmet needs as indicated. In an interview on 07/16/2023 at 1:32 PM, LPN #10 stated Resident #364 was at the nurses' station on 02/24/2022, looking at binders, when Resident #365 walked by and told him/her that he/she should stay out of them. LPN #10 stated neither resident appeared agitated, and each resident wandered toward their respective rooms. LPN #10 stated she started to follow the residents, when she observed Resident #364 slap Resident #365. LPN #10 further stated she had been too far away from the residents to stop the altercation, but separated them immediately afterwards. In an interview on 07/16/2023 at 10:21 AM, the Assistant Director of Nursing (ADON) stated she did not recall the specifics of the altercation between Resident #364 and Resident #38; Resident #364 and Resident #40; and Resident #364 and Resident #365. She stated she remembered Resident #364 going into Resident #367's room, but did not recall specific circumstances that led to the incident. The ADON stated her expectations for supervision of residents were that all staff members were aware of wandering residents and ensured their safety. In further interview, she stated the facility was attempting to find a bed in a facility with a secured memory care unit for Resident #364 during February 2022 because they could no longer provide the level of care he/she required. She stated there was a potential for harm to other residents. In an interview on 07/17/2023 at 3:15 PM, the DON stated Resident #364 slapped Resident #365 in the face while both residents were walking down the hall on 02/24/2022. She further stated LPN #10 witnessed the incident, but was not physically close enough to the residents to prevent the slap. The DON stated the facility found a bed for Resident #364 in a secured unit in another facility because that level of care would keep Resident #364 and other residents in the facility safer. In an interview on 07/17/2023 at 5:06 PM, the ED stated Resident #364 slapped Resident #365 in the face while walking down the hall, after Resident #365 told Resident #364 not to bother things at the nurses' station. The ED stated he believed the facility had done everything they could to prevent Resident #364 from striking other residents because residents had a right to move freely around the facility, as the facility did not have a secured unit. 47711 4. Review of the facility's investigation, dated 12/27/2022, revealed Resident #99 hit Resident #416 on the top of the head with his/her reacher. Further review of the facility's investigation revealed Resident #416 was sitting on the side of the bed with his/her head covered while praying when he/she was hit. Review of Resident #416's Admission Record revealed the facility admitted the resident, on 12/06/2022, with diagnoses of Muscle weakness, COPD, and Chronic Respiratory Failure with Hypoxia. Review of Resident #416 Admission MDS Assessment, dated 12/13/2022, revealed the facility assessed the resident to have a BIMS score of eleven (11) of fifteen (15), which indicated the resident had moderately impaired cognition. Review of Resident #99's Admission Record revealed the facility admitted the resident, on 04/14/2022, with diagnoses of Dementia, Bipolar Disorder, and Acute Kidney Failure. Review of Resident #99's Annual MDS Assessment, dated 12/28/2022, revealed the facility assessed the resident to have a BIMS score of twelve (12) of fifteen (15), which indicated the resident had moderately impaired cognition. Review of Resident #99's care plan, dated 05/18/2022 with a revision on 12/27/2022, revealed the resident had verbal behaviors with paranoid beliefs and had voiced seeing things that were not there. The care plan had no interventions for supervision, only to redirect the resident as needed. Review of a Nursing Progress Note, dated 12/27/2022 at 8:58 PM and entered by LPN #5, revealed Resident #99 went into Resident #416's room and hit him/her over the head with a grabber/reacher. In an interview on 07/16/2023 at 9:10 AM with LPN #5, she stated Resident #416 told her that Resident #99 came into his/her room and hit him/her on the head with a reacher while he/she was praying. Furthermore, LPN #5 stated that Resident #99 had told her that he/she did hit Resident #416. In an interview on 07/15/2023 at 3:07 PM with the Executive Director (ED), he stated he expected all staff to follow all the facility's policies. In another interview with the ED on 07/18/2023 at 11:22 AM, he stated a task of his job was to provide oversight of the operations of the facility, which included investigations of abuse. He stated staff members were educated to provide protection of residents and notify the nurse and himself immediately when there was an allegation of abuse.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure residents' medications were administered at an error rate below five percent (5%). Observation of the medication administration revealed a medication error rate of eleven percent (11%). Medications were not available for four (4) of thirty-six (36) opportunities for two (2) of ten (10) residents sampled for medication administration (Residents #69 and #94). The findings include: Review of the facility's policy titled, Medication Administration, dated 2023, revealed medications were administered by licensed nurses, or other staff who were legally authorized to do so in this state; as ordered by the Physician and in accordance with professional standards of practice; and in a manner to prevent infection from contamination. Further review revealed to keep the medication cart clean, organized, and stocked with adequate supplies. 1. Observation of the medication administration on 07/14/2023 at 8:11 AM, with Licensed Practical Nurse (LPN) #12 revealed Resident #69 had a medication order on his/her Medication Administration Record (MAR) for Ocuvite Adult 50+ (eye vitamins) to be administered three (3) times a day. However, the medication was not available for administration. Observation on 07/13/2023 at 2:59 PM, revealed State Registered Nurse Aide/Certified Medication Technician (SRNA/CMT) #21 failed to administer Resident #65's five (5) milligram (mg) tablet of Buspirone (used to treat anxiety) as ordered. This medication was missing from the medication cart. Further observation revealed CMT #21 went to the facility's Pyxis system (automated medication dispensing system) and searched for the Buspirone. However, the medication was not available. 2. Observation on 07/14/2023 at 9:00 AM, of the medication administration with LPN #12, revealed Resident #94 had Calcium Carbonate 1000 milligrams (mg) chewable medication everyday at 8:00 AM and Miramax 17 grams (gms) in 8 ounces (oz) of water every day. Further observation revealed neither of the medications were available for administration. In an interview on 07/13/2023 at 3:03 PM, CMT #21 stated her process when she encountered an ordered medication that was not available in the medication cart she checked the Pyxis system and emergency box to see if the medication(s) were located there. CMT #21 stated the 5 mg tablet of Buspirone was on order from the pharmacy and would be delivered that evening, at which time the next dose of the medication would be administered. During an interview on 07/14/2023 at 8:32 AM, LPN #12 stated that if a medication was not available on the medication cart the nurse looked in the emergency box for a refill or overstock. LPN #12 stated the nurse administering the medication was responsible for ordering the medications from the pharmacy. The LPN stated the medication should be ordered when the stock was getting low. During an interview on 07/16/2023 at 4:48 PM, the Director on Nursing (DON) stated that it was the charge nurses', who were working on the floors, responsibility to reorder the residents' medications. The DON stated overstock should be checked when the medication on the cart got down to a few doses. She stated if a medication was not in overstock, it should be ordered at that time. The DON further stated that best practice was to order medication before it was out, and she expected staff to order medication when it was low in stock. During an interview on 07/15/2023 at 3:28 PM, the Executive Director (ED) stated that he expected all staff including agency staff to follow the facility's policies.

Based on observation, interview, review of the facility's refrigerator temperature logs, review of the manufacturer's instructions for [NAME] Ready Care Nutrition, and review of the facility's policy, it was determined the facility failed to store food safely for two (2) of two (2) nourishment refrigerators. Observations, on 07/11/2023, of the South Unit nourishment refrigerator revealed residents' food products with no name and no room number. The 06/2023 and 07/2023 temperature logs had elevated temperatures recorded. The temperature logs for 03/2023, 04/2023, and 05/2023 were incomplete. Observation of the North Unit nourishment refrigerator revealed the documentation of the 07/2023 temperature log had a range of recorded temperatures of forty-six (46) to fifty-three (53) degrees Fahrenheit (F). This was higher than the acceptable range of thirty-six (36) to forty-one (41) degrees Fahrenheit on the Refrigerator Temperature Log. Also, the facility's policy temperature range was for the residents' food to store under refrigeration at a maximum temperature of forty-one (41) degrees Fahrenheit. The findings include: Review of the facility's policy titled, Resident Personal Food Policy, dated 06/2018, revealed all residents' foods would be stored in a secured container labeled with the resident's name, date purchased or prepared, and product name. Perishable foods would be stored under refrigeration at a temperature of forty-one (41) degrees Fahrenheit or less. Per the policy, frozen foods would be stored at a temperature of zero (0) degrees Fahrenheit or less. The policy stated perishable food stored under refrigeration would be discarded after three (3) days, and frozen items would be discarded sixty (60) days from the date of storage or per package expiration. Review of the facility's form Refrigerator Temperatures revealed a log with instructions for the temperature to be checked and recorded daily, with an acceptable temperature range of thirty-six (36) to forty-four (44) degrees Fahrenheit; and to notify the supervisor of temperatures out of range. 1. Observation on 07/11/2023 at 11:00 AM of the South Unit nourishment refrigerator revealed a package of Snap Dilly Bites, dated 10/01/2023, with no resident identification; one (1) Pepsi Zero bottle and one (1) regular Pepsi bottle, sixteen (16) ounces, with no date or resident identification. The small freezer section in the refrigerator had two (2) boxes of Klondike Bars with two (2) ice cream bars left in each. The Klondike Bar package, dated 09/09/2023, contained melting soft ice cream that had leaked out of the silver foil wrapper into the box. The other Klondike Bar package, dated 09/11/2023, contained bars which were soft to the touch in a silver foil wrapper. Review of the March 2023 Refrigerator Temperature log on the South Unit revealed no temperatures were recorded for nineteen (19) of thirty-one (31) days, from 03/01/2023 through 03/19/2023. Review of the April 2023 Refrigerator Temperature log on the South Unit revealed no temperatures were recorded for twenty-five (25) of thirty (30) days. Temperatures were not recorded from 04/01/2023 through 04/15/2023; 04/17/2023 through 04/23/2023; 04/27/2023; 04/29/2023; and 04/30/2023. Review of the May 2023 Refrigerator Temperature log on the South Unit revealed no temperatures were recorded for twenty-six (26) of thirty-one (31) days. Temperatures were not recorded from 05/01/2023 through 05/07/2023; 05/09/2023 through 05/15/2023; 05/17/2023; 05/19/2023 through 05/22/2023; 05/24/2023; and 05/26/2023 through 05/31/2023. Review of the July 2023 Refrigerator Temperatures log on the South Unit revealed documented food temperatures of thirty-seven (37) to forty (40) degrees Fahrenheit, with no indication of the freezer temperature. Continued review of the nourishment refrigerator temperature for 07/09/2023 revealed the temperature was recorded as seventy-five (75) degrees Fahrenheit. In an interview on 07/14/2023 at 8:58 AM and 11:31 AM with the Registered Nurse (RN) South Unit Manager (RN/Unit Manager), she stated dietary staff brought food for the nourishment refrigerator and nursing staff restocked the refrigerator. She stated residents' food items needed to be labeled with the resident's name and room number. The RN/Unit Manager stated this was important so the residents had access to their food, and other residents did not receive food that was not on their diet which could be harmful to the resident. She stated staff often should check the refrigerator temperatures and document them on the temperature log. The RN/Unit Manager stated she monitored the food temperature logs because staff forgot to fill out the temperature log. She stated if the food temperature log was not completed, she tried to get staff to fill in the temperatures. The RN/Unit/Manager stated food could spoil if not kept at the appropriate temperature. 2. Observation on 07/11/2023 at 11:10 AM of the North Unit nourishment refrigerator revealed no food products were stored in the freezer. However, the refrigerator had an unopened Ensure (nutritional supplement) container dated 05/14/2023 and a one-quarter (1/4) full opened [NAME] Ready Care Nutrition container with a manufacturer's date of 11/13/2023 and no opened date. Review of the manufacturer's instructions for the [NAME] Ready Care Nutrition, used for medication administration, recommended to use within nine (9) months from production date, to keep at room temperature, and do not freeze. The instructions also stated to refrigerate the product prior to serving, and once opened, recap, refrigerate, and use within seventy-two (72) hours. Review of the Refrigerator Temperatures log on the North Unit, for the nourishment refrigerator revealed on 07/01/2023, a temperature of fifty-three (53) degrees Fahrenheit, and on 07/03/2023, no temperature was recorded. Further review revealed on 07/04/2023, a temperature of fifty (50) degrees Fahrenheit; on 07/05/2023, a temperature of forty-nine (49) degrees Fahrenheit; on 07/06/2023, a temperature of forty-eight (48) degrees Fahrenheit; on 07/07/2023, a temperature of forty-eight (48) degrees Fahrenheit; on 07/08/2023, a temperature of fifty (50) degrees Fahrenheit; and on 07/09/2023, a temperature of forty-six (46) degrees Fahrenheit. In an interview on 07/14/2023 at 11:15 AM with RN #2/North Unit Manager, she stated the staff should have told her the temperature of the nourishment refrigerator was not within the acceptable range, even if the thermometer was broken. She stated if the refrigerator temperature was not within the acceptable range, the residents' food would not be kept at a safe temperature. She further stated the difference in the acceptable temperature ranges between the facility's policy of food being stored at a temperature of forty-one (41) degrees Fahrenheit maximum and the Refrigerator Temperatures log of forty-four (44) degrees Fahrenheit maximum was because the medication, nourishment, and lab refrigerators all used the one (1) monthly form. In an interview, on 07/16/2023 at 5:10 PM with the Director of Nursing (DON), she stated her expectation was for staff to record the nourishment refrigerator temperatures daily and report to the supervisor or DON if the temperatures were out of range. She stated staff should throw out the food if the temperatures were out of range. She also stated food from the resident's family needed to be labeled with the resident's name and dated. In an interview on 07/16/2023 at 5:23 PM with the Executive Director (ED), he stated his expectation for staff was to record daily food nourishment refrigerator temperatures. He stated staff should notify the supervisor if the nourishment refrigerator temperatures were out of range.

Based on interview, record review, review of the facility's investigation report, and review of the facility's policies, it was determined the facility failed to keep the resident free from misappropriation of resident property, for one (1) of fifty (50) sampled residents (Resident #415). On 12/04/2020, Resident #415 reported to the Infection Preventionist/ Staff Development Coordinator (IPSD) that a female (later identified as State Registered Nurse Assistant (SRNA) #31) removed a diamond ring from his/her finger and replaced it with a cheap ring on 12/03/2020. Additionally, review of the facility's investigation report, dated 12/04/2020, revealed SRNA #31 later came to the facility and returned the ring to the Executive Director (ED). The facility terminated SRNA #31 immediately. Further review of the facility investigation revealed that Law Enforcement had been notified after Resident #415 reported his/her ring missing. The findings include: Review of the facility's policy titled, Resident Rights, revised date December 2016, revealed the residents had a right to be free from abuse, neglect, misappropriation of property, and exploitation. Review of the facility's policy titled, Resident Abuse Prevention Protection of Residents, dated 2019, revealed the facility defined abuse as causing intentional pain or harm. The policy further defined misappropriation of property/funds as the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent. Review of Resident #415's Admission record revealed the facility admitted the resident, on 07/29/2020, with diagnoses of Cardiomyopathy, Vascular Dementia, and Cognitive Communication Deficit. Review of Resident #415's Quarterly Minimum Data Set (MDS) Assessment, dated 12/11/2020, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fourteen (14) of fifteen (15), which indicated the resident was cognitively intact. Review of the facility's investigation, dated 12/04/2020, revealed Resident #415 reported his/her ring was missing to the IPSD. Per the report, the resident told the IPSD that on 12/03/2020 a female came into the resident's room and removed his/her ring from his/her finger. Per the report, the female stated she was going to give the resident a manicure in the morning. Resident #415 provided the IPSD a description of the female that had came into her/his room. Continued review revealed the IPSD stated in an interview with the Executive Director (ED) that on 12/03/2020, SRNA #31 had not clocked out at the end of her shift and was in Resident #415's room. Continued review revealed on 12/04/2020 SRNA #31 was interviewed by the ED and denied being in Resident #415's room. Further review revealed SRNA #31 requested a meeting with the ED and returned a ring that was later identified by Resident #415 as belonging to him/her. Per the report, SRNA #31 was immediately terminated. During an interview on 07/15/2023 at 3:07 PM, the IPSD stated SRNA #31 was in Resident #415's room on 12/03/2020, after she was supposed to clock out. The IPSD stated that Resident #415 later told her that an SRNA came into his/her room, removed his/her ring from his/her finger, and replaced it with a cheap ring. During an interview on 07/15/2023 at 3:28 PM, the ED stated the IPSD had reported to him, on 12/04/2020, that Resident #415 reported his/her ring was missing. The ED stated, on 12/04/2020, he interviewed Resident #415, and the resident stated that an SRNA took his/her ring off his/her finger. The ED stated Resident #415 informed him the SRNA told him/her that she was going to give him/her a manicure. The ED stated Resident #415 provided a description of the SRNA during the interview. Furthermore, the ED stated that the first time he spoke with SRNA #31 she denied being in Resident #415's room. However, he stated SRNA #31 later came to his office and returned Resident #415's ring. The ED stated that all staff members were given abuse trainings, and all staff members were expected to follow the facility's policy.

Based on interview, record review, review of 906 [NAME] (Kentucky Administrative Regulations) 1:190, Section 1(4), a disqualifying offense, and review of 21 CFR (Code of Federal Regulations) 1308.11, it was determined the facility failed to screen a new employee for disqualifying offenses in the background check for (1) of eleven (11) personnel files reviewed (the Maintenance Director). The findings include: Review of the Kentucky National Background Check Disqualifying Offenses List revealed, Pursuant to 906 [NAME] 1:190, Section 1(4), a disqualifying offense included, a conviction of, or plea of guilty to a misdemeanor offense of unlawfully possessing or trafficking in a legend drug or controlled substance occurring less than seven (7) years from the date of the criminal background check. Review of 21 CFR 1308.11 (d)(23) revealed it listed marihuana as a controlled substance with a Drug Enforcement Agency (DEA) Controlled Substances Code Number of 7360. Review of the Maintenance Director's employee file revealed he began employment on 02/20/2022. Continued review revealed his background check, dated 02/19/2022 and completed by the facility's contract company. The review revealed the Maintenance Director's background check noted a conviction of operating a vehicle under the influence of alcohol on 10/20/2014 and a second conviction on 06/08/2015. Further review revealed a conviction of possession of marijuana (marihuana) on 06/08/2015. During interview with the Human Resource Specialist on 07/14/2023 at 2:01 PM, she stated she started working at the facility on 01/03/2021. She stated the facility used a contracted service, to perform the background checks for new employees. The Human Resource Specialist stated if there was any criminal charge, the background check was sent to the regional office. She stated when a background check came to her the employee did not have any disqualifying convictions. During telephone interview with the previous Human Resource Specialist on 07/14/2023 at 3:15 PM, she stated if there were no disqualifying convictions the background checks came to her at the facility. She stated she would then continue with the employment process. The previous Human Resource Specialist stated if there was a disqualifying conviction the regional office would not approve employment at the facility, and the application would not have come to her. During telephone interview with the [NAME] President of Human Resources (VPHR), on 07/15/2023 at 10:05 AM, she stated she had been in the position for about four (4) years. She stated the facility used a contract service for the background checks prior to hiring any employee. The VPHR stated the employee listed the states where he/she had previously resided, and those were the states the facility requested background checks. She stated when the background check did not have any disqualifying convictions, she continued with the application for the employee. When interviewed why the facility hired an employee that had a previous conviction for marihuana possession, she stated marihuana was not a controlled substance. During telephone interview with the Senior [NAME] President of Operations on 07/15/2023 at 4:25 PM, he stated he did not have a role in the hiring process at the facility. He stated he relied on the Human Resources Department to assure all background checks were done. The Senior [NAME] President of Operations stated he had been in the position for about ten (10) weeks. He stated he was not told of any problems with employees' background checks. During interview with the Executive Director on 07/16/2023 at 9:55 AM, he stated he got an e-mail when an application came in for a new employee. He stated the corporation did not do the background check until after the employee interviewed. He stated he got a notification if there were any flags on the background check. The Executive Director stated the corporation gave a list of the disqualifying events for employment. He stated he did not think marihuana was a disqualifying conviction.

