Every finding on record at Colonial Nursing and Rehabilitation Center

Based on facility policy review, record review, and interview, the facility failed to provide adequate assistance to prevent falls for 1 of 3 residents sampled for falls (Resident (R) 14). The findings include: Review of a facility policy titled, Falls Policy, last reviewed on 12/22/2025, revealed, The intent of this policy was to ensure the facility provides an environment that was as free from accident hazards as possible, over which the facility has control to prevent avoidable falls/accidents. The policy revealed, 2. A Care Plan would be implemented based on the resident's risk for falls with an individual goal and interventions specific to each resident to attempt to reduce the risk of avoidable falls, to the extent possible. Review of R14's admission Record revealed the facility admitted R14 on 05/06/2022. According to the admission Record, the resident had a medical history that included diagnoses of morbid obesity, left foot drop (difficulty in lifting the front part of the foot), and right foot drop. Review of an annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/27/2026, revealed R14 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated that the resident required supervision or touching assistance for rolling left and right on a bed. Review of R14's Care Plan Report, included a focus area initiated 01/30/2026, that indicated the resident expressed emotional distress, embarrassment, and discomfort related to body image and the need for a two-person assist with bed mobility and in-bed care. Intervention indicated that the resident required assistance from two staff with bed mobility and in-bed care related to bariatric status to ensure resident and staff safety (initiated 01/30/2026). R14's Care Plan Report included a focus area initiated 05/19/2022, that indicated the resident required assistance for activity of daily living (ADL) care related to impaired balance, morbid obesity incontinence, weakness with decreased endurance, and drop foot to bilateral feet. Interventions directed staff to provide the resident with assistance from two staff for bed mobility as the resident required/would allow (initiated 04/26/2023) and to provide the resident with total assistance for incontinence care (initiated 04/26/2023). Review of R14's Acute Change in Condition Assessment, dated 04/15/2026 at 10:43 AM and completed by Licensed Practical Nurse (LPN) 1, revealed R14 slid off of the edge of their bed, to the floor, and onto their knees during perineal care. The Acute Change in Condition Assessment indicated that R14 had abrasions and skin discoloration upon assessment from LPN1. During an interview on 04/20/2026 at 9:22 AM, R14 stated that they fell out of bed the previous week but was feeling fine. R14 stated that a staff member rolled them out of bed during incontinence care. During an interview on 04/21/2026 at 9:45 AM, R14 stated that on 04/15/2026, State Registered Nurse Aide (SRNA) 6 was their assigned SRNA and provided incontinence care by herself. R14 stated that the facility sometimes used two staff members to help perform incontinence care, but SRNA7 was busy in another room and unable to assist. R14 stated they were able to assist with rolling from right to left in the bed by using the assist bars on either side of the bed. R14 stated that while rolling to the right side of the bed, they rolled too far and slid off the edge of the bed. Per R14, SRNA6 was standing on the opposite side of the bed. R14 stated that their lower body was on the floor and their upper body was leaning on the nightstand next to the bed. R14 stated that SRNA 6 yelled into the hallway for assistance, and several staff members used the full body lift to get them back into bed. R14 stated that they were not hurt as a result of the fall and only had minor bruises and abrasions. During an interview on 04/22/2026 at 2:32 PM, SRNA6 stated that if a resident required the assistance of two staff members, the other SRNA in the hall, as well as the nurse, were available to help. SRNA 6 stated that on 04/15/2026, she was assigned to R14, and she normally completed incontinence care for the resident without difficulty since R14 could use the assist bars to turn in the bed. SRNA6 stated that the resident put the head of the bed down, but the resident's knees were slightly elevated at the time she assisted the resident with incontinence care. SRNA6 stated that during the incontinence care for R14, the resident rolled onto their side and threw their leg over the edge of the bed, causing them to slip onto the floor. SRNA6 stated she ran out of the room to get help from LPN1, and several other staff assisted with a full body lift to get the resident back into bed. SRNA6 stated that having another SRNA in the room to assist with the incontinence care could have prevented the incident. During an interview on 04/24/2026 at 11:12 AM, SRNA6 stated that she did not ask any other staff member for assistance on 04/15/2026 to assist with R14's incontinence care because she was used to performing the care by herself. SRNA 6 stated she was the only one who performed the incontinence care at the time of the fall. During an interview on 04/22/2026 at 2:47 PM, SRNA 7 stated she was familiar with R14's care needs. SRNA 7 stated that R14 was able to turn to their left side using the assist bars on their bed but required more assistance when turning to the right. SRNA7 stated she was assisting another resident when she heard something happened and went to R14's room. SRNA7 stated she observed R14 on the floor with their knees close to the window next to the bed. SRNA7 stated she grabbed a mechanical lift, and several staff members assisted R14 back into bed. SRNA7 stated that when Resident #14 was being turned by SRNA6, the resident's leg swung too far, and the resident ended up falling out of the bed. During an interview on 04/21/2026 at 1:51 PM, LPN1 stated that R14 required two-person assistance with incontinence care and the resident was incontinent of bowel and bladder. LPN1 stated that on 04/15/2026, she was assisting another resident, when she heard someone calling for help. LPN1 stated that she entered R14's room and observed the resident on the floor near the right side of the resident's bed. LPN1 stated that the resident rolled off of the edge of the bed with their knees on the ground and hands grabbing the nightstand and assist bar on the bed. LPN1 stated she assisted other staff in getting Resident14 back into bed after assessing the resident. LPN1 stated that the foot of the resident's bed was elevated, which caused an incline and the resident slipped out of the bed. During an interview on 04/22/2026 at 2:55 PM, the Assistant Director of Nursing (ADON) stated SRNA6 should have utilized two staff members to assist with R14's incontinence care. During an interview on 04/22/2026 at 3:19 PM, the Director of Nursing (DON) stated that R14 could assist with turning and repositioning themselves during incontinence care using the assist rails on their bed. The DON stated that the resident could be sensitive at times with using two staff to assist with incontinence care, so the resident was a two-person assist as the resident allowed. The DON stated that on 04/15/2026, SRNA6 was assisting Resident14 with incontinence care and the resident rolled themselves out of the bed and onto the floor. The DON stated that SRN6 should have used another staff member to assist R14 at the time of the fall and should have waited for assistance.

Based on observation, interview, record review and review of a manufacturer's instructions, the facility failed to ensure licensed nursing staff demonstrated competencies and skill set necessary to administer insulin via insulin injector pen for one (Licensed Practical Nurse (LPN) of two licensed nurses observed during the medication administration task for one of 11 residents observed during medication administration (Resident (R) 50). The findings include: Review of LPN1's Competency Assessment Insulin Administration document, dated 04/16/2026, revealed, A) Purpose revealed, To provide guidelines for the safe administration of insulin to residents with diabetes. The document revealed, B) Preparation included 5. The nursing staff would have access to specific instructions (from the manufacturer if appropriate) on all forms of insulin delivery system(s) prior to their use. The document indicated that the Director of Nursing (DON) assessed LPN1's ability to administer insulin via syringe but did not indicate the DON assessed the LPN's ability to administer insulin via a pen injector. Review of NovoLog (insulin aspart) 100 units per milliliter (mL) injection pen's Instructions for Use, revised 02/2023 revealed, Before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing; E. Turn the dose selector to select 2 units; F. Hold your NovoLog FlexPen with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge; and G. Keep the needle pointing upwards, press the push-button all the way in [reference to photographic material in instructions]. The dose selector returns to 0. A drop of insulin should appear at the needle tip. If not, change the needle and repeat the procedure no more than 6 times. Review of R50's admission Record revealed the facility admitted R50 on 04/15/2026. According