Based on interview, record review, review of the facility's investigative reports, and review of the Resident Assessment Instrument (RAI) Manual, it was determined the facility failed to develop and implement effective care plan interventions for four (4) of fifty (50) sampled residents (Residents #364, #264, #89, and #99). Residents #364, #264, #89, and #99 were involved in resident-to-resident altercations and did not have their care plans fully developed or implemented to prevent abuse. The findings include: In an interview with the Director of Nursing (DON) on 07/11/2023 at 9:32 AM, she stated the facility did not have a specific care plan policy; however, utilized the Resident Assessment Instrument (RAI) manual. Review of the RAI manual, section 4.7 titled, The RAI and Care Planning, dated 10/2019, revealed the care plan described the services that were to be furnished to attain or maintain the residents' highest practicable physical, mental, and psychosocial well-being. 1. Review of the facility's investigative reports revealed Resident #364 was involved in the following resident-to-resident altercations: on 10/07/2021, he/she entered Resident #38's room and struck the resident; on 11/07/2021, he/she entered Resident #40's room and struck the resident; on 02/07/2022, he/she entered Resident #367's room and struck the resident; and on 02/24/2022, he/she struck Resident #365 in the face while in the hallway. Review of Resident #364's Admission Record revealed the facility admitted the resident, on 09/14/2021, with diagnoses of Encephalopathy and Sequelae of Infectious Diseases. Further review revealed the facility added Psychotic Disorder with Delusions to Resident #364's diagnoses on 09/27/2021. Review of Resident #364's Admission Minimum Data Set (MDS) Assessment, dated 09/21/2021, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of zero (0) of fifteen (15), which indicated severe cognitive impairment. Further review revealed the facility assessed the resident as requiring supervision when walking in the corridor, on the unit, and/or off the unit. Continued review revealed the facility identified Resident #364 as having behaviors of wandering one (1) to three (3) days during the lookback period. Review of Resident #364's Care Plan, dated 09/26/2021, revealed the facility identified the resident as exhibiting signs of cognitive impairment and dementia and included interventions to be alert to nonverbal cues of unmet needs and intervene as indicated. Further review revealed, on 10/07/2021, the facility added providing redirection if the resident was noted wandering into other residents' rooms and placing large print signage on Resident #364's door to assist the resident in finding his/her room. Continued review revealed, on 02/07/2022, the facility added the intervention, Provide snack, assist to bed and observe whereabouts closely to ensure the safety of all residents for the remainder of night shift. The facility; however, failed to implement the resident's care plan related to observing for the whereabouts of the resident and failed to develop the resident's care plan to include interventions of adding an activity board, to engage the resident. In an interview on 07/14/2023 at 2:05 PM, State Registered Nurse Aide (SRNA) #18 stated care plans were important because that was the tool to communicate to staff what each resident needed and what interventions were effective with each resident. SRNA #18 further stated she took care of Resident #364 when he/she was in the facility and knew to redirect him/her if he/she went into another resident's room. Per the interview, at the time of Resident #364's admission, SRNA #18 stated if she was in another resident's room providing care and heard a call bell or an alarm indicating a stop sign banner had been disconnected, she would make sure the resident she was caring for was safe, and respond to the call light because she knew that could be a resident calling for help in getting Resident #364 out of their room. SRNA #18 stated staff did their best to monitor Resident #364 from entering other resident's rooms, but it was not always possible while caring for other residents. In an interview on 07/16/2023 at 1:32 PM, Licensed Practical Nurse (LPN) #10 stated care plans were important because that was the tool used to ensure residents received the care they needed. LPN #10 further stated she knew to keep an eye on Resident #364 because he/she would wander and had a history of hitting other residents and staff. Per the interview, Resident #364 was not receiving one-to-one (1:1) supervision or monitoring at specific intervals, such as every fifteen (15) or thirty (30) minute checks, unless it was in the immediate follow-up to a resident-to-resident altercation. Further, LPN #10 stated the care plan interventions she would try with Resident #364 were to put on a television show or offer an activity board, but nothing would hold his/her attention for very long. In an interview on 07/14/2023 at 3:29 PM, the Minimum Data Set Coordinator (MDSC) stated she recalled discussing Resident #364's wandering into other residents' rooms at the morning Interdisciplinary Team (IDT) meetings. She further stated she remembered the team added different interventions to Resident #364's care plan, including providing increased supervision if the resident displayed physical aggression, redirection away from other residents' rooms, offering snacks, and offering activity boards to engage the resident. In an interview on 07/14/2023 at 10:41 AM, the North Unit Manager stated Resident #364 frequently wandered into other residents' rooms, but she did not recall specifics of any of the resident-to-resident altercations the facility reported. Per the interview, Resident #364 was redirectable at first, but as his/her dementia progressed, he/she began lashing out physically and was much more difficult to redirect. Therefore, she stated the facility sent Resident #364 to a secured unit, where he/she would be safer. The North Unit Manager stated residents that wander required increased supervision. However, she stated the facility did not provide sustained one-to-one (1:1) supervision because a resident who required that belonged in a secured memory care unit. The North Unit Manager stated she expected staff to be aware of where residents that wandered were on the unit and redirect them if they wandered into other residents' rooms. She stated she expected staff to assess the resident for unmet needs such as hunger or the need for toileting. The North Unit Manager stated she expected staff to follow care plans to help residents have the best outcomes possible in all areas of care. 2. Review of the facility's incident self-report form, dated 09/01/2022, revealed on 08/27/2022, Resident #70 had thrown coffee on Resident #264, as he/she was sitting in the doorway of Resident #70's room. Review of Resident #264's electronic medical record (EMR) revealed the facility admitted the resident, on 06/22/2022, and readmitted the resident on 11/28/2022, with diagnoses that included Altered Mental Status and Alzheimer's Disease. Review of the Annual MDS Assessment, dated 06/29/2022, revealed the facility assessed the resident to have a BIMS score of zero (0) of fifteen (15), indicating severe cognitive impairment. Review of Resident #264's Care Plan, dated 06/29/2022, revealed the resident exhibited behaviors that included wandering. Further review revealed interventions were placed on 07/14/2022 which included provide redirection and remove from situation. However, the care plan was not developed further to prevent wandering after the 08/27/2022 incident to include watching the resident for entering other residents' rooms, since the resident would at times wheel himself/herself around, or increased supervision. In an interview with the DON on 07/16/2023 at 10:40 AM, she stated she was made aware of Resident #70 throwing coffee on Resident #264. She stated she knew Resident #264 had been removed from Resident #70's doorway and taken to his/her room immediately. The DON stated staff was to watch Resident #264 for entering other residents' rooms since he/she at times would wheel himself/herself around. She added she felt there were no other interventions to be placed since staff had been trained and retrained on resident altercations. 3. Review of the facility's investigation, dated 11/23/2022, revealed Resident #1 reported Resident #89 hit his/her left arm on 11/17/2022. Further review of the facility's Self-Reported Incident Form Final Report, no date given, revealed Resident #1 reported to the Assistant DON (ADON) that Resident # 89 hit him/her on the left mid-forearm and left upper arm while the resident attempted to open the window blinds. Review of Resident #89's Admission Record revealed the facility admitted the resident, on 09/01/2021, with diagnoses that included Vascular Dementia and Psychotic Disorder. Review of Resident #89's Quarterly MDS Assessment, dated 11/28/2022, revealed the facility assessed the resident to have a BIMS' score of zero (0) of fifteen (15), which indicated the resident had severe cognitive impairment. Review of Resident #89's Care Plan, dated 11/02/2022, revealed behavior symptoms of yelling, cursing, refusing care, smacking/hitting staff; and during care, refusing to answer assessment questions and telling staff to leave me alone, don't touch me, I'm not talking to you. Further review revealed interventions placed on 11/02/2022 included to provide re-direction and remove the resident from the situation. However, no further development of interventions to protect residents was noted after the 11/17/2022 incident. 4. Review of the facility's investigation, dated 12/27/2022, revealed Resident #99 hit Resident #416 on the top of the head with his/her reacher. Further review of the facility's investigation revealed Resident #416 was sitting on the side of the bed with his/her head covered while praying when he/she was hit. Review of Resident #99's Admission Record revealed the facility admitted the resident, on 04/14/2022, with diagnoses of Dementia, Bipolar Disorder, and Acute Kidney Failure. Review of Resident #99's Annual MDS Assessment, dated 12/28/2022, revealed the facility assessed the resident to have a BIMS score of twelve (12) of fifteen (15), which indicated the resident had moderately impaired cognition. Review of Resident #99's Care Plan, dated 05/18/2022, with a revision on 12/27/2022, revealed the resident had verbal behaviors with paranoid beliefs and had voiced seeing things that were not there. The care plan; however, had no interventions to include increased supervision, only to redirect the resident as needed. In an interview on 07/16/2023 at 10:21 AM, the ADON stated her expectations were for everyone to implement care plans because the purpose of the care plan was to ensure residents achieved their optimal outcomes. She further stated it was her expectation that all staff monitored wandering residents to ensure their safety. In an interview on 07/17/2023 at 5:06 PM, the Executive Director (ED) stated his expectations for care plans were for the facility to develop an interdisciplinary care plan that described the care the resident required and to further develop the care plan when the resident had changes in their care needs.

Based on interview, record review, and review of the Resident Assessment Instrument (RAI) Manual, it was determined the facility failed to update the care plan for one (1) of fifty (50) sampled residents (Resident #5). The facility failed to update Resident #5's care plan following the resident's readmission, with an ostomy on 06/01/2022. The facility did not update the care plan to include interventions to care for the ostomy until 05/12/2023. The findings include: In an interview with the Director of Nursing on 07/11/2023 at 9:32 AM, she stated the facility did not have a specific care planning policy; they followed the Resident Assessment Instrument (RAI) Manual guidance. Review of the RAI Manual, Section 4.7 The RAI and Care Planning, dated 10/2019, revealed the care plan was revised on an ongoing basis to reflect changes in the resident and the care that the resident required. Review of Resident #5's Admission Record revealed the facility admitted the resident, on 05/17/2022, with diagnoses which included Hemiparesis (paralysis of one side of the body) following Cerebrovascular Disease (stroke) Affecting Left Non-Dominant Side, [NAME] Syndrome (unexplained obstruction of the intestines), and Constipation. Review of Resident #5's Discharge Minimum Data Set (MDS) Assessment, dated 05/25/2022, revealed the facility assessed the resident as not having an ostomy prior to discharge to the hospital with return anticipated. Review of Resident #5's Quarterly MDS Assessment, dated 07/29/2022, revealed the facility readmitted the resident on 06/01/2022. Further review revealed the facility assessed the resident as having an ostomy following his/her readmission. Review of Resident #5's Annual MDS Assessment, dated 05/04/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fifteen (15) of fifteen (15), which indicated the resident was cognitively intact. Review of Resident #5's Care Plan, dated 05/12/2023, revealed the facility failed to include interventions for ostomy care prior to 05/12/2023. In an interview on 07/14/2023 at 3:16 PM, the Minimum Data Set Coordinator (MDSC) stated her process for developing and updating care plans was to review the care plan during care plan meetings following any MDS assessment. The MDSC stated everything on the care plan was expected to reflect the resident's diagnoses, medications, and other care needs. In further interview, the MDSC stated the facility did not have their own care planning policy, but followed the RAI manual guidance on developing and updating care plans. In an interview on 07/16/2023 at 10:21 AM, the Assistant Director of Nursing (ADON) stated her expectations for care plans were for them to be updated following a resident's readmission from the hospital. Per the interview, the ADON stated the facility had failed to update Resident #5's care plan timely. In an interview on 07/17/2023 at 5:06 PM, the Executive Director (ED) stated it was his expectation that the facility updated a resident's care plan whenever the resident came back to the facility following a hospitalization or any time the resident had a change in his/her care needs.

Based on observations, interviews, record review, and review of the facility's policy, it was determined the facility failed to have an effective system to ensure the proper temperature ranges for one (1) of two (2) medication refrigerators. The facility failed to store medications in the North Hall medication refrigerator at a proper temperature. Observation of the refrigerator thermometer on 07/14/2023, revealed a temperature of fifty (50) degrees Fahrenheit (F). Also, review of the temperature logs revealed no temperatures were recorded for 07/03/2023, 07/10/2023, and 07/11/2023. The findings include: Review of the facility's policy titled, Storage of Medication Requiring Refrigeration, dated 2023, revealed it was the policy of the facility to assure proper and safe storage of medication requiring refrigeration and to prevent the potential alteration of medication by exposure to improper temperature control. Further review of the policy revealed the facility would ensure that all medications and biologicals would be stored at proper temperatures and other appropriate environment controls according to the manufacturer's recommendations to preserve their integrity. The policy also stated refrigerated referred to the temperature being maintained between thirty-six (36) to forty-six (46) degrees Fahrenheit (F). Observation of the North Hall medication refrigerator, on 07/14/2023 at approximately 10:00 AM, revealed the temperature was observed to be fifty (50) degrees Fahrenheit. Furthermore, medications for twelve (12) Residents, which included insulins Novolog, Levemir, Lantus, and Basaglar, all in unopened packages were observed in the refrigerator. Package inserts for all insulins stated to store unused medications at thirty-six (36) to forty-six (46) degrees Fahrenheit in the refrigerator. Additional medications included Embrel, Acidophilus, and Acetaminophen suppositories were also observed in the refrigerator. The facility had been instructed by the pharmacy to date unopened insulin and put on the medication cart and to dispose of any other medication that had been in the refrigerator. Review of the facility's medication refrigerator logs for the month of July 2023, revealed the medication refrigerator for the North Hall did not temperatures documented on 07/03/2023, 07/10/2023, 07/11/2023 or 07/14/2023 (when it was observed to be fifty (50) degrees Fahrenheit). Review of the facility's binder located at the North Hall nurses' station, revealed a document titled, Midnight Supervisors Duties. Further review revealed the duties included to record the refrigerator and medication room temperatures. During an interview on 07/15/2023 at 10:44 AM, Licensed Practical Nurse (LPN) #14 stated that he had worked the midnight shift twice and had never been told about a binder at the nurses' station with duties outlined. LPN #14 stated he was never told in shift report about the midnight duties which included checking the medication refrigerator temperature. During an interview on 07/14/2023 at 5:11 PM, the Director of Nursing (DON) stated that the medication refrigerator temperatures were to be checked daily and documented by the midnight nurse on duty. The DON stated the Pharmacy had been contacted regarding the medication in the refrigerator and was told to destroy all the medication except the insulin. The DON stated pharmacy informed the facility that the insulin could be dated and put on the medication cart. In interview the DON stated that all the medications that were destroyed would be delivered/replaced that night, and all the medications that had been in the refrigerator were overstock. During an interview on 07/15/2023 at 3:28 PM, the Executive Director (ED) stated he expected the nurses to check the refrigerator temperatures and the unit managers were to check the temperatures periodically. The ED stated that the temperature ranges were posted on the documentation log on the medication refrigerators. He stated if the temperatures were out of range, he expected staff to notify the pharmacy for guidance. The ED further stated he expected all staff to follow the facility's policies.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to accommodate a resident's food allergy for one (1) of fifty (50) sampled residents (Resident #65). Resident #65, whose Medication Administration Record (MAR) documented the resident was allergic to chocolate, received a chocolate fudge cookie with crushed medications during medication administration on 05/12/2023. The findings include: Review of the facility's policy titled, Medication Administration, copyright date 2023, revealed medications were administered by licensed nurses, or other staff who were legally authorized to do so in the state, as ordered by the physician and in accordance with professional standards of practice. There were no references to allergies in the policy. Review of Resident #65's medical record revealed the facility admitted the resident, on 11/06/2017, with diagnoses of Cerebral Palsy, Expressive Language Disorder, and Anxiety. Review of Resident #65's Quarterly Minimum Data Set (MDS) Assessment, dated 05/09/2023, revealed the facility assessed the resident, under Section C 1000 for Cognitive Skills, as severely impaired for daily decision making. Review of Resident #65's Order Summary Report, revealed an admitted [DATE] and listed allergies as chocolate. Review of Resident #65's Kardex (aide care plan), dated 07/14/2023, listed chocolate under allergies. Review of Resident #65's MAR for May 2023 revealed under allergies chocolate was listed. Review of Resident #65's Health Status Note, dated 05/12/2023 at 9:30 PM, revealed Licensed Practical Nurse (LPN) #6 notified the Nurse Practitioner that Resident #65 received his/her medications on a chocolate fudge cookie and had an allergy to chocolate. The Note stated the resident tolerated it well and had no reaction to the chocolate. Per the note, the night nurse was notified as well. In an interview on 07/14/2023 at 10:30 AM, with Agency LPN #6, she stated she crushed Resident #65's medications and gave them in a chocolate fudge cookie. She stated Resident #65 liked to take medication in a cookie. LPN #6 stated she did not review the allergy on the MAR, which listed chocolate as an allergy. She stated she was told by State Registered Nurse Aide (SRNA) #20 that Resident #65 had chocolate crumbs in his/her bed. The LPN stated she called the Nurse Practitioner and monitored the resident for signs or symptoms of an allergic reaction throughout the night. She stated there was no allergic reaction to the chocolate cookie. LPN #6 stated she missed that chocolate was listed as an allergy. In an interview on 07/14/2023 at 2:21 PM with SRNA #20, she stated Resident #65 had a chocolate allergy, and was not to consume dark or milk chocolate. She stated she had observed chocolate cookie crumbs in the resident's bed and alerted LPN #6. The SNRA stated Resident #65's Mother brought all the resident's snacks including white chocolate and chips. She stated the resident kept the snacks in his/her drawer. SRNA #20 stated the resident told her if he/she ate too much chocolate, he/she would have a reaction of bad diarrhea with seizure activity. She stated the information concerning allergies was located on the residents' face sheets and Kardex. In an interview on 07/13/2023 at 9:38 AM, with Unit Manager South Registered Nurse (RN) #1, she stated when at home, Resident #65 would experience an upset stomach and diarrhea after eating chocolate. In an interview on 07/13/2023 at 10:30 AM, with the Registered Dietitian (RD), she stated the resident did not have a true allergy to chocolate. She stated, when at home, the resident ate chocolate and had diarrhea. The RD stated Resident #65's Mother requested not to give the resident chocolate while at the facility. In an interview on 07/16/2023 at 5:10 PM, with the Director of Nursing (DON), she stated Resident #65 had an allergy to chocolate listed because of his/her Mother's request not to give milk chocolate to the resident. She stated Resident #65 ate a lot of milk chocolate at home which caused diarrhea. The DON stated the resident's allergy information was listed on the face sheet, Kardex and the MAR. She stated LPN #20 should have reviewed the allergies listed on the MAR before medication administration. In an interview on 07/16/2023 at 5:23 PM with the Executive Director (ED), he stated he expected the nurses to follow the MAR, with the allergies listed, and not provide chocolate to Resident #65.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to maintain an infection prevention program. Observation on 07/13/2023 and 07/15/2023 revealed State Registered Nurse Aides (SRNA) #11, #25, and #26 failed to wear all the required Personal Protective Equipment (PPE) in a room with a posted Enhanced Barrier Precautions (EBP) sign. The SRNAs were providing ostomy care and changing soiled linens for one (1) of nineteen (19) residents who was on EBP (Resident #5). The findings include: Review of the facility's policy titled, Enhanced Barrier Precautions, dated January 2023, revealed enhanced barrier precautions (EBP) were used to prevent the transmission of multidrug-resistant organisms (MDRO). Further review revealed the definition of EBP referred to the use of gown and gloves during high contact resident care activities for residents with known MDROs or at an increased risk of being infected with MDROs. Continued review of the policy revealed explanation and compliance guidelines which stated staff members were expected to comply with all designated precautions, required personal protective equipment (PPE), and high contact resident care activities that required the use of gown and gloves. Additional review revealed high contact resident care activities included bathing, changing briefs, device care, or wound care, which was defined as any skin opening requiring a dressing. Observation on 07/13/2023 at 11:11 AM revealed a sign on Resident #5's room door. The sign stated Enhanced Barrier Precautions in large print. Further observation revealed the sign described Personal Protective Equipment (PPE), specifically gowns and gloves, that staff should wear when providing high-contact care, such as changing linens, for the resident in that room. Observation on 07/13/2023 at 11:46 AM revealed SRNA #11 changed soiled linens for Resident #5, whose door had the sign indicating the resident required Enhanced Barrier Precautions (EBP). Further observation revealed SRNA was wearing gloves, but not a gown. Observation on 07/15/2023 at 11:05 AM revealed SRNA #25 and SRNA #26 changed soiled linens for Resident #5, with the EBP sign still on the door. Further observation revealed neither SRNA #25 nor SRNA #26 wore a gown. In interview on 07/15/2023 at 11:28 AM, Resident #5 stated staff did not typically wear gowns when providing care, such as changing linens. Resident #5 further stated he/she did not know why some staff wore gowns, while most did not. In interview on 07/13/2023 at 11:58 AM, SRNA #11 stated she should have worn a gown when changing Resident #5's linens, due to the Enhanced Barrier Precautions in place for Resident #5's ostomy. SRNA #11 stated she forgot to don (put on) a gown. In an interview on 07/15/2023 at 11:12 AM, SRNAs #25 and #26 stated they did not believe they had to wear gowns when changing Resident #5's linens. They stated they believed the sign on the door was old and no longer applied because Resident #5 was not infected or colonized with drug-resistant bacteria. In further interview, SRNA #25 stated if it was important for them to wear the gowns, the facility would have placed a container for gowns on or outside Resident #5's door. In interview on 07/12/2023 at 4:15 PM, Infection Preventionist (IP) #1 stated any resident with a wound, catheter, or colostomy required Enhanced Barrier Precautions (EBP). She further stated she expected staff to follow the signage posted on the residents' doors and wear PPE as they were trained to do. In an interview on 07/16/2023 at 10:21 AM, the Assistant Director of Nursing (ADON) stated she expected staff to wear gowns and gloves when providing high contact care to residents on Enhanced Barrier Precautions (EBP). She stated residents with catheters, intravenous lines, wounds, or ostomies would all require EBP. In an interview on 07/17/2023 at 3:15 PM, the Director of Nursing (DON) stated her expectations were for staff to wear gowns and gloves when providing high-contact care, such as changing linens or ostomy care, for residents on EBP. She further stated residents with feeding tubes, catheters, ostomies, and wounds all required EBP. In an interview on 07/17/2023 at 5:06 PM, the Executive Director (ED) stated his expectations for staff providing high-contact care for a resident on EBP were for them to wear a gown and gloves. He further stated wearing appropriate Personal Protective Equipment (PPE) was important to protect the residents from the spread of infection.