to the admission Record, the resident had a medical history that included a diagnosis of type 2 diabetes mellitus with hyperglycemia (a medical condition where a person's blood sugar elevates to potentially dangerous levels). Review of R50's Order Summary Report, with active orders as of 04/22/2026, contained an order, dated 04/16/2026 for, NovoLog FlexPen subcutaneous solution pen injector 100 units per milliliter (mL) as per a sliding scale. The order specified that if blood glucose was 150 to 200, inject 2 units; 201 to 250, inject 4 units; 251 to 300, inject 6 units; 301 to 350, inject 8 units; 351 to 400, inject 10 units subcutaneously before meals and at bedtime for diabetes. The order specified to contact the physician if their blood glucose level was above 401. Resident 50's Order Summary Report contained another order, dated 04/16/2026 for NovoLog FlexPen subcutaneous solution pen injector 100 units per mL, with instructions to inject 16 units subcutaneously before meals for diabetes. During an observation of medication administration on 04/22/2026 at 10:16 AM, LPN1 assessed R50's blood glucose level using a glucometer, which resulted in a reading of 409. LPN1 returned to the medication cart and gathered R50's NovoLog FlexPen, an insulin needle, and alcohol pads and entered R50's room. LPN1 applied the needle to the tip of the pen injector and dialed the dose selector to 16 units. LPN1 did not prime the insulin needle with insulin prior to dialing the dose selector to 16 units. LPN1 performed hand hygiene, donned clean gloves, and administered the insulin to R50. LPN1 removed her gloves, performed hand hygiene, and exited the resident's room. LPN1 stated that she needed to notify R50's physician regarding the resident's blood glucose reading of 409 to check for any additional instructions or orders. LPN1 went to the unit nurses' station and contacted R50's physician via telephone. During an observation of medication administration on 04/22/2026 at 10:28 AM, LPN1 returned to the medication cart and reviewed Resident #50's insulin aspart per sliding scale order and verified the resident was to receive 10 units. LPN1 gathered R50's insulin aspart pen injector, an insulin needle, and alcohol pads and entered Resident #50's room. LPN1 applied the needle to the tip of the NovoLog FlexPen and dialed the dose selector to 10 units. LPN1 did not prime the insulin needle prior to dialing the dose selector to 10 units. LPN1 performed hand hygiene, donned clean gloves, and administered the insulin to R50. LPN1 removed her gloves, performed hand hygiene, and exited the resident's room. During an interview on 04/22/2026 at 10:31 AM, LPN1 stated that she was not aware that the insulin needle on a pen injector needed to be primed prior to administering insulin to a resident. She stated that she had competency training related to insulin administration, but she was not sure if she had education related to the use of insulin pen injectors. During an interview on 04/22/2026 at 11:53 AM, the DON stated that during medication administration competency training, they reviewed insulin administration via an insulin syringe, but they did not conduct training on the use of insulin pen injectors. During an interview on 04/22/2026 at 4:03 PM, the Administrator stated that she expected nursing staff to follow best practices and manufacturer guidelines on the use of insulin pen injectors. She also stated that the facility had not provided competency training related to insulin pens.

Based on observation, interviews, record review, and review of the facility's policy, it was determined the facility failed to provide residents with appropriate care and services to ensure residents were free from neglect for one (1) of sixteen (16) sampled residents (Resident #18). Record review revealed the facility admitted Resident #18 on 12/10/2023 and assessed the resident as having an unstageable pressure injury to his/her right heel. However, there were no orders in place for wound care or monitoring until 01/15/2024. The facility's failure to follow its policy related to providing care for the resident's wound, after being admitted with an unstageable pressure injury, deprived the resident of his/her health care needs and created a situation which prevented the resident's wound from healing. Further, the facility's lack of communication across all shifts to address the resident's treatment of his/her wound caused the resident emotional distress. The resident stated to the State Survey Agency (SSA) surveyor that his/her wound had gotten worse due to the facility's failure to provide treatment to his/her wound upon admission. The findings include: Review of facility's policy titled, Notification of Change in Condition, revised on 06/01/2021, revealed that the facility must immediately inform the resident, consult with the physician, and notify the patients (residents) healthcare decision maker when there was a significant change in the patient's physical, mental or psychosocial status or the need to alter treatment significantly. Review of the facility's policy titled, Abuse Prohibition revised on 10/24/2022, revealed the facility prohibited abuse, mistreatment, and neglect for all patients (residents). Neglect was defined as the failure, indifference or disregard of the center, it's employees or service providers to provide care, comfort, safety, goods and services to a patient (resident) that were necessary to avoid physical harm, pain, mental anguish, or emotional distress. This included the failure to implement effective communication system across all shifts for communicating necessary care and information between the facility, patient (resident), practitioners and resident representatives. Review of the facility's policy titled, Skin Integrity and Wound Management, effective date, 07/01/2001, revised 02/01/2023, revealed, a comprehensive, initial, and ongoing nursing assessment of intrinsic and extrinsic factors that influenced skin health, skin wound impairment, and the ability of a wound to heal would be performed. The plan of care for the patient (resident) would be reflective of assessment findings from the comprehensive assessment and wound evaluation. Further review revealed staff would continually observe and monitor patients (residents) for changes and implement revisions of the care plan as needed; and notify the Medical Director, the Director of Nursing, and Administrator if deviation from the protocol was requested. Continued review revealed the purpose was to provide safe and effective care to promote optimal skin health, prevent pressure injuries, and promote healing. Review of Resident #18's Admission Record revealed the facility admitted the resident on 12/10/2023 with diagnoses including History of Transient Ischemic Attack, with Cerebral Infarction, Acquired Absence of Left Leg below Knee and Type 2 Diabetes Mellitus without complications. Review of the Admission Assessment, dated 12/10/2023 at 3:51 PM, signed by Licensed Practical Nurse (LPN) #3 and co-signed by the Assistant Director of Nursing (ADON), revealed Resident #18 was assessed to have a Braden Score of sixteen (16), indicating the resident was at mild risk for developing pressure injuries. Further review revealed the resident was assessed as having an unstageable Deep Tissue Injury (DTI). However, there was no documented evidence of a wound evaluation to include further description or a measurement of the right heel unstageable DTI on admission. Review of Resident #18's Physician Orders Summary Recap report, dated 12/10/2023, revealed no orders for wound care for Resident #18's right heel pressure injury on admission. Review of Resident #18's Physician's Note, dated, 12/14/2023, revealed Resident #18 was seen by the provider and his/her skin was dry, normal turgor, with no pallor or rash. However, there was no reference to Resident #18's right foot wound. Review of Resident #18's Admission Minimum Data Set (MDS) Assessment, dated 12/15/2023, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of fourteen (14) out of fifteen (15), indicating the resident was cognitively intact. Further review of the assessment, Section M, revealed the facility assessed Resident #18 as having an unstageable pressure injury with suspected deep tissue injury in evolution, that was present on admission. Review of Resident #18's Care Plan revealed the facility did not develop and implement a person-centered care plan for Skin Integrity until 12/26/2023, sixteen (16) days following admission. The care plan revealed a focus problem that stated Resident #18 was at risk for skin breakdown related to frail fragile skin, incontinence, limited mobility and/or had actual skin breakdown, a pressure ulcer to the right heel. Further review of Resident #18's person-centered care plan for Skin Integrity, dated 12/26/2023, revealed there were no specific interventions to protect the resident's right foot wound when the resident was sitting in the wheelchair. Review of the Weekly Skin Check, dated 12/18/2023 12:05 AM, and signed by LPN #3, revealed Resident #18 had a skin injury or wound identified as other. Under location was a typed statement that read,necrotic area to heel. However, no other information was provided. Review of Resident #18's Weekly Skin Check dated 12/26/2023 at 9:34 PM, revealed the resident had a