Based on observation and interview, it was determined the facility failed to ensure all drugs and biologicals were stored in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys, for one (1) of twenty-four (24) sampled residents, Resident #70. Observation of Resident #70's room on 11/04/19, revealed a cup of medications prescribed for Resident #70, sitting on the bedside table. In addition, there was no documented evidence the resident was assessed as able to self-administer medications. The findings include: Review of the facility Policy titled Storage of Medications, undated, revealed medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. Per Policy, the medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Continued review of the Policy, revealed only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications are permitted to access medications. Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access. Review of a document provided by the facility at the time of the survey titled List of Residents that Wander, revealed there were eight (8) residents who wander in the facility. 1. Review of Resident #70's clinical record revealed the facility admitted the resident on 02/10/17 and readmitted the resident on 06/17/19 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 11/04/19, revealed the facility assessed Resident #70 as having a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15), indicating the resident was cognitively intact. Review of Resident #70's current Monthly Physician's Orders for (MONTH) 2019, revealed orders for [MEDICATION NAME] 10 milligrams, take one (1) by mouth daily (calcium channel blocker that dilates blood vessels used for hypertension and chest pain); Folic Acid 1 mg daily (form of folate); Magnesium Oxide 400 MG once a day (mineral supplement to treat low levels of magnesium); Pantoprazole 40 MG once a day (decreases amount of acid in the stomach); [MEDICATION NAME] 40 MG once a day (antidepressant) ; [MEDICATION NAME] 5 mg once a day (glucocorticoid); Vitamin B12 once a day(vitamin supplement); Vitamin D3 once a day(vitamin supplement); [MEDICATION NAME] 325 mg twice a day (Iron supplement); [MEDICATION NAME] 50 mg twice a day (used to treat hypertension); and ICAPS, two (2) tablets once a day (multivitamin). Observation during the initial tour, which began on 11/05/19 at 11:30 AM, revealed twelve (12) pills in a cup on the resident's bedside table in front of the resident's bed. Interview with Resident #70 during this observation, revealed staff left the medication in his/her room and he/she was waiting to take the medication with food. Interview with Licensed Practical Nurse (LPN) #1, on 11/05/19 at 11:40 AM, revealed the medications should not be in Resident #70's room, as there were wandering residents on the unit which could consume the medications. LPN #1 removed the cup of medications from the resident's room. Subsequent interview with Resident #70, on 11/05/19 at 2:05 PM, revealed Nurses normally watched him/her take the medications; however, on this day the Kentucky Medication Aide (KMA) #1 had left the medications for the resident to take at a later time. Review of the Medication Administration Record [REDACTED]. Further review of Resident #70's medical record revealed no documented evidence the resident had been assessed to self-administer medications. In addition, review of the resident's Comprehensive Care Plan, revealed no documented evidence of a Plan of Care related to self-administration of medications. Interview with KMA #1, on 11/07/19 at 9:51 AM, revealed residents were not allowed to have medications or prescriptions in their rooms unless the resident had been assessed to administer his or her own medications. Continued interview revealed the facility did not currently have any residents who had been assessed as able to self-administer medications. She further stated she left Resident #70's medications at the bedside on 11/05/19, because he/she was being contrary about taking the medications and she meant to check back with him/her later. However, she stated she got busy with another resident and forgot to go back and ensure Resident #70 took the medications. She further stated it was a mistake, and she normally did not leave medications for residents to take at a later time. Per interview, the medications were destroyed by LPN #1 after the State Agency Representative found the medications and the Physician was notified. Interview with the Unit Manager Registered Nurse (RN) #1, on 11/07/19 at 9:45 AM, revealed she had worked at the facility for ten (10) years. She stated it was her expectation for staff to administer medications as prescribed. She further stated it was not okay for staff to leave mediations in the resident's room unattended. Per interview, residents were not allowed to have any forms of medications in their rooms and the facility did not have any residents who self-administered medications. Further, there were confused residents in the facility that could consume the medications if accessible. Interview with the Assistant Director of Nursing (ADON), on 11/07/19 at 10:00 AM, revealed medications should not be left in residents rooms where a wandering or confused resident could consume the medication. Continued interview revealed if a confused resident had access to another resident's medication, this could cause the confused resident to have an allergic reaction or to take a double dosage. Interview with the Director of Nursing (DON), on 11/07/19 at 11:10 AM, revealed medications should be locked up in the Medication/Treatment Cart, as per facility policy, and not be left out on the bedside table accessible to wandering confused residents. The DON stated if a confused resident had access to prescription medications which were left unsupervised they could consume the medication which could possibly cause adverse consequences. Further interview with the DON, revealed when medications were refused, she expected the nurse to remove the medication, destroy the medications, and notify the physician. She further stated there were no residents in the facility that could self-administer their own medications. Interview with the Administrator, on 11/07/19 at 11:00 AM, revealed there were no residents at the facility who self-administered medications. He further stated all medications were to be stored under lock and key as per the facility policy. Further interview revealed if medications were refused, staff should not leave the medications at the bedside. Continued interview with the Administrator, revealed it was his expectation staff keep facility residents safe.

Based on interview, record review, review of the facility's Investigation, and review of the Centers' for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Manual 3.0, it was determined the facility failed to adequately review and revise the Comprehensive Care Plan (CCP) for one (1) of twelve (12) sampled residents (Resident #6), when the resident was exhibiting exit seeking behaviors, repeatedly leaving the building unsupervised, and threatening to cut off his/her code alert bracelet (a tracking device designed to prevent persons at risk for wandering from leaving the facility, unless they were accompanied). Resident #6 exited the front lobby door of the building in his/her wheelchair unsupervised on 05/14/19 at 10:18 AM, and staff quickly intervened and assisted the resident back inside. After this incident, the Comprehensive Care Plan (CCP) was initiated 05/14/19, revealing a problem of exit seeking behaviors with interventions including a code alert bracelet and one-on-one (1:1) observation on the evening shift today and discontinue 05/15/19. Resident #6 subsequently exited the front lobby door unaccompanied by staff on 05/18/19 at 7:13 AM, this time self-ambulating while pushing the wheelchair. Staff was alerted by the door alarm set off by the resident's code alert and directed the resident back inside. On 05/19/19, a physician's orders [REDACTED].#6's wheelchair and place it on the resident's left leg. However, the CCP was not revised related to this intervention. Resident #6 exited the front lobby door in elopement attempts four (4) more times from 05/23/19 through 05/27/19. During each of these attempts, the code alert bracelet the resident wore on his/her ankle set off the door alarm and staff intervened. Staff interviews revealed Resident #6 spent most of his/her time in the front lobby with his/her personal possessions bagged up in his/her wheelchair. Staff interviews further revealed the resident asked staff to remove his/her code alert bracelet, and made statements regarding the need for scissors to remove it himself/herself; and, compared the facility to a prison related to the code alert bracelet. However, there was no documented evidence the resident's CCP was revised with interventions to be implemented related to the resident's desire to remove the code alert bracelet; and no documented evidence the CCP was revised related to the need for increased supervision and monitoring to protect the resident from elopement. On 06/16/19, between 4:30 AM and 5:30 AM, Resident #6 exited the facility through the front lobby doors without staff's knowledge. Staff interviews revealed they did not hear an alarm sound. At approximately 5:30 AM on 06/16/19, a neighbor called the facility and reported that a resident was outside and was wearing shoes, socks, a pull over gown, and carrying a purse. Resident #6 was located two-tenths (0.2) of a mile from the facility. The resident was assisted back to the facility at approximately 5:40 AM. Per the facility's Investigation, Resident #6 was not wearing a code alert bracelet during the elopement. Review of the local weather history revealed sunrise was at approximately 6:07 AM, revealing the resident had been outside unsupervised in the dark. (Refer to F-689) The facility's failure to have an effective system in place to ensure each resident's Comprehensive Care Plan was adequately reviewed and revised after elopement attempts caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) was identified on 06/20/19 and was determined to exist on 06/16/19. The facility provided an acceptable credible Allegation of Compliance (AoC) on 07/02/19, alleging removal of the Immediate Jeopardy on 06/18/19. The State Survey Agency determined the Immediate Jeopardy had been removed 06/18/19, as alleged, prior to exit on 07/03/19, with remaining non-compliance at a Scope and Severity of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Interview with the Director of Nursing Services (DNS) on 06/20/19 at 5:07 PM, revealed the facility had no care plan policy, and followed the Resident Assessment Instrument (RAI) Manual. Review of the Centers for Medicare and Medicaid Services Resident Assessment Instrument (RAI) Manual 3.0, dated (MONTH) (YEAR), revealed the Comprehensive Care Plan is an interdisciplinary communication tool and must include measurable objectives and time frames and must describe the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychological well-being. The care plan must be reviewed and revised on an ongoing basis to reflect changes in the resident and the care the resident receives. Review of Resident #6's clinical record revealed the facility admitted the resident on 01/16/19 with [DIAGNOSES REDACTED]. There was no documented evidence a Risk of Elopement Review was completed upon admission. Review of Resident #6's Significant Change Minimum Data Set (MDS) Assessment, dated 04/16/19, revealed the facility assessed Resident #6 as having a Brief Interview for Mental Status (BIMS) score of twelve (12) out of fifteen (15), indicating moderate cognitive impairment. Further review revealed the facility assessed the resident as exhibiting no wandering behaviors or other behaviors. Review of the Departmental Notes, dated 05/14/19 at 10:18 AM, completed by Licensed Practical Nurse (LPN) #3, revealed Resident #6 exited the facility twice that morning and was trying to get into cars. Per the Note, a code alert bracelet was placed on the back of the resident's wheelchair. Further review of Departmental Notes, dated 05/14/19 at 4:15 PM and 9:54 PM, completed by LPN #3, revealed Resident #6 was sitting in the front lobby, refusing to return to his/her room and wanting or attempting to exit, with staff present for one-on-one (1:1) supervision. Review of Resident #6's physician's orders [REDACTED]. Review of the CCP, initiated 05/14/19, revealed Resident #6 had exit seeking behaviors at times; had exited the building; and had a code alert bracelet. The goal with a target date of 07/17/19, revealed Resident #6 would remain free of injury during exit seeking behaviors. There were several interventions initiated 05/14/19 to include: re-direct as needed; alert staff to resident's favorite exit areas; provide with diversional activities when restless; staff to redirect when resident observed near front lobby; ensure updated information and picture is listed in Elopement Book; code alert bracelet; one-on-one (1:1) observation on evening shift today and discontinue 05/15/19; and administer medications for agitation as ordered. Review of the facility's Investigation Template, dated 05/15/19, revealed Resident #6 exited the facility on 05/14/19 at 10:18 AM, following the community-wide elopement drill, with multiple emergency vehicles out front, and was attempting to open car doors. Continued review of the Investigation, revealed Hospice and the Physician were consulted and a code alert bracelet was placed on the wheelchair to prevent further episodes of the resident exiting undetected. Further review of the Investigation, revealed the resident became agitated after exiting the facility and [MEDICATION NAME] 0.5 milligrams (anti-anxiety medication) was administered IM (intramuscular) and ordered every four (4) hours as needed (PRN) due to agitation; and one-on-one (1:1) observation was initiated until the resident went to bed. According to the Investigation, LPN #3 witnessed this incident. Review of the Departmental Note, dated 05/18/19 at 7:13 AM, completed by LPN #8, revealed Resident #6 had been sitting in his/her wheelchair in the front lobby, when he/she got out of his/her wheelchair and walked outside. Per the Note, the resident was assisted back into the wheelchair and assisted back inside by nursing staff, while the resident screamed that he/she could not, Do a damn thing right. Review of the Departmental Note, dated 05/19/19 at 5:45 PM, late entry for 8:00 AM, signed by LPN #8, revealed Resident #6 had been trying to get guests to hold the front door open for him/her so he/she could exit. Resident #6 told staff he/she was looking for his/her son. Per the Note, Resident #6 allowed staff to remove the code alert from the wheelchair and place it on his/her left leg. Review of Resident #6's physician's orders [REDACTED].#6's wheelchair and placed on the resident's left leg. Review of the Investigation Template, dated 05/20/19, revealed Resident #6 exited the facility through the front lobby door on 05/18/19 at 7:13 AM. According to the Investigation, the resident had been sitting in his/her wheelchair in the front lobby when he/she ambulated out the door pushing his/her wheelchair. Staff was alerted by the door alarm from the code alert. Further review revealed the code alert bracelet was removed from the wheelchair and placed on Resident #6's left ankle. Continued review revealed the resident was agitated, but cooperative in returning inside. Per the Investigation, LPN #8 witnessed this incident. Further review of Resident #6's CCP, initiated 05/14/19, related to exit seeking behaviors, revealed no revision related to the resident exiting the building unsupervised on 05/18/19 or attempting to exit the building on 05/19/19. Continued review revealed no intervention was added for the code alert to be placed on the resident's leg, as per the physician's orders [REDACTED].>Review of the Departmental Note, dated 05/23/19 at 8:52 AM, signed by LPN #8, revealed Resident #6 exited the facility into the parking lot while pushing the wheelchair, and was redirected by staff back to the lobby. According to the Note, the resident was on the couch in the lobby when the nurse inquired about the resident's sensor pad. Per the Note, the resident stated someone had taken his/her sensor pad. Further review revealed staff found the resident's sensor pad in the resident's room attached to the bedrail. The sensor pad was taken to the resident's wheelchair, and the resident became irritated with the nurse when he/she was told that he/she would need to sit in the wheelchair with the senor pad, but he/she eventually agreed. (Wheelchair alarms along with a sensor pad operate by detecting a reduction in pressure, and will cause the alarm to sound when pressure is removed from the sensor pad such as when a resident changes position from a sitting position to a standing position). Review of Resident #6's CCP, initiated 05/14/19, related to exit seeking behaviors, revealed there was no revision related to the resident walking outside the building unsupervised on 05/23/19. However, there was a new intervention dated 05/23/19, to redirect the resident when he/she was observed near the front lobby door. Review of the Investigation Template, dated 05/24/19, revealed Resident #6 exited the facility on 05/23/19 at 8:52 AM, after removing a sensor pad from his/her wheelchair, and exited the front lobby door. Per the Investigation, staff responded to the alarm and walked behind the resident as he/she walked toward the front parking lot. The investigation further revealed Resident #6 returned to the facility with redirection. Per the Investigation, LPN #8 witnessed this incident. Review of the Departmental Note, dated 05/24/19 at 9:33 AM, signed by LPN #8, revealed Resident #6 was out in the parking lot pushing the wheelchair. According to the Note, the resident reported to staff he/she was waiting on the bus, but the sheriff kept blocking the bus every time it would try to pull out as the bus driver was drunk. Per the Note, the resident became irritated with staff, but was eventually redirected back to the wheelchair and back into the facility, with the sensor pad in place on the wheelchair and the code alert in place on his/her ankle. Review of Resident #6's CCP initiated 05/14/19, related to exit seeking behaviors, revealed there was no revision to indicate there was an elopement attempt on 05/24/19. However, there was a new intervention dated 05/24/19, to provide the resident time outside in the patio area with supervision upon request of the resident. Review of the Investigation Template, dated 05/27/19, revealed Resident #6 exited the facility on 05/24/19 at 9:33 AM, again through the front lobby doors. Per the Investigation, staff responded to the door alarm and located the resident outside in the side parking lot pushing the wheelchair. The Investigation further revealed the resident was cooperative with staff, and requested to sit outside and eat lunch on the patio, and the resident was permitted to do so with staff supervision. Continued review of the Investigation, revealed the resident would sit in the front lobby a great deal of the time, and declined participation in group activities. Review of the Departmental Note, dated 05/27/19 at 10:50 AM, signed by LPN #8, revealed Resident #6 was out in the parking lot trying to get into a vehicle. Resident #6 became irritated with staff, and stated staff never let {him/her} do a damn thing for {him/herself}. Further review revealed the resident sat down in the wheelchair and was brought back into the facility. Review of the Departmental Note, dated 05/27/19 at 11:23 PM, revealed Resident #6 went out the front door into the parking lot, and informed staff he/she was waiting on his/her boyfriend to pick him/her up. Per the Note, Resident #6 was agitated with staff, and he/she hoped the building burned down. Further review revealed staff was eventually able to redirect the resident inside. Review of Resident #6's CCP, initiated 05/14/19, related to exit seeking behaviors, revealed there was no revision to indicate there was an elopement attempt on 05/27/19 at 10:50 AM. However, there was an intervention dated 05/27/19 for medication review by Behavioral Health Services due to increased exit seeking behaviors. Review of the Investigation Template, dated 05/28/19, revealed Resident #6 exited the facility on 05/27/19 at 10:50 AM. Per the Investigation, the resident opened the front lobby doors and was pushing the wheelchair, and staff responded to the front door alarm. Staff then followed the resident and was able to redirect the resident back inside. According to the Investigation, the resident reported to staff he/she was waiting on his/her boyfriend to pick him/her up. Per the Investigation, LPN #8, and the Administrator witnessed this incident. Review of the subsequent Investigation Template, dated 05/28/19, revealed Resident #6 exited the facility on 05/27/19 at 11:23 PM. Per the Investigation, staff responded to the front door alarm, and despite the resident being agitated, staff was able to redirect the resident from the front parking area to the inside. Resident #6 then received [MEDICATION NAME] due to increased agitation. LPN #10 witnessed this incident. Review of Resident #6's CCP, initiated 05/14/19, related to exit seeking behaviors, revealed there was no revision to address the elopement attempt on 05/27/19 at 11:23 PM; however, there was an intervention dated 05/28/19 for the Hospice Physician to review for possible medication changes with next visit. Review of Resident #6's Departmental Notes from 06/01/19 through 06/04/19 revealed the resident spent most of the time in the front lobby. Review of the Departmental Notes, from 06/11/19 through 06/15/19, revealed the resident spent most of his/her time in the front lobby. Review of the Investigation Template, dated 06/16/19, revealed Resident #6 exited the facility undetected and unsupervised after 4:30 AM and prior to 5:40 AM, when the facility received a call from Neighbor #1 stating she came out of her home to go to work and found someone standing behind her car that she believed was a resident of the nursing home. LPN #5 called and alerted the DNS, and then LPN #5, State Registered Nurse Aide (SRNA) #3, and SRNA #4 left the facility and followed directions given to the home of Neighbor #1, to assist Resident #6 back to the facility. Further review of the Investigation, revealed Dietary Aide #1 was driving past in her car and observed staff outside of Neighbor #1's home with Resident #6, and was able to transport Resident #6 back to the facility in her car. The Investigation further revealed Resident #6 did not appear to be in any distress upon returning to the facility and requested to go to bed. Per the Investigation, LPN #4 last checked placement of Resident #6's code alert bracelet at 1:30 AM, on 06/16/19. According to the Investigation, the Administrator attempted to interview Resident #6 regarding the incident, and described the resident as verbally aggressive, cursing, and the resident stated he/she had a right to leave the facility. Continued review of the Investigation, revealed Resident #6 was not wearing a code alert bracelet upon return, and refused to allow staff to place a code alert bracelet on him/her, at which point a code alert was placed on the resident's wheelchair. According to the Investigation, a staff member was placed at the front doors until an upgrade could be made to the doors, and Resident #6 was placed on fifteen (15) minute checks. Additional review revealed a new Mag Lock key pad was installed during the investigation on 06/17/19, that required a code for entry and exit of the front doors. (A Mag lock requires anyone coming in or exiting the building to punch in a code for the door to open without alarming. Also, the door still locks down when a resident with a code alert comes near, and will alarm (even if already open) when a resident with a code alert comes near). Review of Resident #6's e-TAR (electronic Treatment Administration Record) revealed an intervention for staff to check placement of the code alert to the resident's left ankle daily at 5:30 AM, 1:30 PM, and 9:30 PM, beginning on 05/20/19, with the order discontinued following a check documented at 5:30 AM on 06/16/19 by LPN #4. Review of the online Maps, revealed Neighbor #1 lived approximately two tenths (0.2) of a mile from the facility. Observation of the route to the home of Neighbor #1, on 06/19/19 at 5:30 PM, revealed Neighbor #1 lived beyond two (2) three (3) way stops and up two (2) hills from the facility. Review of the online local weather history, revealed it was approximately sixty-seven (67) degrees on the morning of 06/16/19, and sunrise was not until 6:07 AM. Interview with Neighbor #1, on 06/19/19 at 7:30 PM revealed the morning of 06/16/19 at 5:30 AM, she observed Resident #6 standing by her mailbox behind her car wearing shoes, socks, and a pullover gown, with a purse slung across his/her shoulder. Per interview, Resident #6 identified himself/herself by name, and asked for a ride to 29th Street in Ashland. Neighbor #1 stated she told Resident #6 she wouldn't be able to take him/her to Ashland, and excused herself to call the facility. Per interview, a short time later, three (3) staff members arrived and someone the staff knew pulled up in a car, and that person was able to convince Resident #6 to get in the car. Per interview, it was a little dark outside during this incident. Interview with SRNA #4, on 06/19/19 at 1:16 PM, verified Resident #6 was assigned to SRNA #3 on the North Unit the evening of 06/15/19 through the morning of 06/16/19 and SRNA #4 also worked the North Unit during these dates and times. The SRNA stated that in the past she observed Resident #6 going to the front lobby doors a lot, but she knew Resident #6 had a code alert bracelet which would alarm when he/she was near the doors. She stated that she didn't actually see the code alert on Resident #6's ankle the evening of 06/15/19 through the morning of 06/16/19, as she was not looking for the code alert. Interview with LPN #4, on 06/19/19 at 12:37 PM, revealed the night of 06/15/19 through the morning of 06/16/19 was her first shift working as the only nurse on the North Unit. She stated she was working with SRNA #3 and SRNA #4 during that shift. LPN #4 stated when she conducted rounds between 1:30 AM and 2:00 AM, she observed Resident #6's code alert bracelet on his/her wrist, although she wasn't sure which wrist. However, she stated she didn't chart this on the e-TAR until 5:30 AM. Per interview, she did not hear an alarm sounding the morning of 06/16/19, and she was unaware Resident #6 was missing until she was informed by LPN #5 that morning. Interview with LPN #6, on 06/19/19 at 5:18 PM, who worked the North Unit, revealed Resident #6 would often sit in the front lobby, stating he/she was waiting on the bus to come pick him/her up. Per interview, once or twice in the past prior to the resident eloping, the resident had asked her to cut the code alert bracelet off; however she did not think about reporting this to the DNS or administrative staff. She further stated did not update the Care Plan related to the resident asking her to cut off the code alert bracelet. Interview with SRNA #6, on 06/20/19 at 10:08 AM, revealed she assisted Resident #6 in a whirlpool bath on 06/13/19, and also assisted the resident with baths on 06/14/19 and 06/15/19 and the resident did not have a code alert bracelet on his/her ankle on those dates. SRNA #6 stated the code alert bracelet had been missing from Resident #6's left ankle for at least a week prior to the resident eloping on 06/16/19. She stated she thought the nurses must have removed the code alert bracelet as the nurses were responsible for checking placement of the devices, and therefore she did not question the code alert not being on the resident's ankle. The SRNA stated when Resident #6 was wearing the code alert bracelet he/she described the facility as a prison due to the facility keeping an ankle bracelet on him/her. Interview with SRNA #5, on 06/20/19 at 10:45 AM, who worked on the North Unit, revealed Resident #6 had verbalized to her, he/she was going to get the code alert bracelet off and asked her for scissors, which she reported to the nurse. However, she could not remember the date or who she had spoken to about this. She stated she knew Resident #6 did have a code alert bracelet on a few days prior to eloping, because Resident #6 was upset and asking her to take it off. Interview with SRNA #8, on 06/20/19 at 2:19 PM, who worked on the North Unit, revealed a few days prior to the resident eloping on 06/16/19, Resident #6 was asking her to remove the code alert bracelet from his/her ankle. She stated she alerted nursing staff the resident was talking about cutting off the code alert, but she was unable to recall which nurse. Interview with Registered Nurse (RN) #1, on 06/20/19 at 4:26 PM, who worked on the North Unit, revealed Resident #6 determined he/she was going to get out, and often sat in the front lobby with his/her belongings packed. RN #1 stated that prior to the elopement on 06/16/19, it was reported to her that Resident #6 had attempted to remove the code alert bracelet from his/her ankle, although she couldn't remember who had reported this, or precisely when it had been reported. She stated she did not report this to the DNS or management. Further interview revealed she did not know if Resident #6's attempts to remove the code alert bracelet were discussed in daily morning meetings with administrative staff, or if administrative staff were aware of the resident wanting the code alert bracelet removed. However, further interview revealed it would be important to report the resident attempting to remove the code alert bracelet to administrative staff in order for the Care Plan to be revised related to this behavior. Interview with the DNS, on 06/19/19 at 5:01 PM, revealed she was unaware of any instances in which Resident #6 attempted to remove the code alert bracelet and was unaware of the resident making any statements related to removing the bracelet. However, the DNS did state she was aware Resident #6 would sit in the front lobby with belongings packed and made several attempts to leave the facility unaccompanied prior to the elopement on 06/16/19. Additional interview with the DNS, on 06/20/19 at 5:07 PM, revealed staff were to document any unusual incidents on the Twenty-four Hour Reports, and these Reports were reviewed and the incidents discussed during the morning meetings with the interdisciplinary team (IDT). Per interview, she did not recall there being a concern documented on these Reports, related to Resident #6 attempting to remove his/her code alert, and she was not aware of this behavior until she was informed by the State Survey Agency. The DNS stated if it had been reported to administrative staff that Resident #6 was attempting to remove the code alert bracelet, this would have been discussed in the morning meetings and the CCP could have been revised with further interventions including closer supervision for the safety of the resident in order to attempt to prevent an elopement. Interview with the Administrator, on 06/20/19 at 5:27 PM, revealed staff did not mention anything to him related to Resident #6 wanting his/her code alert bracelet off, or trying to remove his/her code alert bracelet. Per interview, if staff had reported this behavior the resident's CCP could have been revised with further interventions to keep the resident safe and to possibly prevent the elopement on 06/16/19. The Facility provided an acceptable credible Allegation of Compliance (AoC) on 07/02/19, with the facility alleging removal of the Immediate Jeopardy on 06/18/19. Review of the AoC revealed the facility implemented the following: 1. On 06/16/19 at 5:45 AM, the facility was notified of the elopement and Resident #6 was returned to the facility after leaving without supervision. Resident #6 was assessed by the Director of Nursing Services (DNS) with no injuries noted. It was determined that Resident #6 did not have his/her code alert bracelet on his/her person, allowing the resident to exit without an alarm sounding. The resident's Physician and Hospice representative were notified by the DNS. Resident #6 refused to allow the re-application of the code alert to his/her person; therefore, it was applied to his/her wheelchair. Resident #6 was placed on fifteen (15) minute checks after being assisted to bed. On 06/16/19 Resident # 6's elopement care plan was updated to reflect additional interventions of the door monitor and the application of code alert bracelet. On 06/18/19, Resident #6 was transferred to the behavioral unit for evaluation and treatment of [REDACTED]. 2. On 06/16/19, the DNS was physically stationed at the door for visual observation of anyone leaving the center regardless of their bracelet placement. 0n 06/16/19, in addition to doors being observed by rotating team members around the clock, a one-hundred (100%) percent head count, directed by the DNS, was completed to ensure all residents were present and accounted for. After 06/18/19, the door alarms weekly checks were increased to daily checks for three (3) weeks, then will be reverted to weekly if no issues were found with the daily checks. This will be completed by the Director of Maintenance or designee. 3. On 06/16/19, a risk elopement assessment was completed by the DNS on all residents currently residing in the center. There were no care plan update or changes required. 4. On 06/16/19, all code alert bracelets currently in use were checked for placement and function by the DNS with no negative findings. Additionally, on 06/16/19 all outside doors were checked for appropriate alarm functioning, using the code alert testing system by the DNS. 5. Beginning 06/17/19, residents that required supervision outside (as identified for risk for elopement) were offered periods outside throughout the day, and once in the evening with supervision of team members. Logs of periods outside were completed for those residents that required supervision. 6. On 06/16/19, The Regional Vice President contacted an alarm service. On 06/17/19, the alarm service successfully installed Maglocks to provide extra security for any patient/resident who may have removed their code alert bracelet. 7. On 06/16/19, an impromptu QAPI meeting was held with the Administrator, DNS, Medical Director, Regional Vice President, and Director of Clinical Operations. The meeting reviewed the actions, education, and audits taken by the center on 06/16/19. Findings of the audits and actions taken after 06/16/19 were reviewed daily by the Regional Nurse Consultant and/or Regional Vice President and during a weekly QAPI meeting, by the QAPI team until the Immediate Jeopardies are abated. Any audits and actions taken after 06/16/19 will be reviewed at the monthly QAPI meeting, by the QAPI team. The QAPI team included the Medical Director, Administrator, DNS, and at least three (3) other departmental leaders. 8. Beginning 06/16/19, the Administrator, DNS or designee will conduct an audit related to the outdoor supervised periods daily for two (2) weeks, then weekly for four (4) weeks. This was to ensure the periods are being offered and the supervision is present for the residents that require it. All findings will be reviewed by Regional Vice President and with QAPI team. 9. Starting on 06/16/19, the Director of Clinical Education and the Administrator educated all team members (Licensed Nurses, SRNAs, Dietary, Housekeeping, Laundry, Therapy, Maintenance and Office Staff) related the Elopement Care System Guideline document in use by the facility as the elopement prevention and intervention protocol. Additionally, the Elopement Care System Guideline addressed care plan revision. Any team member that did not complete the training was not allowed to have direct resident contact until the education was completed. Five (5) of one-hundred and eight (108) team members remain that required the education. The Facility does not use Agency Staff. 10. On 06/19/19 the facility conducted an Elopement Drills and it was identified the team members required additional practice. They will conduct an Elopement Drill once per shift, per month for three (3) months and as needed (PRN). These drills will be conducted by the Administrator or DNS designee. 11. On 06/17/19, care plans were audited to ensure interventions related to elopement risks and documentation was addressed by the DNS, Registered Nurse (RN) Supervisor, Unit Manager or Administrator daily for six (6) weeks. 12. On 06/24/19, the Regional Vice President, Director of Clinical Operations, Administrator, or DNS will conduct a total of twelve (12) team member interviews per week for four (4) weeks and then six (6) team member interviews for four (4) weeks. The interviews will include specific questions regarding the Center's Elopement Guidelines and most recent education to ensure continued and thorough understanding of the guidelines and education. All findings will be reviewed daily by the Regional Nurse or Regional Vice President until the Immediate Jeopardies are abated. The findings will be reviewed monthly until the QAPI members determined the facility is in substantial compliance after six (6) weeks of continued monitoring. The State Survey Agency validated the implementation of the facility's AoC as follows: 1. Review of Resident #6's Clinical Records/Nursing Notes, dated 06/16/19, revealed the resident had new orders to discontinue his/her code alert bracelet to his/her left ankle and to apply new a code alert bracelet to his/her wheelchair due to exit seeking behaviors. Review of Resident #6's Body Audit sheet, dated 06/16/19 and signed by the DNS, revealed the resident refused to remove his/her clothing for skin inspection. Review of Resident #6's Compreh