skin injury or wound. However, no other information was provided. Review of the Treatment Administration Record (TAR) for December 2023, revealed there were no orders in place for wound care or monitoring. Review of the Weekly Skin Check dated 01/01/2024 at 5:49 PM, signed by the Director of Nursing (DON), revealed the resident had a new skin injury or wound, and moisture associated skin damage to the coccyx. However, there was no documentation related to Resident #18's wound to the right foot. Review of the Weekly Skin Check dated 01/08/2024 at 8:09 PM, revealed the resident had a wound identified as other wound, necrotic to heel. However, no further information was provided. Review of the Nurse Aide Care Plan (Kardex), dated 01/25/2024, under Skin Care, revealed staff was to observe skin condition daily during care and report abnormalities, float heels when in bed with device or pillow as resident would allow, and pat, do not rub skin when drying. There was no documentation on the nurse aide Kardex that indicated Resident #18 had a pressure injury to the right heel, nor was there an intervention in place for protection to the resident's right foot when in the wheelchair. Review of the Progress Note, completed by the Advanced Practice Registered Nurse (APRN) on 01/12/2024, revealed Resident #18 was alert and oriented to all spheres and had a chronic right heel pressure injury, and an unroofed callus with non-blanchable redness. Continued review revealed Resident #18 had a pressure injury of the skin of the right heel, with unspecified injury, stage. Review of Resident #18's Progress Note, dated 01/14/2024 at 8:29 PM, as a late entry and signed by LPN #3, revealed a change in condition was completed due to a change in skin color or condition. Continued review revealed the calloused area on the resident's heel that was previously noted on admission, and in the medical records from the hospital, had come off with some drainage noted. The parameter was red and tender and the bed had yellow and discolored tissue noted. The provider was made aware of the changes to the resident's heel. Review of the Treatment Administration Record (TAR) for January 2024, revealed there were no orders in place for wound care or monitoring until 01/15/2024. Review of Resident #18's Physician's orders, dated 01/15/2024, revealed an order that read, right heel, paint area with Betadine every shift for one week, then reevaluate every shift for right heel wound. Further review revealed an order that read, check heels for support in place every shift, heels up cushion. This Physician's order dated 01/15/2024 was the first treatment order for this resident's right heel wound since admission (12/10/2023), therefore the resident went thirty-six (36) days without an order for wound treatment and monitoring. Review of the Weekly Skin Checks, dated 01/15/2024 at 9:32 PM, and 01/22/2024 at 8:50 PM, revealed the resident had a skin or wound identified as other wound and a necrotic left heel. {Resident #18 had a Left Below the Knee Amputation (BKA)}. Review of Resident #18's Wound Evaluation, dated 01/15/2024 at 11:29 AM and signed by the Director of Nursing (DON), revealed the resident had an unstageable pressure ulcer to the right heel, age unknown, that was present on admission. Measurements were recorded as, length 4.21 centimeters (cm) by width 2.42 cm. The wound bed was described as 20% (percent) slough and 80% eschar, with slight drainage. Per the evaluation, the treatment order was Betadine, with no dressing to be applied. Continued review revealed the wound was deteriorating and the Nurse Practitioner and Physician were aware. This was the first Wound Evaluation to include an assessment with measurements of the resident's right foot wound, although the resident was admitted with the pressure injury to the right foot on 12/10/2023, thirty-six (36) days earlier. Review of the Physician's Note, dated 01/16/2024, revealed Resident #18 had a right heel diabetic wound. His/her heels were to be offloaded and to continue with Betadine and close monitoring. Review of Resident #18's Wound Evaluation, dated 01/21/2024 at 5:11 PM, completed by the Assistant Director of Nursing (ADON), revealed the resident had an unstageable pressure ulcer to the right heel that was improving, age was unknown, and wound was present on admission. The wound measured 3.11 centimeters (cm) length by 3.82 cm width. Continued review revealed the wound bed was 100% eschar, had moderate drainage and the current treatment was wound cleanser and apply Betadine with no dressing. Review of Resident #18's Physician's orders dated 01/23/2024, revealed an order to clean pressure wound to