Based on observation, interview, record review, review of the facility's Policy, and review of the facility's Investigation, it was determined the facility failed to have an effective system to ensure each resident received adequate supervision, monitoring, and assistive devices to prevent elopement for one (1) of twelve (12) sampled residents (Resident #6). On 05/14/19 at 10:18 AM, Resident #6 exited the front lobby door of the building in his/her wheelchair and was immediately redirected and assisted back inside by staff. After this incident, the facility assessed the resident as an elopement risk and a physician's orders [REDACTED]. On 05/18/19 at 7:13 AM, Resident #6 again exited the front lobby door, this time self-ambulating while pushing his/her wheelchair. Staff were alerted by the door alarm set off by the resident's code alert and assisted Resident #6 back inside. On 05/19/19, a physician's orders [REDACTED]. Resident #6 exited the front lobby door on 05/23/19 at 8:52 AM; 05/24/19 at 9:33 AM; 05/27/19 at 10:50; and 05/27/19 at 11:23 PM, unsupervised. At the time of each incident, the code alert bracelet the resident wore on his/her ankle would set off the door alarm and staff would bring the resident back inside or ensure the resident was supervised while sitting outside. Staff interviews revealed Resident #6 would spend most of his/her time in the front lobby with personal possessions bagged up in his/her wheelchair. When asked what he/she was doing, the resident would reply he/she was waiting on a bus, or waiting for someone to come pick him/her up, and staff were often unable to redirect the resident away from the front lobby. Resident #6 asked staff to remove his/her code alert bracelet, made comments regarding needing scissors to remove it himself/herself, and compared the facility to a prison due to restrictions as a result of the code alert bracelet. However, this was not documented. There was no documented evidence the facility modified interventions after Resident #6's statements related to the desire to remove the code alert bracelet and there was no documented evidence the facility increased supervision and monitoring to protect the resident from elopement. On 06/15/19 at 9:30 PM, staff documented visual check of Resident #6's code alert bracelet to his/her left ankle. On 06/16/19, staff observed Resident #6 in his/her room in bed at approximately 4:30 AM. On 06/16/19, between 4:30 AM and 5:30 AM, Resident #6 exited the facility through the front lobby doors without staff's knowledge. According to staff, they did not hear an alarm sound. At approximately 5:30 AM on 06/16/19, staff received a call from a Neighbor, two-tenths (0.2) of a mile from the facility notifying the facility that Resident #6 was outside and was wearing shoes, socks, a pull over gown, and carrying a purse. Facility staff responded, assisted Resident #6 back to the facility at approximately 5:40 AM, and assessed the resident as having no injuries. The facility's investigation revealed the resident was not wearing a code alert bracelet during the elopement. Review of the local weather history revealed the temperature was approximately sixty-seven (67F) degrees Fahrenheit, and sunrise was at approximately 6:07 AM, revealing the resident had been outside unsupervised in the dark. (Refer to F-657) The facility's failure to have an effective system in place to ensure each resident receives adequate supervision to prevent elopement caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) was identified on 06/20/19 and was determined to exist on 06/16/19. The facility provided an acceptable credible Allegation of Compliance (AoC) on 07/02/19, alleging removal of the Immediate Jeopardy on 06/18/19. The State Survey Agency validated removal of the immediate Jeopardy as alleged on 06/18/19, prior to exit on 07/03/19, with remaining non-compliance at a Scope and Severity of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's Elopement Policy, dated (MONTH) (YEAR), revealed newly admitted or readmitted residents would be assessed for elopement risk using a risk of elopement evaluation. Per Policy, residents would be re-assessed after any elopement attempt. Further review revealed an individualized plan would be established and implemented to mitigate the risk of elopement. Interview with the Director of Nursing Services (DNS), on 06/20/19 at 1:57 PM, revealed the facility had no policy related to the code alert system or code alert bracelets. Review of Resident #6's medical record revealed the facility admitted the resident on 01/16/19 with [DIAGNOSES REDACTED]. There was no documented evidence of a Risk of Elopement Review completed on admission. Review of the Social Services Admission Progress Note, dated 01/23/19, revealed prior to hospitalization and admission to the facility, Resident #6 lived alone with daily support services from case management. Continued review revealed Resident #6 had a long history of mental illness, including several psychiatric hospitalization s, as well as delusional thoughts and hallucinations. The Note further stated the resident had some agitation, restlessness, and depression and had made negative statements since admission. Per the Note, the resident planned to return home to continue to live independently with case management assistance if able. Review of Resident #6's Significant Change Minimum Data Set (MDS) Assessment, dated 04/16/19, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of twelve (12) out of fifteen (15), indicating moderate cognitive impairment. Further review of the MDS Assessment, revealed the facility assessed the resident as exhibiting no behaviors of wandering or other behaviors. Review of the Departmental Notes, dated 05/14/19 at 10:18 AM, completed by Licensed Practical Nurse (LPN) #3, revealed Resident #6 exited the facility twice that morning and was trying to get into cars. Per the Note, the resident was screaming at staff about not wanting to go upstairs because they would try to give him/her a shot. Further review of the Note, revealed a code alert bracelet was placed on the back of the resident's wheelchair. Review of Resident #6's Risk of Elopement Review, dated 05/14/19, revealed the Review was completed due to an elopement attempt. Risk factors related to risk of elopement included: cognitive impairment with poor decision making skills; pertinent mental health [DIAGNOSES REDACTED]. Per the Review, based on the risk factors and the resident's status, the resident was at risk for elopement. Review of Departmental Notes, dated 05/14/19 at 4:15 PM and 9:54 PM, completed by LPN #3, revealed the resident was sitting in the front lobby, refusing to return to his/her room and wanting or attempting to exit, with staff present for one-on-one (1:1) supervision. Review of Resident #6's physician's orders [REDACTED]. Review of Resident #6's Comprehensive Care Plan, initiated 05/14/19, revealed Resident #6 had exit seeking behaviors at times; had exited the building; and had a code alert bracelet. The goal with a target date of 07/17/19, revealed the resident would remain free of injury during exit seeking behaviors. There were several interventions initiated on 05/14/19 including: re-direct as needed; alert staff to resident's favorite exit areas; provide with diversional activities when restless; staff to redirect when resident was observed near front lobby; ensure updated information and picture was listed in the Elopement Book; code alert bracelet; one-on-one (1:1) observation on evening shift today and discontinue 05/15/19; and administer medications for agitation as ordered. Review of the facility's Investigation Template, dated 05/15/19, revealed Resident #6 exited the facility on 05/14/19 at 10:18 AM, following the community-wide elopement drill, with multiple emergency vehicles out front, and was attempting to open car doors. Further review of the Investigation, revealed Hospice and the Physician were consulted and a code alert bracelet was placed on the resident's wheelchair to prevent further episodes of the resident exiting undetected. Continued review of the Investigation, revealed the resident became agitated after exiting the facility and [MEDICATION NAME] 0.5 milligrams (anti-anxiety medication) was administered IM (intramuscular) and ordered every four (4) hours as needed (PRN), due to agitation; and one-on-one (1:1) observation was initiated until the resident went to bed. Per the Investigation, LPN #3 was witness to this incident. Review of the Departmental Notes, dated 05/18/19 at 7:13 AM, completed by LPN #8, revealed Resident #6 had been sitting in his/her wheelchair in the front lobby, when he/she got out of his/her wheelchair and walked outside. The Note further stated the resident was assisted back into the wheelchair and assisted back inside by nursing staff, with the resident screaming he/she could not, Do a damn thing right. Review of Resident #6's Risk of Elopement Review, dated 05/18/19, revealed the Review was initiated after an elopement attempt. Risk factors related to risk of elopement included: cognitive impairment with poor decision making skills; pertinent mental health [DIAGNOSES REDACTED]. Per the Review, based on the risk factors and the resident's status, the resident was at risk for elopement. Review of the Departmental Note, dated 05/19/19 at 5:45 PM, late entry for 8:00 AM, signed by LPN #8, revealed Resident #6 had been trying to get guests to hold the front door open for him/her so he/she could exit. The resident told staff he/she was looking for his/her son. Staff explained if his/her son visited, the son would look for the resident in his/her room. Per the Note, the resident allowed staff to remove the code alert from the wheelchair and place it on his/her left leg. Review of physician's orders [REDACTED].#6's wheelchair and placed on the resident's left leg. Review of Resident #6's Comprehensive Care Plan, initiated 05/14/19, related to exit seeking behaviors, revealed no revision related to the resident exiting the building unsupervised on 05/18/19, or attempting to exit the building on 05/19/19, nor was there an intervention added for the code alert to be placed on the resident's leg. Review of the facility's Investigation Template, dated 05/20/19, revealed Resident #6 exited the facility through the front lobby door on 05/18/19 at 7:13 AM. Per the Investigation, Resident #6 had been sitting in his/her wheelchair in the front lobby when he/she ambulated out the door pushing his/her wheelchair. Team members were alerted by the door alarm from the code alert. The Investigation further stated the code alert bracelet was removed from the wheelchair and placed on Resident #6's left ankle at that time. Further review revealed the resident was agitated, but cooperative in returning inside. Per the Investigation, LPN #8 was witness to this incident. Review of the Departmental Note, dated 05/23/19 at 8:52 AM, signed by LPN #8, revealed Resident #6 exited the facility into the parking lot pushing his/her wheelchair, and was redirected by staff back to the lobby. Per the Note, the resident was on the couch in the lobby when the nurse inquired about the resident's sensor pad. Further review of the Note, revealed the resident stated someone had taken his/her sensor pad. Further review revealed the nurse found the resident's sensor pad in the resident's room attached to the bedrail. According to the Note, the sensor pad was placed the resident's wheelchair, and the resident became irritated with the nurse when she told him/her that he/she would need to sit in the wheelchair with the senor pad, but he/she eventually agreed. (Wheelchair alarms combined with a sensor pad operate by detecting a reduction in pressure, and will cause the alarm to sound when pressure is removed from the sensor pad such as when a resident changes position from a sitting position to a standing position). Review of Resident #6's Risk of Elopement Review, dated 05/23/19, revealed the Review was initiated after an elopement attempt. Risk factors related to risk of elopement included: cognitive impairment with poor decision making skills; pertinent mental health [DIAGNOSES REDACTED]. Per the Review, based on the risk factors and the resident's status, the resident was at risk for elopement. Review of Resident #6's Comprehensive Care Plan, initiated 05/14/19, related to exit seeking behaviors, revealed there was no revision related to the resident walking outside the building unsupervised on 05/23/19. However, there was a new intervention dated 05/23/19, to redirect the resident when he/she was observed near the front lobby door. Review of the Investigation Template, dated 05/24/19, revealed Resident #6 exited the facility on 05/23/19 at 8:52 AM. The Investigation revealed the resident removed a sensor pad from his/her wheelchair, exited his/her room and exited the front lobby door pushing his/her wheelchair. Nursing team members responded to the alarm and walked behind the resident as he/she walked toward the front parking lot. The investigation revealed Resident #6 returned to the facility with redirection. Per the Investigation, LPN #8 was witness to this incident. Review of the Departmental Note, dated 05/24/19 at 9:33 AM, signed by LPN #8, revealed the resident was out in the parking lot pushing the wheelchair. Per the Note, the resident reported to staff he/she was waiting on the bus, but the sheriff kept blocking the bus every time it would try to pull out as the bus driver was drunk. According to the Note, the resident became irritated with staff, but was eventually redirected back into the facility, with the sensor pad in place to the wheelchair and the code alert in place on his/her ankle. Review of Resident #6's Risk of Elopement Review dated 05/24/19, revealed the Review was initiated following an elopement attempt. Risk factors related to risk of elopement included: cognitive impairment with poor decision making skills; pertinent mental health [DIAGNOSES REDACTED]. Per the Review, based on the risk factors and the resident's status, the resident was at risk for elopement. Review of Resident #6's Comprehensive Care Plan initiated 05/14/19 related to exit seeking behaviors, revealed there was no revision to indicate there was an elopement attempt on 05/24/19. However, there was a new intervention dated 05/24/19, to provide resident time outside in the patio area with supervision upon the resident's request. Review of the Investigation Template, dated 05/27/19, revealed Resident #6 exited the facility on 05/24/19 at 9:33 AM, through the front lobby doors. Per the Investigation, staff responded to the door alarm and found the resident outside in the side parking lot pushing the wheelchair. The Investigation further stated the resident was cooperative with staff, and requested to sit outside and eat lunch on the patio. Resident #6 was permitted to do so with staff supervision. Further review of the Investigation, revealed the resident would sit in the front lobby a great deal of the time, and declined participation in group activities. Per the Investigation, the team checked on the resident frequently and provided snacks frequently throughout the day. Further review revealed LPN #8 was witness to this incident. Review of the Departmental Note, dated 05/27/19 at 10:50 AM, signed by LPN #8, revealed Resident #6 was out in the parking lot trying to get into a vehicle. Resident #6 became irritated with staff, and stated staff never let {him/her} do a damn thing for {him/herself}, but the resident sat down in the wheelchair and was brought back into the facility. Review of a Departmental Note, dated 05/27/19 at 11:23 PM, revealed Resident #6 went out the front door into the parking lot, and told staff he/she was waiting on his/her boyfriend to pick him/her up. Per the Note, the resident was agitated with staff, and he/she hoped the building burned down. Further review of the Note, revealed staff was eventually able to redirect the resident inside. Review of Resident #6's Risk of Elopement Review, dated 05/27/19, revealed the Review was initiated after an elopement attempt. Risk factors related to risk of elopement included: cognitive impairment with poor decision making skills; pertinent mental health [DIAGNOSES REDACTED]. Per the Review, based on the risk factors and the resident's status, the resident was at risk for elopement. Review of Resident #6's Comprehensive Care Plan initiated 05/14/19 related to exit seeking behaviors, revealed there was no revision related to the elopement attempt on 05/27/19 at 10:50 AM. However, there was an intervention dated 05/27/19 for medication review by Behavioral Health Services due to increased exit seeking behaviors. Review of the Investigation Template, dated 05/28/19, revealed Resident #6 exited the facility on 05/27/19 at 10:50 AM. The Investigation revealed the resident opened the front lobby doors and was pushing the wheelchair and staff responded to the front door alarm. Staff followed the resident and was able to redirect the resident back inside. Per the Investigation, the resident reported to staff he/she was waiting on his/her boyfriend to pick him/her up. Per the Investigation, LPN #8, and the Administrator were witnesses to this incident. Review of an Investigation Template, dated 05/28/19, revealed Resident #6 exited the facility on 05/27/19 at 11:23 PM. The Investigation revealed staff responded to the front door alarm, and despite the resident being agitated, staff was able to redirect the resident from the front parking area to the inside. Resident #6 received [MEDICATION NAME] due to increased agitation. Per the Investigation, LPN #10 was witness to this incident. Review of Resident #6' Risk of Elopement Review, dated 05/28/19, revealed the Review was initiated after an elopement attempt. Risk factors related to risk of elopement included: cognitive impairment with poor decision making skills; pertinent mental health [DIAGNOSES REDACTED]. Per the Review, based on the risk factors and the resident's status the resident was at risk for elopement. Review of Resident #6's Comprehensive Care Plan initiated 05/14/19, related to exit seeking behaviors, revealed there was no revision related to the elopement attempt on 05/27/19 at 11:23 PM. However, there was an intervention dated 05/28/19 for the Hospice Physician to review for possible medication changes with the next visit. Review of the Departmental Notes dated 06/01/19 through 06/04/19, revealed Resident #6 spent most of the time in the front lobby. Review of Resident #6's Risk of Elopement Review, dated 06/08/19, revealed no documentation that addressed what prompted the Review. Risk factors related to risk of elopement included: cognitive impairment with poor decision making skills; pertinent mental health [DIAGNOSES REDACTED]. Per the Review, based on the risk factors and the resident's status the resident was at risk for elopement. Review of the Departmental Notes, from 06/11/19 through 06/15/19, revealed Resident #6 spent most of his/her time in the front lobby. Review of the Risk of Elopement Review, dated 06/16/19 revealed the Review was triggered as a result of an elopement. Risk factors identified included cognitive impairment with poor decision making and intermittent confusion despite current BIMS score of thirteen (13); persistent mental illness including hallucinations, Depression, Anxiety, and [MEDICAL CONDITION] Disorder; independent ambulation; history of leaving the facility without supervision or informing staff more than three (3) times; and expressed desire to go home as evidenced by packing belongings and remaining near the exit. Per the Review, based on the risk factors and the resident's status the resident was at risk for elopement. Review of the Investigation Template, dated 06/16/19, revealed Resident #6 exited the facility undetected and unsupervised after 4:30 AM and prior to 5:40 AM, when the facility received a call from Neighbor #1 stating she came out of her home to go to work and found someone standing behind her car that she believed to be a resident of the nursing home. Continued review revealed LPN #5 called and alerted the DNS, and then LPN #5, State Registered Nurse Aide (SRNA) #3, and SRNA #4 left the facility and followed directions given to the home of Neighbor #1, to assist Resident #6 back to the facility. Continued review of the Investigation, revealed Dietary Aide #1 was driving past in her car when she observed staff outside of Neighbor #1's home with Resident #6, and was able to transport Resident #6 back to the facility in her car. The Investigation revealed Resident #6 did not appear to be in any distress upon returning to the facility and requested to go to bed. The Investigation stated LPN #4 checked placement of Resident #6's code alert bracelet at 1:30 AM, on 06/16/19. Per the Investigation, the Administrator attempted to interview Resident #6 regarding the incident, and described Resident #6 as becoming verbally aggressive, cursing, and stating he/she had a right to leave the facility. Review of the online Maps, revealed Neighbor #1 lived approximately two tenths (0.2) of a mile away from the facility. Observation on 06/20/19 at 5:30 PM, of the route to the home of Neighbor #1, revealed she lived beyond two (2) three (3) way stops and up two (2) hills from the facility. Review of the online local weather history, revealed it was approximately sixty-seven (67) degrees on the morning of 06/16/19, with sunrise not until 6:07 AM. Additional review of the Investigation, revealed Resident #6 was not wearing a code alert bracelet upon return, and refused to allow staff to place a code alert bracelet on him/her, at which point a code alert was placed on Resident #6's wheelchair. Per the Investigation, a staff member was placed at the front doors until an upgrade could be made to the doors, and Resident #6 was placed on fifteen (15) minute checks. Further review revealed a new Mag Lock key pad was installed during the investigation on 06/17/19, that required a code for entry and exit of front doors. Additional review revealed if a resident with a code alert bracelet locked down the door, the delayed egress function would not operate until the resident moved away from the door. Review of Resident #6's Comprehensive Care Plan, initiated 05/14/19, related to exit seeking behaviors, revealed there was a revision on 06/16/19 for a code alert on the wheelchair; fifteen (15) minute checks; and Behavioral Health services were to revisit the resident during the week of 06/16/19. Review of Resident #6's e-TAR (electronic Treatment Administration Record) revealed an intervention for staff to check placement of the code alert to the resident's left ankle daily at 5:30 AM, 1:30 PM, and 9:30 PM, beginning on 05/20/19, with the order discontinued following a check documented at 5:30 AM on 06/16/19 by LPN #4. Interview with the Maintenance Supervisor, on 06/18/19 at 2:19 PM, revealed prior to 06/17/19, the front exit remained unlocked during the day, only locking down if someone with a code alert bracelet came near the door. He further stated if the door was pushed open, by being pushed for fifteen (15) seconds, after being secured due to a code alert, it would alarm. Per interview, if a code alert bracelet passed the sensors while the door was open, and no code was punched in to the keypad to prevent it, it would likewise alarm. Further interview revealed mag locks were installed on the front doors on 06/17/19, and with the mag lock, the key pad had to be used to go in or out of the front doors. Interview with Neighbor #1, on 06/19/19 at 7:30 PM revealed she was leaving for work the morning of 06/16/19 at 5:30 AM, when she observed Resident #6 standing by her mailbox behind her car wearing shoes, socks, and a pullover gown, with a purse slung across his/her shoulder. She stated Resident #6 identified him/herself by name, and asked for a ride to 29th Street in Ashland. She further stated Resident #6 verbalized he/she wasn't going back to the clinic, and asked where different roads led. Per interview, Neighbor 1 informed Resident #6 she wouldn't be able to take him/her to Ashland, and the resident then asked about calling an ambulance to take him/her to the hospital in Ashland. Further interview with Neighbor #1, revealed she excused herself, and ran inside to wake her daughter to stay with the resident while she called the facility. Neighbor 1 stated Resident #6 had a confused look on his/her face, and she wasn't going to leave the resident alone. Per interview, when she returned outside, Resident #6 had already started up the road. She stated she then called out to the resident and reassured him/her she hadn't called the clinic, but had called the ambulance, and he/she returned. Per interview, a short time later, three (3) staff members came walking up the road, but the resident would not allow them to get close to him/her. Neighbor 1 stated whenever staff would try to get close, the resident would hit them with his/her purse. She further stated the resident was upset with her (Neighbor 1) for calling the facility. Neighbor #1 stated someone the staff knew pulled up in a car, and that person was finally able to convince Resident #6 to get in the care. Per interview, she didn't know how long Resident #6 had been outside, but stated it was a little dark outside during this incident. Interview with LPN #5, on 06/19/19 at 12:59 PM, revealed she was working on the South unit on the morning of 06/16/19 when Neighbor #1 called at approximately 5:30 AM, reporting a resident was in Neighbor #1's driveway. Per interview, after a headcount was done it was determined Resident #6 was missing. LPN #5 stated she alerted the DNS, then took two (2) State Registered Nurse Aides (SRNAs #3 and #4) and followed the directions given by Neighbor #1 to her home. She further stated they discovered Resident #6 was there in the subdivision adjacent to the facility. Per interview, when they found the resident he/she was confused and combative, asking to go to Ashland. LPN #5 further stated two (2) Dietary Aides who were in a car were able to convince the resident to get in the car with them. LPN #5 stated she did not notice whether or not the resident had a code alert bracelet on as she was more concerned about the resident's safety at that time. She stated she did not notice any injuries to Resident #6, although the lighting was poor at that time of the morning. She stated by the time she got back to the facility, the DNS was there. Per interview, LPN #5 took the resident back to the North Unit, where the resident resided. LPN #5 stated she then informed LPN #4, who was the nurse assigned to Resident #6 of what happened. Attempts were made via telephone to interview SRNA #3, on 06/19/19 at 1:13 PM and 06/27/19 at 11:18 AM, at which time messages were left. However, SRNA #3 had since resigned and did not return phone calls. Interview with SRNA #4, on 06/19/19 at 1:16 PM, revealed Resident #6 was assigned to SRNA #3 on the North Unit the evening of 06/15/19 through the morning of 06/16/19 and SRNA #4 also worked the North Unit during these dates and times. Per interview, in the past she had observed Resident #6 going to the front lobby doors a lot, but knew the resident had a code alert bracelet which would alarm when he/she was near the doors. She stated she didn't actually see the code alert on Resident #6's ankle the evening of 06/15/19 through the morning of 06/16/19, as she was not looking for it and the resident wore socks and it could have been hidden under the sock. Further interview with SRNA #4, revealed when she and SRNA #3 conducted their rounds, first at 1:30 AM, then at 4:30 AM, on the North Unit, Resident #6 was in his/her room sleeping in bed. She stated she did not hear any alarms going off after those rounds, but a little later LPN #5 reported a resident was missing, at which point they did a head count and determined Resident #6 was not in his/her room. Per interview, SRNA #3, SRNA #4 and LPN #5 followed directions to the home of Neighbor #1, where they found Resident #6. She stated when they got there Resident #6 became upset, and was swinging his/her purse and saying he/she wasn't going back to the insane asylum. She further stated a Dietary Aide came by in her car, and was able to convince the resident to ride with her. Interview with Dietary Aide #1, on 06/19/19 at 10:33 AM, revealed she was on her way to work when she observed a nurse and two (2) SRNAs walking around in the neighborhood, and the nurse told her they were looking for Resident #6. Dietary Aide #1 further stated at approximately 5:40 AM, she observed Resident #6 in his/her night gown and carrying his/her purse, in the driveway of a home along with the nurse and the two (2) SRNAs. Dietary Aide #1 stated Resident #6 asked if she worked with them, indicating the nurse and two (2) SRNAs, to which she responded no, and told the resident she worked in the kitchen. She stated Resident #6 was then agreeable to getting into her car as long as she didn't take him/her back to the clinic. Further interview revealed the resident was pleasant until they returned to the facility, at which point he/she became very upset and was cursing her. She stated she returned to the facility with Resident #6 prior to 5:50 AM. Interview with LPN #4, on 06/19/19 at 12:37 PM, revealed she was new to the facility and the night of 06/15/19 through the morning of 06/16/19 was her first shift working as the only nurse on the North Unit, with SRNA #3 and SRNA #4. Further interview revealed she completed her rounds between 1:30 AM and 2:00 AM, on 06/16/19 and had observed Resident #6's code alert bracelet on his/her wrist at that time, although she wasn't sure which wrist. She stated she didn't chart this on the e-TAR until 5:30 AM. Per

Based on interview, record review, review of the facility policies, and review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, it was determined the facility failed to ensure the Comprehensive Care Plan was reviewed and revised after each assessment for one (1) of thirty-five (35) sampled residents (Resident #6). Resident #6's Quarterly Minimum Data Set (MDS) Assessment, dated 07/16/18, revealed the facility assessed the resident as requiring the assistance of two (2) persons for transfers and was only able to stabilize with staff assistance when moving from seated to standing position and surface-to-surface transfers. Also, the Lift Transfer Evaluation, revised 07/16/18, revealed the resident could not safely transfer independently or with oversight, bear weight on at least one (1) leg, or turn and pivot while maintaining balance, requiring a Sit to Stand (STS) lift as needed. However, the Comprehensive Care Plan (CCP) dated 11/12/12, revealed an intervention to assist with transfers as needed. The CCP was not revised to specify the transfer technique required, or how many staff were required to assist the resident with transfers. In addition, the Care Giver Information Sheet (CGIS), dated 08/31/18, which was a source used by the State Registered Nursing Assistants (SRNAs) in providing care and was to reflect interventions from the CCP, revealed Resident #6 required a Stand to Sit (STS) mechanical lift with a large sling PRN (as needed) for transfers. Neither the CCP or the CGIS were revised to address the specific transfer technique and the number of staff required for transfers to ensure this resident's safety. On 09/20/18, Resident #6 attempted to transfer independently with only supervision by one (1) SRNA and the resident fell sustaining a Closed [MEDICAL CONDITION] End of the Right Fibula. Actual Harm was determined to exist on 09/20/18. (Refer to F-689) The findings include: Interview with the Director of Nursing (DON), on 10/03/18 at 3:00 PM, revealed the facility did not have a policy related to revising the Care Plan; however, used the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0 as a guide. Review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, dated (MONTH) (YEAR), revealed the Comprehensive Care Plan is an interdisciplinary communication tool and must include measurable objectives and time frames and must describe the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Further review revealed the results of the assessments must be used to develop, review, and revise the resident's Comprehensive Care Plan. Review of Resident #6's Electronic Medical Record (EMR) revealed the facility admitted the resident on 11/01/12, with [DIAGNOSES REDACTED]. Review of Resident #6's Comprehensive Care Plan (CCP), initiated 11/12/12, revealed the resident was at risk for injury due to history of fall with injury related to: impaired mobility; medical [DIAGNOSES REDACTED]. The goal revealed the resident would have no unidentified complications related to being at risk for falls. There were several interventions including: assist with transfer as needed, with no initiation date; refer for Physical Therapy evaluation as needed; and observe for changes in condition that may warrant increased assistance and notify the physician. However, the CCP was not revised to include the resident's required transfer technique, assistive device required for transfers, or the number of staff required for transfers. Review of the Lift Transfer Evaluation, revised 07/16/18, revealed Resident #6 could not safely transfer independently or with oversight, bear weight on at least one (1) leg, or turn and pivot while maintaining balance and required a STS lift (mechanical assistive device used to transfer a person between surfaces by the use of electrical or hydraulic power) with a large sling. Further review of the Evaluation revealed the resident required STS lift PRN due to muscle weakness. Review of the Quarterly MDS Assessment, dated 07/16/18, revealed the facility assessed Resident #6 as having a Brief Interview for Mental Status (BIM) score of fifteen (15) out of fifteen (15), indicating the resident was cognitively intact. Additional review revealed the facility assessed the resident as only able to stabilize with staff assistance when moving from seated to standing position and surface-to-surface transfers. Further review of the MDS Assessment revealed the facility assessed the resident as requiring extensive assistance of two (2) staff for transfers. Review of the Care Giver Information Sheet (CGIS) dated 08/31/18, revealed Resident #6 was a Fall Risk, requiring a STS lift with a large sling PRN for transfers. However, the CGIS did not include the resident's self-performance level, type of transfer if the STS lift was not used, or the number of staff required for transfers with or without the STS lift. Review of the Incident Report, dated 09/20/18 at 7:35 PM, completed by Licensed Practical Nurse (LPN) #4, revealed Resident #6 had an assisted fall in the bedroom, from the bed with assistance from SRNA #2. According to the Report, Resident #6 was being assisted to the wheelchair from bed when his/her knee gave out. SRNA #2 assisted the resident to the floor, but in doing so trapped and twisted the resident's right ankle under the wheelchair. Per the Report, the resident was assisted back to bed and then complained of ten (10) out of ten (10) pain to the right ankle, which had swelling, bruising, and a hard bony protrusion noted. The Report further revealed LPN #4 assessed the resident, applied ice to the swelling right ankle, notified the Physician at 7:55 PM, and sent the Resident to the emergency room at 8:15 PM. This Report was signed by LPN #4, Director of Nursing (DON), Administrator, and Medical Director. Review of Resident #6's Nurse's Note, dated 09/20/18 at 9:32 PM, completed by LPN #4, revealed the resident was being assisted to the wheelchair from bed when his/her knee gave out. SRNA aided the resident to the floor, but in doing so trapped and twisted the right ankle under the wheelchair. The resident at that time did not have complaints of pain. Further review of the Note, revealed the resident was assisted back to bed and then complained of ten (10) out of ten (10) pain to the right ankle, which upon assessment was noted to have swelling, bruising, and a hard bony protrusion noted. Continued review of the Note, revealed LPN #4 applied ice to swelling on the right ankle, notified the physician at 7:55 PM, and sent the resident to the emergency room for evaluation and treatment. Review of the Hospital Emergency Department Discharge Summary, dated 09/20/18, revealed Resident #6 was diagnosed with [REDACTED]. Further review revealed a follow up with an orthopedic surgeon was necessary in one (1) week. Interview with Resident #6, on 10/02/18 at 10:26 AM, revealed he/she fell which resulted in a fracture approximately two (2) weeks ago. Per interview when SRNA #2 answered the call bell, on the evening of the fall, both Resident #6 and SRNA #2 decided together not to use the STS lift because the resident was not feeling weak. Resident #6 revealed he/she took a few steps from the bed towards the electric wheelchair, while SRNA #2 was with him/her and was supervising with no hands on assistance, and just stand by assistance for the transfer. Resident #6 further stated during the transfer he/she became weak and fell on to both knees. Additional interview revealed SRNA #2 assisted him/her to a lying position and alerted LPN #4, who came to his/her room and assessed him/her. Per interview, LPN #4 and SRNA #2 then used the full mechanical lift (Hoyer lift) to assist him/her from the floor to the bed, and then used the STS lift to transfer him/her back to the electric wheelchair for dinner. Per interview, the STS lift was used again after dinner to transfer him/her back to bed. Further interview revealed he/she noted discomfort and swelling to his/her right ankle when being transferred per the STS lift from the wheelchair to the bed after dinner, and he/she was transferred to the Hospital Emergency Department for further evaluation. Interview with SRNA #2, on 10/03/18 at 5:00 PM, revealed on the evening of 09/20/18, he answered Resident #6's call bell before dinner and the resident stated he/she was ready to get out of bed. SRNA #2 stated he asked Resident #6 how he/she felt that day and the resident verbalized he/she was ok to stand and pivot, and did not need to use the STS lift. SRNA #2 revealed he assisted the resident to sit up on the side of the bed, and unhooked the resident's indwelling catheter urinary drainage bag so the resident could stand and pivot. SRNA verified he did not assist hands on with the transfer, and he was the only staff in the resident's room during the transfer. SRNA #2 stated when the resident stood to pivot, his/her right foot got caught on the small wheel on the electric wheelchair, and the resident started yelling oh God I'm falling. Continued interview with SRNA #2, revealed he then tried to stabilize the resident; however, the resident slowly fell down. Per interview, he assisted the resident to a sitting position on the floor and then laid him/her back. SRNA #2 revealed the resident's right foot was behind him/her, and his/her right leg was bent at the knee. Per interview, he straightened out the resident's leg and went to alert LPN #4. SRNA #2 stated LPN #4 came to Resident #6's room and assessed the resident, and then helped use the total mechanical lift (Hoyer lift) to assist the resident back into bed. Further interview revealed the resident did not complain of pain after the fall. He stated he then used the STS lift to transfer Resident #6 from the bed to the wheelchair for dinner and later transferred the resident back to bed after dinner. However, SRNA #2 revealed when he removed Resident #6's TED hose after dinner he noticed swelling and bruising to the resident's right ankle and the resident verbalized pain. Per interview, LPN #4 assessed the resident and had the resident transferred to the hospital. Additional interview with SRNA #2, revealed prior to Resident #6's transfer on 09/20/18, he reviewed the CGIS to check the level of assistance and care the resident required. Per interview, according to the CGIA at that time the resident was to be transferred with a STS lift PRN. He further stated prior to the resident's fall, he also relied on shift report from the SRNA on the previous shift and the resident's decision when determining if the STS lift should be used for Resident #6's transfers during his shift. Continued interview revealed prior to the resident's fall, Resident #6's transfer status varied related to his/her [DIAGNOSES REDACTED]. However, he revealed in order to ensure safety during transfer on 09/20/18, Resident #6's transfer technique should have been consistent and specific i.e. extensive assist of two (2) staff with STS lift for all transfers to avoid any question on the correct transfer status and to decrease the risk of injury for the resident and staff. Phone interview on 10/04/18 at 1:00 PM, with LPN #4, revealed he was assigned to Resident #6 at the time of the fall on 09/20/18. Per interview, direct care staff used the CGIS as a guide for providing the required assistance needed for each resident. He stated the CGIS was to indicate how many staff were required for transfers and if a mechanical lift was required. However, he revealed prior to Resident #6's fall on 09/20/18, the resident was weaker on some days and would verbalize to staff if he/she was able to stand and pivot for transfer or needed to use the STS lift for transfer. Further interview revealed with either transfer technique two (2) staff were required to transfer Resident #6, but it was up to the SRNAs to determine if the resident was strong enough before each transfer to stand and pivot or needed to use the STS lift. Additional interview revealed on 09/20/18 around 7:30 PM, he was alerted by SRNA #2 that Resident #6 was on the floor. He stated SRNA #2 told him Resident #6 was transferring independently from bed to the wheelchair when his/her knee gave out, and SRNA #2 had to ease the resident to the floor. Continued interview with LPN #4, revealed upon entering the resident's room, the resident was lying on the floor, on his/her back by the bed. LPN #4 stated he assessed Resident #6's ankles after the resident complained he/she twisted his/her ankle. LPN #4 stated he removed the TED hose, and there was no swelling, bruising or complaints of pain from the resident at the initial assessment. LPN #4 further stated the resident was assisted off the floor to bed with the total mechanical lift (Hoyer lift) and he assessed the resident again for injuries once he/she was in the bed. Additional interview, revealed thirty (30) minutes later, Resident #6 complained of pain and swelling to the right ankle, the Physician was notified, and the resident was transferred to the Hospital Emergency Department for further evaluation. Additional interview, revealed the CCP and the CGIS should specify how many staff are required for each resident's transfer and the specific transfer technique to be used to ensure residents were provided consistent and safe care. Interview with the MDS Coordinator, on 10/03/18 at 4:01 PM, revealed prior to Resident #6's fall on 09/20/18, the resident had fluctuating functional status and lower extremity weakness and therefore the resident's transfer status regarding assistance needed varied on a day-to-day, hour-to-hour basis. She stated there was a Lift Binder on each hallway with Lift Transfer Evaluations for each resident's mechanical lift requirements. She further stated the SRNAs were to use these Evaluations along with the CGIS to check for transfer technique when transferring residents. Additional interview revealed the SRNA who transferred Resident #6 on 09/20/18, had to determine at time of transfer if the resident was able to stand and transfer, or was too weak requiring the Lift. Further interview with the MDS Coordinator, revealed the MDS Assessments, the CCP and the CGIS should have consistent information related to assistance needed for transfers. However, she revealed at the time Resident #6 sustained the fall on 09/20/18, the resident's CCP did not include the requirement for two (2) staff for transfers as per the MDS Assessment, and the CCP was not specific related to transfer technique. Further interview revealed it was important to revise the falls CCP to include specific transfer interventions in an attempt to reduce the residents' risk for falls and injury, and this information was to be carried over to the CGIS used by the SRNAs to provide care. The MDS Coordinator stated there should be no confusion as to transfer technique on the CCP or the CGIS. Interview with the DON, on 10/04/18 at 2:54 PM, revealed there were safety risks involved for residents and staff when placing the SRNAs in a situation where they had to determine the transfer status of residents before each transfer. She stated Resident #6 sustained a fall during transfer as the resident was not transferred per his/her most dependent transfer technique. Continued interview revealed the MDS Nurse was responsible for Care Planning each resident's Activities of Daily Living (ADL) function including transfers as per the Resident Assessment Instrument. The DON stated Resident #6's CCP for transfer status should have been revised to include the resident's self-performance level, the level of staff support required for transfers and a STS lift, prior to the resident sustaining the fall on 09/20/18. Per interview, the CGIS used by the SRNAs were to match the CCP interventions related to transfers. Interview with the Administrator, on 10/04/18 at 3:08 PM, revealed there was the risk of resident and staff safety involved when SRNAs had to determine the transfer status of residents. Further interview revealed Resident #6's CCP and CGIS should have been revised to specify the resident's self-performance level, the level of staff support required for transfers, and the STS lift for transfers prior to the resident being transferred on 09/20/18 and sustaining the fall. Additional interview revealed the MDS Coordinator was to follow the RAI guidelines related to revising the CCP, and the CCP should be specific to the MDS coding. Per interview, the MDS process drives the CCP based on assessment and dictates the resident's care needs. Interview with Medical Director on 10/04/18 at 3:50 PM, revealed a resident's CCP should address the type of transfer and how many staff were required to assist with transfers. Per interview, it was important for the CCP to be specific to each resident's needs to ensure staff provided the resident with safe, consistent care.