right heel daily with wound cleanser and apply Betadine every day shift for his/her pressure ulcer to the right heel. Review of Resident #18's Wound Evaluation dated 01/23/2024 at 2:46 PM, signed by the ADON, revealed an unstageable pressure ulcer that measured 1.77 cm length X 3.16 cm width. Continued review revealed the wound bed had epithelial tissue at 20% and eschar at 80%. There was moderate drainage, and the treatment remained the same, to cleanse with wound cleanser and apply Betadine. Observation on 01/23/2024 at 10:55 AM, revealed Resident #18 was sitting up in the wheelchair at the bedside. While speaking with Resident #18, the State Survey Agency (SSA) surveyor asked if he/she had any wounds or skin concerns and he/she held up his/her right foot. The resident had just a sock on his/her right foot and his/her right foot was resting directly on the metal wheelchair footrest. There was no heel protector or pressure reducing device in place. Resident #18 had an elevator device on the bed and when asked if he/she used the device, his/her response was, hell no. Continued observation of Resident #18 on 01/23/2024 at 2:18 PM, revealed the resident was sitting in the wheelchair with his/her socked foot resting directly on the metal wheelchair foot rest. Observation of the wound assessment performed by LPN #1, on 01/26/2024 at 10:10 AM, revealed Resident #18's right heel wound was 100% eschar, and measured 2.45 cm length X 3.47 cm width. Observation on 01/24/2024 at 8:45 AM, revealed Resident #18 was sitting up in the wheelchair with his/her socked foot resting directly against the metal wheelchair pedal. During the observation of Resident #18, on 01/24/2024 at 10:00 AM, the resident's daughter was present in the room and she stated the resident's foot wound had worsened since admission. Per the interview, she stated the resident had what looked like a big callous on his/her right foot, and staff told her it fell off a couple of weeks ago. The daughter stated she did not know callouses could just fall off. Resident #18 was observed to be sitting up in the wheelchair with his/her socked foot resting directly against the metal wheelchair pedal. During further interview with Resident #18's daughter, on 01/24/2024 at 10:30 AM, she stated the facility should have at least been checking the area to the resident's right foot. During this conversation, the daughter took a photograph of the wound area and shared it with the SSA surveyor. The photograph revealed the right posterior ankle/heel had an area with black eschar. During as interview with Resident #18 on 01/24/2024 at 10:30 AM, he/she stated he/she had something on his/her foot that he/she thought was a callous. The resident stated he/she did nothing for it at home and the facility had not provided any treatments until the area callous came off a couple of weeks ago. She stated the wound had gotten worse in just a couple of weeks and did not feel like it would have if the facility had been watching it. Further observation of Resident #18, on 01/24/2024 at 1:48 PM, and 4:20 PM; and on 01/25/2024 at 8:50 AM, 10:25 AM, 11:58 AM, and 3:33 PM, revealed the resident was up in the wheelchair with his/her right socked foot resting directly against the metal footrest. Observation of the wound assessment performed by LPN #1, on 01/26/2024 at 10:10 AM, revealed Resident #18's right heel wound was 100% eschar, and measured 2.45 cm length X 3.47 cm width. During an interview with Certified Nursing Assistant (CNA) #2, on 01/24/2024 at 11:11 AM, he stated he was providing care for Resident #18, but was unaware the resident had a pressure injury, and was unaware of any interventions care planned to provide pressure relief of the resident's right foot when the resident was sitting in the wheelchair. During an interview with Certified Nursing Assistant (CNA) #5 on 01/26/2024 at 10:29 AM, she stated she had provided care to Resident #18 but was not aware that he/she had a pressure ulcer. She stated Resident #18 had a heel up device when in bed, but he/she had no pressure relieving device to the foot when up in the wheelchair. During an interview with Certified Nursing Assistant (CNA) #7 on 01/27/2024 at 10:51 AM, she stated that if the facility failed to provide care, goods or services to a resident that would be considered neglect. She stated if a resident had a wound and had not received treatment, that could result in a worsening wound, a possible need for hospitalization , and the potential to lose his/her limbs. During an interview with Licensed Practical Nurse (LPN) #3 on 01/26/2024 at 3:39 PM, she stated she had completed Resident #18's admission assessment. She stated Resident #18 had discolored thick skin to the right heel that was blackish brown in color. LPN #3 stated the area was unstageable and was not opened. She stated she did not measure the area or obtain any photographs. LPN #3 further stated she could not recall any treatment orders for the area, but that she reported the area to the Director of Nursing (DON). She stated the facility usually monitors unstageable pressure injuries to make sure they did not get worse, and the monitoring would be on the treatment record if an order was put in place. LPN #3 further stated she would not necessarily call not providing care to the resident's wound neglect. However, review of the facility's policy revealed that neglect was defined as the failure to provide goods and services to the resident(s) to avoid physical harm, mental anguish, or emotional distress. In an interview with Advance Practice Nurse Practitioner (APRN) on 01/26/2024 at 2:29 PM, she stated she was unaware that Resident #18 was admitted with an unstageable wound to the right foot. She stated Resident #18 was admitted with a skin tear on the right foot and had a foam dressing. The APRN stated the right heel was red from the foam dressing. She stated it was after Christmas before she saw Resident #18 and was unsure of the date that the physician saw him/her. The APRN stated she did not recall any sort of wound on admission and would have to check her notes. She stated the facility followed an algorithm provided by facility corporate staff and that she did not give wound care orders. The APRN further stated heel protectors/boots were not used as it would contribute to extra pressure on the heel. She stated if interventions were not in place, then a wound would deteriorate. In an interview with the Physician on 01/26/2024 at 4:35 PM, she stated she was informed Resident #18 had a skin tear on admission, not a pressure injury. She stated she was notified of a pressure injury on 01/16/2024. The Physician stated the facility followed corporate protocols and she expected to be notified if there were changes so orders could be given if needed. She stated if the facility did not follow protocols such as offloading the heel an outcome would be worsening of a wound. In an interview with the Assistant Director of Nursing, (ADON) on 01/27/2024 at 2:54 PM, she stated the facility nurses provided wound care and that everything was done in-house following the facility's wound protocols. She stated residents with wounds were not given referrals for outside wound care unless it was a last resort. The ADON stated she never observed or assessed Resident #18's foot on admission. Further she was not aware that any photos or measurements had been taken on admission. She stated she was not aware of any issues with Resident #18's foot until a couple of weeks ago when the calloused area fell off. She stated the facility took photos and initiated a treatment, however, no new interventions were put into place to relieve pressure from the resident's foot. She stated she was not aware of Resident #18's foot resting on the metal wheelchair footrest and was unsure if it would make it worse or do any more damage. During an interview with the Director of Nursing (DON) on 01/27/2024 at 3:54 PM, she stated the facility had a company wound care protocol and she expected that to be followed with any wound care or treatments. The DON stated she assessed Resident #18's wound and no treatments were put into place except to offload the heels. She stated Resident #18 had a growth, an extremely dry area but it was not eschar or a deep tissue injury. She further stated she was unsure why LPN #4 had documented a necrotic area on the weekly skin assessments. In an interview with the Administrator on 01/27/2024 at 6:07 PM, she stated her expectation was that wounds would be assessed on admission, a treatment put in place if applicable, and a baseline care plan initiated. The Administrator stated she believed Resident #18's foot had been assessed incorrectly on the admission assessment. She stated the facility did not know what was underneath the growth. The Administrator further stated the weekly skin assessments would be sufficient monitoring for a wound. However, review of the facility's policy related to wound management revealed staff would continually observe and monitor the residents for changes and implement revisions to the resident's care plan. Additionally, the Medical Director, Director of Nursing (DON), and Administrator would be notified should there have been deviation from the protocol. Further review of the policy revealed the purpose of the policy was to provide a safe and effective care to promote healing.