Based on interview, record review, review of the facility Guidelines, and review of the Incident Report, dated 09/20/18, it was determined the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for one (1) of three (3) sampled residents reviewed for falls out of a total sample of thirty-five (35) residents (Resident #6). Resident #6 was assessed by the facility to require assistance of two (2) persons for transfers per the Quarterly Minimum Data Set (MDS) Assessment, dated 07/16/18. According to the Comprehensive Care Plan (CCP) dated 11/12/12, staff was to assist with transfers as needed. Further, Resident #6's Care Giver Information Sheet (CGIS), which was used by the State Registered Nursing Assistants (SRNA) as a reference for providing care, dated 08/31/18, revealed the Resident was a Fall Risk and required a Stand to Sit (STS) mechanical lift with a large sling as needed for transfers. Neither the CCP or the CGIS addressed the specific transfer technique and the number of staff required for transfers to ensure the resident's safety. These inconsistencies in transfer technique left the resident's transfer status to be determined by the SRNA's assessment of the resident's functional ability at the time of each transfer. On 09/20/18, Resident #6 attempted to transfer independently with only supervision by one (1) SRNA and the resident fell to the floor sustaining a Closed [MEDICAL CONDITION] End of the Right Fibula. Actual Harm was determined to exist on 09/20/18. (Refer to F-657) The findings include: Review of the facility's Fall Clinical Care Guidelines, dated (MONTH) (YEAR), revealed the purpose of the guidelines was to identify risk and establish interventions to mitigate the occurrence of falls. Additional review revealed fall risk would be assessed on admission and re-admission and identified risk factors and corresponding interventions would be documented on the CCP and CGIS. Further review revealed a post fall evaluation would be completed to assist with developing and implementing interventions to prevent future falls. Review of Resident #6's Electronic Medical Record (EMR) revealed the facility admitted the resident on 11/01/12, with [DIAGNOSES REDACTED]. Review of the Comprehensive Care Plan (CCP), initiated 11/12/12, revealed Resident #6 was at risk for injury due to history of fall with injury related to: impaired mobility; medical [DIAGNOSES REDACTED]. The goal stated the resident would have no unidentified complications related to being at risk for falls. Interventions included, but were not limited to: assist with transfer as needed, with no initiation date; refer for Physical Therapy evaluation as needed; and observe for changes in condition that may warrant increased assistance and notify the physician. However, the CCP did not specify the resident's required transfer technique, assistive device required for transfers, or the number of staff required for transfers. Review of Resident #6's Lift Transfer Evaluation, revised 07/16/18, revealed the resident could not safely transfer independently or with oversight, bear weight on at least one (1) leg, or turn and pivot while maintaining balance and required a STS lift (mechanical assistive device used to transfer a person between surfaces by the use of electrical or hydraulic power) with a large sling. Additional review of the Evaluation revealed the resident required STS lift PRN (as needed) due to muscle weakness. Review of Resident #6's Clinical Health Status Quarterly Assessment, dated 07/16/18, revealed the resident required assistance of two (2) staff for transfers and toileting. Additional review revealed the resident used side rails, a walker, and a wheelchair. However, STS lift was not documented under other assistive devices. Further review of the Assessment, revealed the resident's Fall Risk Factors included impaired gait or balance, impairment in lower extremity strength, and medications, indicating Resident #6 was a Fall Risk. Review of Resident #6's Quarterly MDS Assessment, dated 08/23/18, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIM) score of fifteen (15) out of fifteen (15), indicating the resident was cognitively intact. Continued review of the MDS Assessment revealed the facility assessed the resident as only able to stabilize with staff assistance when moving from seated to standing position and surface-to-surface transfers, and as requiring extensive assistance of two (2) staff for transfers. Review of the Care Giver Information Sheet (CGIS) dated 08/31/18, revealed Resident #6 was a Fall Risk and required a STS lift with a large sling PRN for transfers. However, the CGIS did not specify the resident's self-performance level, type of transfer if the STS lift was not used, or the number of staff required for transfers with or without the STS lift. Review of the Incident Report, dated 09/20/18 at 7:35 PM, completed by Licensed Practical Nurse (LPN) #4, revealed Resident #6 had an assisted fall in the bedroom, from the bed. Per the Report, Resident #6 was being assisted to the wheelchair from bed when his/her knee gave out. State Registered Nurse Aide (SRNA) #2 assisted the resident to the floor, but in doing so trapped and twisted the resident's right ankle under the wheelchair. The resident was assisted back to bed and then complained of ten (10) out of ten (10) pain to the right ankle, which had swelling, bruising, and a hard bony protrusion noted. Further review of the Report, revealed LPN #4 notified the Physician at 7:55 PM, and sent the Resident to the emergency room at 8:15 PM. Further review revealed medical risk factors possibly related to the incident included sensory limitations, fall history, and incontinence. The Report was signed by LPN #4, Director of Nursing (DON), Administrator, and Medical Director. Review of the Fall investigation Form, dated 09/20/18, completed by LPN #4, revealed Resident #6 was engaged in transferring from bed to wheelchair, did not call for help, and the fall event was witnessed by SRNA #2. Continued review revealed the resident was incontinent of stool at the time of the fall event. Further review revealed the resident's fall occurred during a transfer while not using a gait belt or mechanical lift. This Form was not signed by the DON, Administrator, or Medical Director Review of Resident #6's Fall Root Cause Analysis (RCA) Worksheet, undated, and not signed, revealed Resident #6 stated he/she was trying to move to the wheelchair when his/her knee gave out. Further review revealed the resident fell inches away from the bed, and was lying on his/her back with arms at side. Continued review revealed the surrounding area was not busy, noisy or cluttered; the lights were on; the bed was at the correct height; the resident was wearing non-skid socks; and SRNA #2 was in the area when the Resident fell . Interview with LPN #4 on 10/04/18 at 1:00 PM, revealed he completed the Worksheet; however, there was no designated line on the worksheet for a signature. Review of the Nurse's Note, dated 09/20/18 at 9:32 PM, completed by LPN #4, revealed Resident #6 was being assisted to the wheelchair from bed when his/her knee gave out. Per the Note, SRNA aided the resident to the floor, but in doing so trapped and twisted the right ankle under the wheelchair. The resident at that time did not have complaints of pain. Continued review of the Note, revealed the resident was assisted back to bed and then complained of ten (10) out of ten (10) pain to the right ankle, which upon assessment had swelling, bruising, and a hard bony protrusion noted. Further review of the Note, revealed LPN #4 applied ice to swelling on the right ankle, notified the physician at 7:55 PM, and sent the resident to the emergency room for evaluation and treatment. Per the Note, Medic transported the resident via stretcher with two (2) attendants to the Emergency Department. Review of the Hospital Emergency Department Discharge Summary, dated 09/20/18, revealed Resident #6 was diagnosed with [REDACTED]. Further review revealed a follow up with an orthopedic surgeon was necessary in one (1) week, and if symptoms worsen follow up with the Hospital Emergency Department. Review of the Nurse's Note, dated 09/21/18 at 12:22 AM, completed by, LPN #4 revealed Resident # 6 returned from the Emergency Department via Medic transport via stretcher with two (2) attendants, with a [DIAGNOSES REDACTED]. Per the Note, the resident was wearing a hard splint and had no complaints of pain or discomfort. Further review of the Note, revealed surgery was to be scheduled by the facility, no new orders were received, and the resident's call light was in reach. Review of the subsequent Nursing Note, dated 09/21/08 at 9:18 AM, revealed Resident #6's fall event on 09/20/18 at 7:30 PM, was reviewed during clinical startup meeting. Per the Note, the Root Cause Analysis of the fall was determined to be bilateral lower extremity weakness with buckling of the right knee related to a [DIAGNOSES REDACTED].#6 pending recommendations from the Ortho-surgeon. Interview with Resident #6, on 10/02/18 at 10:26 AM, revealed he/she sustained a fall resulting in a fracture approximately two (2) weeks ago. Resident #6 stated he/she had to ring the call bell for help getting up from his/her bed to the wheelchair; however, he/she did not recall why he/she was getting up. Continued interview revealed when SRNA #2 answered the call bell, on the evening of the fall, both Resident #6 and SRNA #2 decided together not to use the STS lift because the resident was not feeling weak. Resident #6 stated he/she transferred independently many times after staff assisted him/her to sit on the side of the bed, and moved the chair close to the bed, and he/she felt the lift was not needed. Resident #6 stated he/she took a few steps from the bed towards the electric wheelchair, while SRNA #2 was with him/her and was supervising with no hands on assistance, and just stand by assistance for the transfer. Per interview, during the transfer he/she became weak and fell on to both knees. Continued interview revealed SRNA #2 assisted him/her to a lying position and alerted LPN #4, who came to his/her room and assessed him/her. Resident #6 revealed LPN #4 and SRNA #2 then used the full mechanical lift (Hoyer lift) to assist the resident from the floor to the bed, and the STS lift to transfer him/her back to the electric wheelchair for dinner. Per interview, the STS lift was used again after dinner to transfer the resident back to bed. Resident #6 stated he/she noted discomfort and swelling to his/her right ankle when being transferred per the STS lift from the wheelchair to the bed after dinner. Per interview, LPN #4 told the resident he/she could have broken his/her ankle and the physician recommended transferring him/her to the Emergency Department for further evaluation. Interview with SRNA #2, on 10/03/18 at 5:00 PM, revealed he was assisting Resident #6 on 09/20/18 when the resident fell and broke his/her ankle. He stated the fall occurred before dinner when he was assisting the resident to get out of bed. Per interview, SRNA #2 asked Resident #6 how he/she felt that day and the resident verbalized he/she was ok to stand and pivot, and did not need to use the STS lift. SRNA #2 stated he assisted the resident to sit up on the side of the bed, and unhooked the resident's indwelling catheter urinary drainage bag so the resident could stand and pivot. SRNA confirmed he did not assist hands on with the transfer, and he was the only staff in the resident's room during the transfer. SRNA #2 further stated when the resident stood to pivot, his/her right foot got caught on the small wheel on the electric wheelchair. He stated the resident started yelling oh God I'm falling. Additional interview with SRNA #2, revealed his first reaction was to prevent the resident from falling and he tried to stabilize him/her. However, he stated the Resident slowly fell down and he assisted the resident to a sitting position on the floor and then laid him/her back. SRNA #2 stated the resident's right foot was behind him/her, and his/her right leg was bent at the knee. SRNA #2 further stated he straightened out the resident's leg and went to alert LPN #4. Per interview, LPN #4 came to Resident #6's room and assessed the resident, and then helped use the total mechanical lift (Hoyer lift) to assist the resident back to bed. Further interview revealed Resident #6 had on TED ( [MEDICAL CONDITION]-Embolic Deterrent) hose and non-skid socks during the fall, and did not complain of pain after the fall. SRNA #2 stated he then used the STS lift to transfer Resident #6 from the bed to the wheelchair for dinner and then transferred the resident back to bed after dinner. However, he stated when he removed Resident #6's TED hose after dinner he noticed swelling and bruising to the resident's right ankle and the resident verbalized pain. SRNA #2 stated he asked LPN #4 to assess the resident and the nurse had the resident transferred to the hospital. Continued interview with SRNA #2, revealed prior to Resident #6's transfer on 09/20/18, he reviewed the CGIS to check the level of assistance and care the resident required. He stated at that time the resident was to be transferred with a STS lift PRN. SRNA #2 further stated prior to the resident's fall he relied on shift report from the SRNA on the previous shift and what the resident told him when determining if the STS lift should be used for Resident #6's transfers during his shift. Further interview revealed prior to the resident's fall, Resident #6's transfer status varied related to his/her [DIAGNOSES REDACTED]. However, he stated in order to ensure safety during transfer on 09/20/18, Resident #6's transfer technique should have been consistent and specific i.e. extensive assist of two (2) staff with STS lift for all transfers to avoid any question on the correct transfer status and to decrease the risk of injury for the resident and staff. Telephone interview with LPN #4, on 10/04/18 at 1:00 PM, who was assigned to Resident #6 at the time of the fall on 09/20/18, revealed direct care staff used the CGIS as a guide for providing the required assistance needed for each resident. Per interview, the CGIS was to indicate how many staff were required for transfers and if a mechanical lift was required. However, he stated prior to Resident #6's fall on 09/20/18, the resident was weaker on some days and would verbalize to staff if he/she was able to stand and pivot for transfer or needed to use the STS lift for transfer. Per interview, with either transfer technique two (2) staff were required to transfer the resident, but it was up to the SRNAs to determine if the resident was strong enough before each transfer to stand and pivot or needed to use the STS lift. Continued interview with LPN #4, revealed on 09/20/18 around 7:30 PM, he was alerted by SRNA #2 that Resident #6 was on the floor. Per interview, SRNA #2 told him Resident #6 was transferring independently from bed to the wheelchair when his/her knee gave out, and SRNA #2 eased the resident to the floor. Further interview with LPN #4, revealed upon entering the resident's room, the resident was lying on the floor, on his/her back by the bed. Continued interview revealed the resident told LPN #4 he/she thought he/she twisted his/her ankle. LPN #4 stated he assessed Resident #6's ankles after removing the TED hose, and there was no swelling, bruising or complaints of pain from the resident at the initial assessment. Per interview, the resident was assisted off the floor to bed with the total mechanical lift (Hoyer lift) and LPN #4 assessed the Resident again for injuries. Further interview, revealed thirty (30) minutes later, Resident #6 was complaining of pain and swelling to the right ankle. Per interview, the Physician was notified and the resident was transferred to the Hospital Emergency Department for further evaluation. LPN #4 stated the CCP and the CGIS should specify how many staff are required for each resident's transfer and the specific transfer technique to be used to ensure residents were provided consistent and safe care. Interview with SRNA #1/Restorative Aide on 10/04/18 at 2:00 PM, revealed Resident #6 was receiving Transfer Training per the Restorative program prior to his/her most recent fall on 09/20/18. Per interview, Resident #6 would stand from a sitting position with assistance of two (2) staff. Additional interview revealed Resident #6 did require weight bearing assistance with transfers in the Restorative Program and some days the resident was weaker and required more assistance. Further interview revealed prior to the most recent fall, Resident #6 used a STS lift PRN with assistance of one (1) to two (2) staff outside of the Restorative Program when the SRNAs on the floor were transferring the resident related to his/her fluctuating functional/transfer status due to the [DIAGNOSES REDACTED]. Interview with the Occupational Therapist, on 10/04/18 at 2:12 PM, revealed the Therapy Department became involved with a resident's transfer status and use of mechanical lifts only when there was an identified change in a resident's current transfer status and nursing staff requested a therapy evaluation. She stated the licensed nursing staff completed Lift Transfer Evaluations otherwise. Further interview revealed Resident #6 had not been seen recently by therapy services related to transfer technique prior to the fall on 09/20/18. However, she stated if a resident sometimes required the use of a mechanical lift for transfers, the mechanical lift should be used consistently for safety. Interview with the MDS Coordinator, on 10/03/18 at 4:01 PM, revealed prior to Resident #6's fall on 09/20/18, the resident had fluctuating functional status and lower extremity weakness on most days. Per interview, at that time, the resident's transfer status related to assistance needed varied on a day-to-day, hour-to-hour basis. Further interview revealed there was a Lift Binder on each hallway with Lift Transfer Evaluations for each resident's mechanical lift requirements. Per interview, the SRNAs were to use these Evaluations along with the CGIS to check for transfer technique when transferring residents. Continued interview revealed the SRNA who transferred Resident #6 on 09/20/18, had to determine at time of transfer if the resident was able to stand and transfer, or was too weak requiring the Lift. Additional interview with the MDS Coordinator, revealed at the time Resident #6 sustained the fall on 09/20/18, the resident's CCP did not specify two (2) staff were required for transfer as per the MDS Assessment, and the CCP was not specific related to transfer technique required due to the resident's fluctuating functional status. She stated the CGIS which was to be a reflection of the CCP and was used as a source of reference in providing care by the SRNAs, did not specify the exact transfer technique or number of staff to assist with transfers. Continued interview revealed it was important to revise the CCP to ensure staff had specific guidance in providing care to residents. She acknowledged it was important to ensure the falls CCP had specific transfer interventions in an attempt to reduce the residents' risk for falls and injury. The MDS Coordinator further revealed there should be consistent individualized care to all residents for their safety, and there should be no confusion as to transfer technique on the CCP or the CGIS. Interview with the DON, on 10/04/18 at 2:54 PM, revealed she expected staff to provide adequate supervision and assistive devices to prevent accident to residents. Per interview, the facility's goal was to keep residents as safe as possible and provide the best care. She stated she expected facility policy, state and federal regulation and professional standards to be followed in all care. Per interview, she felt the PRN use of mechanical lifts was acceptable practice because the facility wanted the residents to remain as independent as possible. She stated she would not want to limit residents to a STS lift if the resident was capable of transferring with assistance of staff on some days. However, she stated she did realize there were safety risks involved for residents and staff when placing the SRNAs in a situation where they had to determine the transfer status of residents before each transfer. Continued interview with the DON, revealed staff was aware Resident #6 was at high risk for falls prior to the fall on 09/20/18, related to his/her [DIAGNOSES REDACTED]. Per interview, on 09/20/18 the resident sustained [REDACTED]. Continued interview revealed the MDS Nurse was responsible for Care Planning each resident's Activities of Daily Living (ADL) function per the Resident Assessment Instrument. Per interview, she could see how the CCP and the CGIS needed to be specific and consistent related to transfer technique and number of staff needed for transfers to maintain resident safety and quality care. Interview with the Administrator, on 10/04/18 at 3:08 PM, revealed it was acceptable practice for a mechanical lift to be used PRN because it allowed residents to have the most independence possible. However, further interview revealed there was the risk of resident and staff safety involved when SRNAs determined the transfer status of residents for each transfer. Continued interview revealed Resident #6's CCP and CGIS should have specified the resident's self-performance level, the level of staff support required for transfers, and the STS lift for transfers, prior to the resident's transfer on 09/20/18. Interview with Medical Director on 10/04/18 at 3:50 PM, revealed she expected the licensed staff at the facility to determine a resident's transfer status. Additional interview revealed SRNAs or residents should not determine transfer status at the time of transfer because they may not have the knowledge or skills to assess for proper transfer technique. Continued interview revealed a resident's CCP should be specific and should specify the type of transfer and how many staff were required to assist with transfers. Further interview revealed it was important for the CCP to be specific to each resident's needs to ensure staff provided the resident with safe, consistent care.

Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to ensure services were provided by the facility in accordance with each resident's written plan of care for (2) of twenty-three (23) sampled residents (Resident #11 and Resident #23). Review of Resident #11's Comprehensive Plan of Care revealed the resident was at risk of impaired skin integrity and approaches included the Certified Nursing Assistants (CNAs) assessing the skin with AM (morning) care and reporting any changes to the nurse. Further review revealed the nurses would to provide weekly skin audits and document and notify the physician of any changes, and apply Zinc Oxide Ointment to the bilateral buttocks as ordered. Review of the last Skin Check Report of Non-Decub Skin Issues, dated 10/05/12, revealed Resident #11 had an area which was described as excoriation on the buttocks. However, on 10/11/12 during a skin assessment with the surveyor, the area was observed to have an unidentified area of black eschar 2.3 centimeters (cm) in length x 1.6 cm in width and was described by the nurse as unstageable with an area of white maceration surrounding the eschar and scant serous drainage just below the coccyx/on the right buttocks. There was no documented evidence the Plan of Care had been followed related to the staff documenting and notifying the physician of any changes related to the wound on the resident's coccyx/right buttock as evidenced by the facility failing to recognize the change in the wound when the wound progressed from an excoriation to an unstageable wound. However, although the Plan of Care stated the Zinc Oxide was to be applied to the resident's buttocks by the nurses which would allow for the nurses to assess the area each shift, interviews revealed the nurses had the CNAs apply the medication. Review of Resident #23's Comprehensive Plan of Care revealed the resident had the potential for injury related to being a smoker. The approaches included keeping lighter and cigarettes in locked smokers cabinet or nurses station and resident to smoke only in designated smoking areas with staff supervision at all times. However, interviews with staff revealed they were unaware the resident was a supervised smoker, and were aware the resident went outside to smoke unescorted and was allowed to keep cigarettes in his/her nightstand. The facility failed to follow the plan of care, on 10/11/12, when staff entered Resident #23's room, smelled smoke and noted a cigarette in a cup of water at the resident's bedside. Interviews with Resident #23 revealed she/he had been smoking in the room. The findings include: Review of the facility "Comprehensive Plan of Care Policy", revised 08/01/12, revealed it was the responsibility of each Interdisciplinary Team Member involved in the resident's care to provide input into the development, implementation, maintenance and evaluation of the resident's Plan of Care. All staff personnel who provide care should be knowledgeable and have access to the resident's Plan of Care. 1. Review of Resident #11's clinical record revealed he/she was readmitted to the facility from the hospital, on 09/04/12, with [DIAGNOSES REDACTED]. The Departmental Notes, dated 09/04/12 at 11:13 PM, revealed the resident was readmitted to the facility with a [DIAGNOSES REDACTED]. The Re-admission physician's orders [REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 09/17/12, revealed the facility assessed Resident #11 as having a Brief Interview for Mental Status (BIMS) score of fifteen (15) indicating the resident was cognitively intact. Continued review revealed the facility assessed the resident as requiring extensive assistance of two (2) persons for bed mobility, transfers, and toilet use, as ambulation not occurring, and as having functional limitation in range of motion of the lower extremities. Further review revealed the facility assessed the resident as being at risk for pressure ulcers and as having no pressure ulcers. Review of a "Body Audit", dated 10/05/12, revealed a diagram of a body with a line drawn to the coccyx/buttocks area which stated "red". Review of the Skin Check Report of Non-Decub Skin Issues, dated 10/05/12, revealed the resident's buttocks had excoriation, and the treatment was Zinc Oxide. Review of the Comprehensive Plan of Care, with a problem onset date of 02/09/09, revealed Resident #11 was at risk of impaired skin integrity related to decreased mobility, a history of skin breakdown, and [DIAGNOSES REDACTED]. The Plan of Care was revised 9/24/12 to indicate the resident had an unstageable area to the left heel. The goal, with a target date of 12/21/12, stated the resident would be free of any further skin breakdown. Further review revealed the interventions were specific as to which staff were responsible; Certified Nursing Assistants (CNAs) were to assess the skin with am care, and report any changes to the nurse. The licensed nurses were to provide weekly skin audits and document, and notify physician of any changes, and were to apply Zinc Oxide Ointment to the bilateral buttocks as ordered. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The MAR indicated [REDACTED]. Interview, on 10/12/12 at 10:15 AM, with CNA #9 revealed she was assigned to Resident #11 on 10/07/12 and she remembered the area to the resident's buttocks/coccyx was white on that date. She stated the nurses were aware and told her to put Zinc Oxide on the area. Continued interview revealed the nurses did not routinely apply the Zinc Oxide and the CNAs applied it after the nurse obtained it from the treatment cart. There was no documented evidence the wound was assessed by a licensed nurse after the wound was noted to change from an excoriation on 10/05/12 to the appearance of white tissue at the wound on 10/07/12. Interview, on 10/12/12 at 9:15 AM, with Resident #11 revealed he/she received a shower on 10/09/12 and received a bed bath daily all over his/her body and lotion was also applied to his/her body with the bed bath. Resident #11 further stated he/she was unaware he had an area of skin breakdown to his/her coccyx/buttocks. Continued interview revealed the nurses did not come in each shift to apply the Zinc Oxide to the area; however, the aides did apply creams and lotions to the area. Interview, on 10/12/12 at 10:45 AM, with CNA #10 revealed she had assisted Resident #11 with a shower on 10/09/12 and the resident's coccyx/buttocks was "red" which was usual for this resident. Interview, on 10/12/12 at 9:30 AM with CNA #3, revealed she had assisted CNA #9 in transferring Resident #11 to the bathroom on 10/11/12 early on the day shift about 6:30 AM and she noted an area to the top of the buttocks which looked different because it was white in color and was usually red, and she reported it to the night nurse Licensed Practical Nurse (LPN) #3. She further stated LPN #3 said she would report it to the next nurse because she (LPN #3) was about to leave. CNA #3 stated she did not ask LPN #4, who was the day shift nurse to look at the area and was unsure if LPN #4 had assessed it. There was no documented evidence a licensed nurse had assessed this resident after the change in the wound was reported by CNA #3. Interview, on 10/12/12 at 9:00 AM, with LPN #4 revealed she was not notified on 10/10/12 or 10/11/12 of a change in Resident #11's skin. Observation, on 10/11/12 at 3:00 PM, of a skin assessment performed by the Nurse Manager of the South Unit, revealed an area below the coccyx/on the right buttock which the nurse described as black eschar, 2.3 cm in length x 1.6 cm in width, unstageable, with an area of white maceration surrounding the eschar and scant serous drainage. Interview at the time of the skin assessment with the Nurse Manager revealed she was unaware of the unstageable wound. Interview, on 10/12/12 at 3:00 PM with LPN #3, who was assigned to the resident on 10/10/12 from 10:00 PM until 6:00 AM on 10/11/12, revealed the CNAs applied the Zinc Oxide to Resident #11's coccyx/buttocks area which was obtained from central supply and came in packets, or she could obtained the medication from the treatment cart to give to the CNAs to apply. She stated she had not recently seen or assessed the area; however, no one had mentioned the area had changed. Continued interview, on 10/12/12 at 10:15 AM, with CNA #9 revealed the nurses did not routinely apply the Zinc Oxide and the CNAs applied it after the nurse obtained it from the treatment cart. She stated she was not assigned to the resident again until 10/11/12 and when she performed the bed bath the morning of 10/11/12 she noticed a place on the buttocks/coccyx area which was white with redness around it. She further stated, she did not tell the nurse because it did not look different from 10/07/12, and she applied Zinc Oxide to the area which she obtained from the storage closet. Continued interview revealed the CNAs were to tell the nurses if they find a new area or a change in skin; however, she had concerns because sometimes the nurses would not follow up to check the skin when notified of changes. Interview, on 10/12/12 at 12:00 PM, with LPN #2 revealed she had done treatments on the South Unit on 10/11/12 on day shift and did treatments all over the buildings on the days she worked. She stated she remembered applying Zinc Oxide to the resident's buttocks area that day. She stated she did treatments for Resident #11 all week and described the area to the coccyx/buttock as black areas and red areas and stated the wound looked the same all week. She further stated she was unsure when the eschar first occurred and was unaware if she had notified nursing or the physician. Further interview revealed she knew she was to notify the physician if she saw a change; however, she thought the Zinc Oxide was the treatment ordered for the eschar. She stated the Zinc Oxide that she applied was from pharmacy and was kept in the treatment cart. She further stated, she did not allow the CNAs to apply it. Further interview, with the Nurse Manager of the South Hall, on 10/12/12 at 3:00 PM, revealed the CNAs and nurses were to notify the charge nurse or herself if a wound changed or if there was a new area of skin breakdown. After reviewing Resident #11's chart, she stated the "Body Audit" was done 10/05/12 and the wound must have worsened sometime between 10/05/12 and 10/11/12 at the time of the skin assessment with the surveyor. Further interview revealed the physician should have been notified a soon as the change in the wound occurred because Zinc Oxide would not be effective for eschar. Interview, on 10/12/12 at 5:45 PM, with the DON revealed there was a failure by staff to report a change in Resident #11's wound as the area changed from a non-pressure area to a pressure area. She stated, there was a physician's orders [REDACTED]. Further interview revealed when a nurse or a CNA found a change in a wound or a new area of skin breakdown the nurse assigned was to assess the skin, notify the Unit Manager, Charge Nurse or herself as well as the physician was to be notified, as per the Plan of Care. The DON stated, there was a weekly Focus Meeting which she attended and skin problems were discussed. She stated if a new or worsened area of skin breakdown was noted, the nurses were to document this on the Twenty-Four (24) Hour Report in order for it to be discussed in the morning meeting in which all department heads attended; however, there was no notification on the 24 Hour Report related to Resident #11's change in the wound. 2. Review of Resident #23 medical record revealed she/he was admitted to the facility, on 08/10/12, with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident as having a Brief interview for Mental Status (BIMS) score of twelve (12) which indicated moderate impairment in cognitive status. Further review revealed the facility assessed the resident as requiring extensive assistance with transfers and bed mobility, and locomotion, and as not ambulating. Review of the Comprehensive Plan of Care, dated 09/21/12 and revised on 10/02/12, revealed Resident #23 had the potential for injury related to being a smoker with a goal that the resident would be free daily of injury related to smoking and would have no unidentified complications from smoking. The approaches included keeping lighter and cigarettes in locked smokers cabinet or nurses station, resident to smoke only in designated smoking areas with staff supervision at all times, redirect when resident is inappropriate with smoking habits, assist to supervised smoking areas at designated times, and provide smoking materials at supervised smoke breaks only. Review of the Safe Smoking Evaluation, dated 09/21/12, completed by Registered Nurse (RN) #7/MDS Nurse revealed the resident had short term memory loss. Review of the Summary of Evaluation Section, revealed the resident had to be supervised by staff, volunteer, or family member at all times while smoking. Also, the Evaluation stated, the resident must request smoking materials from staff, the resident/ representative/family have been informed of smoking evaluation results, the resident/representative/family have been informed of smoking policies/procedures, and the plan of care had been updated. Observation, on 10/12/12 at 8:30 AM, revealed Resident #23 approached the surveyor and the South Unit Manager in the hall and stated he/she did a "boo boo" last night. When the Unit Manager asked the resident what she/he had done, the resident stated she/he had smoked in her/his room. Interview, on 10/12/12 at 10:00 AM, with the Unit Manager of the South Unit revealed she was not informed of the smoking incident by staff. She further stated there was no documentation in the medical record and no Incident Report was completed related to the smoking incident. Further interview, revealed she did not know how Resident #23 could have obtained cigarettes unless her/his family brought them in as she/he was a supervised smoker. Interview, on 10/12/12 at 11:15 AM and 1:45 PM, with Resident #23, revealed she/he was unsure of the exact time that she/he smoked in his/her room last night and further stated she/he was allowed by staff to carry cigarettes with him/her until today. Continued interview revealed Resident #23 had been recently admitted and he/she became confused and thought he/she was at home when he/she smoked in the room. Resident #23 stated his/her son brought cigarettes in and gave some to the nurses to lock up and let her/him keep some with him/her. Further interview, on 10/12/12 at 2:15 PM, with the Unit Manager revealed she had found a note which was placed under her office door related to the incident and was unsure who the note was from. The Unit Manager stated she filled out the Incident Report after finding the note; however, the nurse who witnessed the incident should have completed an Incident Report related to the smoking incident. Interview, on 10/12/12 at 2:30 PM, with CNA #7 revealed she worked the South Unit on 10/11/12 from 2:00 PM until 10:00 PM but was not assigned to Resident #23. He stated he had been assigned to the resident in the past and was unsure if she/he was a supervised smoker. He further stated, he was aware the resident carried cigarettes with him/her and kept them in the drawer in the nightstand drawer. Continued interview revealed there was a list for staff to refer to in regards to supervised smokers, however this resident was not on either the supervised or unsupervised smoking list and the list needed to be updated. He further stated he had asked the evening shift nurses in the past, if the resident could go outside to smoke unescorted and he was told that the resident could. He stated he had observed Resident #23 to go outside to smoke alone. Interview, on 10/12/12 at 2:50 PM, with CNA #13 revealed she worked 10/11/12 on the South Unit from 10 PM until 6 AM and around 11:00 PM she and CNA #12 noted movement in Resident #23's room and went to check on the resident. She stated upon entering the room near the privacy curtain, they smelled smoke. She further stated the window was open and the resident had already put out the cigarette. Continued interview revealed she reported this to LPN #3 and LPN #5, who immediately came into the resident's room. CNA #13 stated, LPN #5 told the CNAs to get the cigarettes and put them in the locked drawer in the designates smoking area. According to CNA #13, Resident #23 kept apologizing for smoking in the room. CNA #13 indicated Resident #23 must be an unsupervised smoker because she had witnessed the resident to carry cigarettes with her/him. She further stated when the resident went to the hospital a few weeks ago, she (CNA #13) had put the resident's cigarettes and lighter in the top drawer of the night stand. Further interview revealed supervised smokers were not to have cigarettes and lighters and there was a list which indicated which residents were supervised smokers at the nurse's station. She was unsure if this resident was on the list. Interview, on 10/12/12 at 3:15 PM, with Certified Nursing Assistant (CNA) #12 revealed she had worked the South Unit on 10/11/12 from 2:00 PM until 10:00 PM upon entering Resident #23's room after hearing movement she smelled smoke and observed a cigarette in a cup of water at the resident's bedside. She also observed the window was open in the resident's room. Further interview, revealed LPN #5 was notified and came in and confiscated the cigarettes and lighter while she and another CNA searched the room for more cigarettes and lighters, and some cigarettes were found in the resident's night stand. Interview, on 10/12/12 at 4:05 PM, with LPN #5 revealed she had worked the South Unit on 10/11/12 and worked from 2:00 PM until sometime after 10:00 PM. She stated she saw Resident #23 moving about in his/her room and asked CNA #12 and CNA #13 to go see about the resident as the resident may need to have assistance. LPN #5 stated CNA #13 told her Resident #23 was smoking in the room; however, when she (LPN #5) entered the room, the cigarette was already in the water. "It was obvious the resident had been smoking". She said the cigarettes and lighter were removed from the room by the CNAs. She further stated the resident had been a unsupervised smoker and had been going outside to smoke unescorted and always had cigarettes on his/her person. Further interview revealed there was a list at the nurse's station which indicated which residents required supervision and which residents could smoke independently. LPN #5 stated, as far as she knew, the residents who could smoke unsupervised could have lighters and she was aware some residents had lighters. Interview, on 10/12/12 at 4:35 PM, with RN #7/MDS Nurse revealed she had completed the Smoking Evaluation for Resident #23 and based on the resident's cognitive status she felt the resident should be supervised when smoking. Continued interview revealed after the Smoking Evaluation was completed, she was to inform MDS Nurse #2 who was responsible for updating the smoking list and the list was kept at the North Unit, South Unit and in the activities office Observation, on 10/12/12 at 4:40 PM, of the Smokers List on the bulletin board at the nurses station on the South Hall where Resident #23 resided revealed Resident #23 was not on the list as a non supervised smoker or a supervised smoker. Further interview with RN #7/MDS Nurse, on 10/12/12 at 4:45 PM, revealed Resident #23 was admitted on a Friday and she may not have told MDS Nurse #2 to update the list with Resident #23's name as a supervised smoker. She stated MDS Nurse #2 was on leave and unavailable for interview. Interview, on 10/12/12 at 5:30 PM, with the Director of Nursing (DON) revealed Resident #23 was to be on the supervised smoker list which was kept at both nurse's stations and she was unaware this resident was not on the list at all. She indicated the resident would need to be on the supervised smoker list in order for staff to know whether the resident needed supervision with smoking as that was the reference used. She further stated the charge nurses or MDS nurses completed smoking assessments, and the MDS nurses were responsible for checking the list frequently to update them. Continued interview revealed as soon as the nurse completed the Smoking Evaluation, the nurse should have immediately update the Smokers List; however, she stated she was unsure of how quickly the resident's name went on the list after a Smoking Evaluation was completed. The DON further stated, there was a breakdown in communication if Resident #23's name was not on the supervised smoking list. She stated no smokers were allowed to have lighters and the staff gathered lighters from the residents frequently. When asked if there was any scheduled check/audit to see if supervised smokers had cigarettes or lighters, or if unsupervised smokers had lighters, she stated staff did not check the rooms on a routine or scheduled basis. Continued interview, revealed if staff recognized an issue with a supervised smoker having cigarettes or a unsupervised smoker having a lighter, the room would be checked. Further interview revealed the potential for harm was there if a resident was smoking in the room, and it would be important for staff to know which residents could not have cigarettes in their possession. Interview, on 10/09/12 at 6:15 PM, with the Administrator and the Quality Assurance Director revealed the resident's name should go on the smoking list as soon as the smoking evaluation was completed which would be the day of admission for a new admit. Continued interview revealed there was a breakdown in communication related to the smoking policy and it would be important for staff to be knowledgeable as to who was a supervised smoker so that a staff member could be with a supervised smoker during smoking times per the plan of care.

Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to ensure a residents having pressure sores received the necessary care and services to promote healing, prevent infection, and prevent new sores from developing for one (1) of twenty-three (23) sampled residents (Resident #11). Resident #11 was assessed to have several small shear areas to the coccyx which were red in color upon re-admission to the facility on [DATE], and Zinc Oxide was ordered to the area. The area was described as excoriation on the Skin Check Report of Non-Decub Skin Issues, dated 10/05/12. However, observation on 10/11/12 during a skin assessment revealed the area was observed to have an unidentified area of black eschar 2.3 cm in length x 1.6 cm in width and was described by the nurse as unstageable with an area of white maceration surrounding the eschar and scant serous drainage just below the coccyx/on the right buttocks. Although there was conflicting interviews with staff as to the appearance of Resident #11's coccyx/buttocks wound prior to the skin assessment with the surveyor on 10/11/12, there was no documented evidence the facility recognized the change in the wound when the wound became unstageable in order to obtain an appropriate treatment to promote healing. The findings include: Review of the facility's policy entitled "Pressure Sores Policy", dated 08/01/12, revealed if a resident developed a pressure sore, he or she would receive care and treatment to heal and prevent further development of pressure sores. Review of the facility's policies entitled "Pressure Ulcer Guideline", revised 03/01/06, and "Introduction to Prevention and Management of Wounds", revised 03/01/06, revealed these policies were based on those developed by the Agency for Health Care Policy and Research and Quality. The "Pressure Ulcer Prevention Guideline" policy stated staff was to perform systematic skin inspections daily; review or modify as needed the individual's positioning, transfer, range of motion, sitting and turning schedule; update the individualized care plan as needed; and educate staff related to identification and role of those responsible for pressure sore prevention, etiology and risk factors for pressure sores, characteristics of normal skin, characteristics of tissue deformation, and staging of pressure ulcers. Review of the 'Introduction to Prevention and Management of Wounds'" policy revealed if a wound developed the goal of the program was to promote healing and revise and further monitor the facilities clinical wound management programs. Review of Resident #11's medical record revealed he/she was readmitted to the facility from the hospital on [DATE] with [DIAGNOSES REDACTED]. Review of the Departmental Notes, dated 09/04/12 at 11:13 PM, revealed the resident was readmitted to the facility with a [DIAGNOSES REDACTED]. The Re-admission physician's orders [REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of fifteen (15) indicating the resident was cognitively intact. Further review revealed the facility assessed the resident as requiring extensive assistance of two (2) persons for bed mobility, transfers, and toilet use, as ambulation not occurring, and as having functional limitation in range of motion of the lower extremities. Continued review revealed the facility assessed the resident as being at risk for pressure ulcers and as having no pressure ulcers. Review of the Skin Risk Assessment, dated 09/17/12, revealed the resident scored a fifteen (15) which indicated the resident was at risk for pressure related to; skin often moist, chair fast, made frequent though slight changes in body or extremity position independently, and required moderate to maximum assistance with moving. Review of a weekly :"Body Audit", dated 09/28/12, revealed a diagram of a body with a line drawn to the coccyx/buttocks area which stated "pink". Further review of a "Body Audit", dated 10/05/12, revealed a diagram of a body with a line drawn to the coccyx/buttocks area which stated "red". Review of the Skin Check Report of Non-Decub Skin Issues, dated 10/05/12, revealed the resident's buttocks had excoriation, and the treatment was Zinc Oxide. Review of the Comprehensive Plan of Care with a problem onset date of 02/09/09, revealed the resident was at risk of impaired skin integrity related to decreased mobility, a history of skin breakdown, and [DIAGNOSES REDACTED]. Further review revealed the Plan of Care was revised 9/24/12 to indicate the resident had an unstageable area to the left heel. The goal with a target date of 12/21/12 revealed the resident would be free of any further skin breakdown. The interventions were specific as to which staff were responsible; Certified Nursing Assistants (CNAs) were to assess the skin with am care, and report any changes to the nurse. Nurses were to provide weekly skin audits and document, and notify physician of any changes, and nurses were to apply Zinc Oxide Ointment to the bilateral buttocks as ordered. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The MAR indicated [REDACTED]. Interview, on 10/12/12 at 10:15 AM, with CNA #9 revealed she was assigned to Resident #11 on 10/07/12 and the area to the resident's buttocks/coccyx was white at that time. She said the nurses were aware and told her to put Zinc Oxide on the area. Further interview revealed the nurses did not routinely apply the Zinc Oxide and the CNAs applied it after the nurse obtained it from the treatment cart. There was no documented evidence the wound was assessed after the wound was noted to change from an excoriation on 10/05/12 to the appearance of white tissue at the wound on 10/07/12. Interview, on 10/12/12 at 9:15 AM, with Resident #11 revealed he/she received a shower on 10/09/12 and received a bed bath daily all over his/her body and lotion was also applied to his/her body with the bed bath. Resident #11 further stated he/she was unaware he had an area of skin breakdown to his/her coccyx/buttocks because it was not sore. Further interview revealed the nurses did not come in each shift to apply the Zinc Oxide to the area; however, the aides did apply creams and lotions to the area. Interview, on 10/12/12 at 10:45 AM, with CNA #10 revealed she had assisted Resident #11 with a complete shower on 10/09/12 and the resident's coccyx/buttocks was "red" which was usual for this resident. Interview on 10/12/12 at 9:30 AM with CNA #3, revealed she had helped CNA #9 assist Resident #11 to the bathroom on 10/11/12 early on the day shift about 6:30 AM and she noted an area to the top of the buttocks which looked different because it was white in color and was usually red. She stated she reported it to the night nurse Licensed Practical Nurse (LPN) #3. She stated LPN #3 said she would report it to the next nurse because she was about to leave. CNA #3 stated she did not ask LPN #4, the day shift nurse to look at it and was unsure if LPN #4 had assessed it. There was no documented evidence staff had assessed this resident after the change in the wound was reported by CNA #3. Observation of a skin assessment performed by the Nurse Manager of the South Unit on 10/11/12 at 3:00 PM, revealed an area below the coccyx/on the right buttock which the nurse described as black eschar, 2.3 cm in length x 1.6 cm in width, unstageable, with an area of white maceration surrounding the eschar and scant serous drainage. Interview at the time with the Nurse Manager who was conducting the skin assessment revealed she was unaware of the unstageable wound. Interview, on 10/12/12 at 3:00 PM with LPN #3, who was assigned to the resident on 10/10/12 from 10:00 PM until 6:00 AM on 10/11/12 revealed the CNAs applied the Zinc Oxide to Resident #11's coccyx/buttocks area which was obtained from central supply and came in packets, or she could obtained the tube from the treatment cart to give to the CNAs to apply. She stated she had not recently seen or assessed the area, however, no one had mentioned the area had changed. Interview, on 10/12/12 at 9:00 AM, with LPN #4 revealed she was not notified on 10/10/12 or 10/11/12 of a change in Resident #11's skin. Further interview, on 10/12/12 at 10:15 AM, with CNA #9 revealed the nurses did not routinely apply the Zinc Oxide and the CNAs applied it after the nurse obtained it from the treatment cart. She stated she was not assigned to the resident again until 10/11/12 and when she performed the bed bath the morning of 10/11/12 she noticed a place on the buttock/coccyx area which was white with redness around it. She further stated, she did not tell the nurse because it did not look different from 10/07/12, and she applied Zinc Oxide to the area which she obtained from the storage closet. Continued interview revealed the CNAs were to tell the nurses if they found a new area or a change in skin; however, she had concerns because sometimes the nurses would not follow up to check the skin when notified of changes. Interview, on 10/12/12 at 12:00 PM, with LPN #2 revealed she had done treatments on the South Unit on 10/11/12 on day shift and did treatments all over the buildings on the days she worked. She stated she remembered applying Zinc Oxide to the resident's buttocks area that day. She stated she did treatments for Resident #11 all week and described the area to the coccyx/buttock as black areas and red areas and stated the wound looked the same all week. She further stated she was unsure when the eschar first occurred and was unaware if she had notified nursing or the physician. Further interview revealed she knew she was to notify the physician if she saw a change; however, she thought the Zinc Oxide was the treatment ordered for the eschar. She stated the Zinc Oxide that she applied was from pharmacy and was kept in the treatment cart. She further stated, she did not allow the CNAs to apply it. Review of the Prescriptions delivered from pharmacy for Resident #11 revealed there was only one prescription filled for Zinc Oxide Ointment on 09/05/12 and none filled after this date. Further interview, on 10/12/12 at 3:00 PM, with the Unit Manager revealed the CNAs and nurses should notify the charge nurse or herself if there were wound changes or if there was a new area of skin breakdown. She reviewed the chart and stated the "Body Audit" was completed 10/05/12 and the wound must have worsened sometime between 10/05/12 and 10/11/12 at the time of the skin assessment that was requested by the surveyor. She further stated the physician should have been notified a soon as the change in the wound occurred because Zinc Oxide would not be effective for eschar. Interview, on 10/12/12 at 5:45 PM, with the Director of Nursing (DON) revealed there was a failure by staff to report a change in the wound as the area changed from a non-pressure area to a pressure area. She further stated, there was a physician's orders [REDACTED]. Continued interview revealed when a nurse or a CNA found a change in a wound or a new area of skin breakdown the nurse assigned was to assess the skin, notify the Unit Manager, Charge Nurse or herself and the Physician was to be notified. She stated there was a weekly Focus Meeting which she attended and skin problems were discussed. She further stated if a new or worsened area of skin breakdown was noted, the nurses would document this on the Twenty-Four (24) Hour Report in order for it to be discussed in the morning meeting in which all department heads attended; however, there was no notification on the 24 Hour Report related to Resident #11's change in the wound. Review of the physician's orders [REDACTED].

Based on interview and record review, it was determined the facility failed to implement the written plan of care for indwelling catheter care for one (1) of six (6) sampled and two (2) unsampled residents. The facility developed a care plan to monitor Resident #1's catheter use with staff to observe for symptoms of a Urinary Tract Infection [MEDICAL CONDITION] which included: reduced urine output, reduced fluid intake, fever, odor, and notify the physician of any changes. On 03/14/12, the facility inserted a catheter for bladder distention and on 03/18/12 the resident was diagnosed with [REDACTED]. Another urinalysis was obtained on 04/12/12 with positive findings of bacteria for a UTI. An additional care plan was developed on 04/14/12 for the use of an antibiotic medication to treat a UTI. This care plan had approaches to obtain and record temperatures every shift, observe urine for color/consistency, and to observe and document resident's condition at least every shift or as otherwise specified. However, the facility failed to monitor the resident's temperature and urine output according to the written plan of care. On 04/16/12, the resident was found unresponsive, hypotensive, pulse of 141, temperature of 101.8 degrees Fahrenheit (F) with mottled legs. The resident had no urine output. The facility called Emergency Medical Services (EMS) and the resident was transported to the hospital for emergency treatment. The resident was discharged from the facility to the hospital on [DATE]. The hospital diagnosed the resident [MEDICAL CONDITION] secondary to UTI, fever (102 degrees F.), altered mental status, and dehydration. The facility's failure to monitor the resident's temperature and urine output per the resident's plan of care caused the resident harm and required hospitalization . (Refer to F315) The findings include: Interview with the Assistant Director of Nursing, on 04/25/12 at 10:40 AM, revealed the facility utilized the Resident Assessment Instrument (RAI) Manual for development, revision, and implementation of the written plan of care. Review of the clinical record for Resident #1 revealed the facility admitted the resident on 03/09/12 with the following Diagnoses: [REDACTED]. The resident did not have an indwelling catheter on admission. On 03/14/12, the facility documented the resident's abdomen as distended and tender. An order to "straight cath" ( a procedure where the catheter is inserted in to the bladder and then removed) the resident was received and when the nurse performed the procedure, 2000 ml of urine was obtained from the resident's bladder. The physician ordered for the catheter to remain in place. A care plan was developed to address the catheter use on 03/14/12. Interventions directed staff to observe for symptoms of a Urinary Tract Infection [MEDICAL CONDITION] which included: reduced urine output, reduced fluid intake, fever, odor, and notify the physician of any changes. Further review of the clinical record revealed on 03/18/12 Resident #1 was diagnosed with [REDACTED]. Review of the admission Minimum Data Set (MDS) assessment, dated 03/20/12, revealed the facility assessed the resident to have severe cognitive impairment and to require extensive assistance with toileting needs. The MDS assessment revealed the resident was currently experiencing a UTI with treatment. On 04/12/12 another urinalysis was obtained with findings of bacterial growth indicating a UTI. An additional care plan was developed on 04/14/12 for the use of antibiotic medication to treat the UTI. This care plan had approaches to obtain and record temperatures every shift, observe urine for color/consistency, and to observe and document resident's condition at least every shift or as otherwise specified. Interview with LPN #3, #4, and #5, on 04/25/12 at 11:45 AM, 2:00 PM, and 2:10 PM respectively revealed the nurses had failed to obtain a temperature or monitor Resident #1's urine output on 04/15/12 and 04/16/12 per the resident's plan of care. On 04/16/12 at 8:09 PM, Resident #1 was found unresponsive with no urine output. The resident's temperature was 101.8 degrees F., blood pressure 106/66, Pulse of 141, and Respirations of 26. The resident's bilateral lower extremities were documented as mottling with no urine output noted. Emergency Medical Services (EMS) was called and the resident was transferred to the hospital for emergency treatment. Review of the hospital documentation (History and Physical) revealed the resident was unconscious upon arrival with a recorded temperature of 102 degrees F. The hospital documented when the indwelling catheter was removed, the resident had 200 ml of purulent discharge from the urethra. With insertion of a new catheter, 1300 ml of urine was obtained. The hospital admitted the resident with [DIAGNOSES REDACTED]. Interview with the Assistant Director of Nursing, on 04/25/12 at 10:40 AM, revealed it was the facility's practice to place the residents' names that were currently taking an antibiotic on the daily report. This would alert nurses to obtain a temperature and monitor the resident every shift. She stated the nurse who took the order for the antibiotic for Resident #1 on 04/14/12, had failed to place the resident's name on the antibiotic list. She stated through investigation it was found the nurses had failed to obtain a temperature or monitor the resident's urine every shift according to the care plan. The nurse who took the physician order [REDACTED].

Based on interview, record review, and review of the facility's policies, it was determined the facility failed to ensure one (1) of six (6) sampled and two (2) unsampled residents received the appropriate treatment and services to prevent urinary tract infections [MEDICAL CONDITION]. The facility admitted Resident #1 without an indwelling catheter. On 03/14/12, the facility inserted a catheter for bladder distention and obtained over 2000 milliliters (ml) of residual urine. After insertion of the catheter, the resident experienced a UTI on 03/18/12 and treatment was obtained for ten (10) days. Another urinalysis was obtained on 04/12/12 with positive findings of bacteria for a UTI. The results were reported to the facility on [DATE]. The nurse called the lab results to the resident's physician; however, the nurse failed to report the correct findings. The nurse's failure to report correct lab findings resulted in the physician ordering an antibiotic that did not treat the UTI effectively. In addition, the facility failed to monitor the resident's temperature according to the facility's protocol for any resident placed on an antibiotic and failed to monitor the resident's urine output. The resident had a decrease in urine output from 475 ml on 04/15/12 down to 10 ml on 04/16/12 at 1:49 PM. On 04/16/12 at 8:00 PM, a Certified Nursing Assistant (CNA) found the resident with no urine output and unresponsive. The nurse's assessment, on 04/16/12 at 8:09 PM, found the resident unresponsive, hypotensive, pulse of 141, temperature of 101.8 degrees Fahrenheit (F) with mottled legs. The facility called Emergency Medical Services (EMS) and the resident was transported to the hospital for emergency treatment. The hospital diagnosed the resident [MEDICAL CONDITION] secondary to UTI, fever (102 degrees F.) altered mental status, and dehydration. The resident was discharged from the facility on 04/16/12 to the hospital. The facility's failure to monitor the resident's temperature, urine output, and obtain the correct antibiotic caused the resident harm and required hospitalization . The findings include. Review of the facility's policy regarding "Catheter" (Indwelling Utilization Policy), revised 12/01/10, revealed catheter care must be performed. The policy did not direct the staff in monitoring of a resident with an indwelling catheter. Review of the facility's policy regarding "Intake and Output Procedure", effective 12/01/10, revealed the purpose of the procedure was to decrease the susceptibility of residents who are predisposed to urinary tract infections. Review of the clinical record for Resident #1 revealed the facility admitted the resident on 03/09/12 with the following Diagnoses: [REDACTED]. Continued review of the record revealed the resident did not have an indwelling catheter in place when admitted . Review of the nurses' notes and physician's progress notes for 03/14/12 revealed the resident's abdomen was distended and tender. An order to "straight cath" (a procedure to insert a catheter in to the bladder and then remove) the resident was received and when the nurse performed the procedure, 2000 ml of urine was obtained from the resident's bladder. The physician ordered the catheter to remain in place. The care plan, dated 03/14/12, revealed the staff were to observe for symptoms of UTI (reduced urine output, reduced fluid intake, fever, odor, and notify the physician of any changes). The record revealed a urinalysis report with findings positive for a UTI were reported to the facility on [DATE] and an antibiotic treatment was obtained for 10 days. Review of the admission Minimum Data Set (MDS) assessment, dated 03/20/12, revealed the facility assessed the resident to have severe cognitive impairment and to require extensive assistance with toileting needs. The resident was currently experiencing a UTI with treatment. Record review revealed on 04/12/12 another urinalysis was obtained. On 04/14/12 the findings of the urinalysis, which was positive for bacteria, were reported to the facility by the lab. The nurse called the lab result to the physician; however, she incorrectly reported a medication (Bactrim) was resistant to the bacteria. Therefore, the antibiotic ordered (Bactrim DS twice a day for 10 days) was ineffective in treating the UTI. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. An additional care plan was developed on 04/14/12 for the use of antibiotic medication to treat the UTI. This care plan had approaches to obtain and record temperatures every shift, observe urine for color/consistency, and to observe and document resident's condition at least every shift or as otherwise specified. Review of the urine output records for Resident #1 dated 04/01/12 through 04/14/12 revealed the resident's urine output averaged [PHONE NUMBER] ml per day. On 04/15/12 the resident's urine output had decreased to 475 milliliter (ml) from 5:39 AM to 9:52 PM. From 9:52 PM on 04/15/12 to 6:04 AM on 04/16/12 the resident's urine output was only 50 ml for eight (8) hours, and from 6:04 AM to 1:49 PM on 04/16/12, the resident's urine output was 10 ml. Review of the nurses' notes, dated 04/16/12 at 8:09 PM, revealed the nurse was called to the resident's room and found the resident with a increased temperature of 101.8 degrees F., blood pressure 106/66, Pulse of 141, and Respirations of 26. The resident's bilateral lower extremities was documented as mottling with no urine output noted. Emergency Medical Services (EMS) was called and the resident was transferred to the hospital for emergency treatment. Review of the hospital documentation (History and Physical) revealed the resident was unconscious upon arrival with a recorded temperature of 102 degrees F. The hospital documented when the indwelling catheter was removed, the resident had 200 ml of purulent discharge from the urethra. When a new catheter was inserted, 1300 ml of urine was obtained. The hospital admitted the resident with [DIAGNOSES REDACTED]. Interview with LPN #4, on 04/25/12 at 11:45 AM, revealed she had worked the night shift (10 PM- 6 AM) for 04/15/12 - 04/16/12. She stated she did not receive any information in report regarding Resident #1. She stated the resident's low urine output (50 ml) was not reported to her; therefore, she did not report those findings to the day shift nurse. She said she did not check the catheter, did not assess the resident, nor obtained a temperature during her shift. She stated she did not know the resident was on an antibiotic because Resident #1 had not been placed on the antibiotic list. On 04/25/12 at 11:55 AM, interview with CNA #2 revealed she had worked the 6 AM-2 PM shift on 04/16/12. She stated Resident #1's urine output was very low (10 ml) during her shift and she had reported the low urine output to LPN #3. She said the resident had not yelled or cried out during care that day; and that was very unusual for this resident. Interview with LPN #3, on 4/25/12 at 2:20 PM, revealed she worked the 6 AM-2 PM shift on 04/16/12. She said CNA #2 came up to her at the end of the shift and told the nurse Resident #1's urine output was low (10 ml). "I thought I told the oncoming nurse, but I can't really recall." She stated she did not know about the resident's low urine output of 50 ml at the start of her shift. She revealed she did not assess the resident or the catheter and did not obtain a temperature. She said the resident was not on the antibiotic list. Interview with LPN #5, on 04/25/12 at 2:10 PM, revealed she had worked the evening shift 2:00 PM to 10:00 PM on 04/16/12 when Resident #1 was sent to the hospital. During report from the day shift nurse, she stated she did not receive any information regarding Resident #1's low urine output. (10 ml) She did not know the resident was on an antibiotic; therefore, she did not obtain a temperature nor did she assess the resident's catheter. At 8:00 PM, the nurse said CNA #6 came to her and reported the resident had no urine output and was unresponsive. The nurse said she found the resident in bed, unresponsive, and no urine was observed to be in the catheter drainage bag or tubing. LPN #5 stated she tried to arouse the resident, but was unsuccessful. She revealed the resident's legs were mottled and she thought the resident was dying. She called for the RN Supervisor to stay with the resident while she called EMS. Interview with the RN Supervisor (RN #1), on 04/24/12 at 5:00 PM, revealed she was called to Resident #1's room by LPN #5 on 04/16/12 at around 8:00 PM. She stated she found the resident unresponsive with no urine output. The resident's vital signs were abnormal as documented in the record and the resident's legs were mottled. She indicated she stayed with the resident while LPN #5 called EMS. Continued review of the clinical record revealed no documented evidence the facility obtained or recorded a temperature every shift according to the care plan. Review of a computer generated flow sheet revealed, on 04/11/12 at 6:58 PM, the facility recorded a temperature of 99.6 degrees F. Another temperature (101.8 F.) was not obtained until 04/16/12 at 8:00 PM, when the CNA found the resident unresponsive with no urine output. Interview with the Assistant Director of Nursing, on 04/25/12 at 10:40 AM, revealed she reviewed the shift report forms, dated 04/11/12 - 04/16/12, and could not find where the urinalysis results were discussed or when the physician ordered the antibiotic. She stated it was the facility's practice to put the residents' names who were on an antibiotic on the daily report to alert nurses to obtain a temperature and monitor the resident every shift. She stated the nurse who took the order for the antibiotic for Resident #1 was responsible for placing the resident's name on the list. Review of the report forms for April 11 - 16, 2012 revealed Resident #1's name was not included on the antibiotic list. Interview with the Director of Nursing (DON), on 04/24/12 at 5:15 PM, revealed the facility identified the nurse had given the wrong lab findings to the physician during an audit on 04/17/12. The DON conducted an investigation and found the nurse reported the bacteria was sensitive to Bactrim, not resistant as indicated on the lab report. Therefore, the physician ordered the wrong antibiotic. She revealed the lab results were not faxed but called to the physician. In addition, the DON stated during the investigation, it was found the resident had decreased urine output. She stated nurses were suppose to review intake and output records and act on any changes. Continued interviewed with the DON, on 05/25/12 at 4:00 PM, revealed the facility had not identified the failure to place Resident #1 on the antibiotic list; therefore, no temperatures were obtained according to facility protocol. She revealed there was no specific policy regarding obtaining temperatures when a resident was on an antibiotic. She indicated there was a lack of communication between the nurses in regard to the resident's urine output. She said the shift report needed to be more thorough. Interview with Resident #1's primary physician at the nursing facility, on 04/24/12 at 4:50 PM, revealed she was given the wrong information regarding the urine culture and ordered an antibiotic that was resistant not sensitive to the bacteria found in the resident's urine. The physician stated the resident was drinking well; however, she was prone to UTI's and the resident had experienced a UTI in March 2012. She indicated the facility discovered the mistake and informed her; however, the resident was already in the hospital at that time.