Based on interview, record review and review of facility policy, it was determined the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for two (2) of sixteen (16) sampled residents (Resident #18 and Resident #195). Although the facility admitted Resident #18 on 12/10/2023, and assessed the resident as having a right heel unstageable Deep Tissue Injury (DTI) on that date (with no measurement of the wound), the facility did not develop a Baseline Person-Centered care plan for Skin Integrity until 12/26/2023, sixteen (16) days following admission. Additionally, the care plan dated 12/26/2023, was not developed and implemented related to interventions for weekly wound evaluations to include description and measurement of the resident's right foot pressure injury, nor was it developed and implemented related to interventions to obtain treatment orders for the wound as necessary. There was no documented evidence of a Wound Evaluation to include description and measurements until 01/15/2024, thirty-six (36) days after admission, when the wound was described as unstageable measuring 4.21 centimeters (cm) length X 2.42 cm. width with 20% (percent) slough and 80% eschar. Furthermore, there was no documented evidence of Physician's orders for wound treatment and monitoring for the right heel pressure injury until 01/15/2024, thirty-six (36) days after admission. Observation of Resident #18's skin assessment on 01/26/2024, revealed the resident's right heel wound was unstageable, and measured 2.45 cm length X 3.47 cm width and was noted to have 100% eschar. Additionally, the care plan was not developed and implemented related to interventions to protect the resident's right foot wound when the resident was up in the wheelchair. Observations on 01/23/2024, 01/24/2024, 01/25/2024, and 01/26/2024, revealed the resident was sitting in a wheelchair with his/her socked right foot resting directly on the metal wheelchair pedal. Refer to F686 Additionally, the facility admitted Resident #195 on 01/17/2024 with diagnoses to include Malignant Neoplasm of the Bladder, and Urostomy. (A urostomy is a surgical procedure that creates a stoma for the urinary system, and is made to avail for urinary diversion in cases where drainage of urine through the bladder and urethra is not possible). However, there was no baseline care plan related to urostomy/urostomy care developed for this resident. The findings include: Review of the facility's policy titled, Person-Centered Care Plan, reviewed and revised on 10/24/2022, revealed the facility would develop and implement a Baseline Person-Centered Care Plan within forty-eight (48) hours of admission for each resident that included the instructions needed to provide effective and person-centered care that met professional standards of quality care 1) Resident #18's Admission Record revealed the facility admitted the resident on 12/10/2023 with diagnoses including History of Transient Ischemic Attack, with Cerebral Infarction, Acquired Absence of Left Leg below Knee and Type 2 Diabetes Mellitus without complications. Resident #18's Admission Assessment, dated 12/10/2023 at 3:51 PM, signed by Licensed Practical Nurse (LPN) #3 and co-signed by the Assistant Director of Nursing (ADON), revealed the resident was assessed as having an unstageable Deep Tissue Injury (DTI). However, there was no documented evidence of further description or a measurement of the right heel unstageable DTI on admission. Resident #18's Physician Orders Summary Recap report, dated 12/10/2023, revealed no orders for wound care for the resident's right heel pressure injury on admission. Resident #18's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/15/2023, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of fourteen (14) out of fifteen (15), indicating intact cognition. Further, the facility assessed the resident as having an unstageable pressure injury with suspected deep tissue injury that was present on admission. Review of the Care Area Assessment (CAA) worksheet for Pressure Ulcer/ Injury, completed by the MDS Coordinator on 12/26/2023, revealed Resident #18 was at risk for developing pressure ulcers. Further, documentation revealed Resident #18 had an unstageable pressure ulcer due to suspected deep tissue injury and a care plan would be developed. The facility did not develop a baseline person-centered care plan for Skin Integrity until 12/26/2023, sixteen (16) days following admission. The care plan dated 12/26/2023, revealed a focus stating the resident was at risk for skin breakdown related to frail fragile skin, incontinence, limited mobility and/or had actual skin breakdown, and had a pressure ulcer to the right heel. The goals dated 12/26/2023, revealed the resident would not show signs of skin breakdown through next review, and the maintenance goal revealed the wound would remain free from signs and symptoms of infection through the next review. The interventions dated 12/26/2023, included: offload/float right heel while in bed with pillows or other device; weekly skin check by licensed nurse; provide wound treatment as ordered; observe skin condition daily with care and report abnormalities; apply barrier cream with each cleansing; provide treatment to skin tear per order and observe for signs of infection until healed; provide preventative skin care, lotions, barrier creams as ordered; provide patient and or health care decision maker education regarding risk factors; and Pat, (do not rub) skin when drying. However, Resident #18's care plan was not developed and implemented related to interventions for weekly wound evaluations to include description and measurement of the resident's right foot pressure injury, nor was it developed and implemented related to interventions to obtain treatment orders for the wound as necessary. Resident #18's Treatment Administration Record (TAR), dated December 2023, revealed there were no orders in place for wound care or monitoring. Resident #18's Progress Note dated 01/14/2024 at 8:29 PM, as a late entry and signed by Licensed Practical Nurse (LPN) #3, revealed a change in condition was noted as the calloused area on the resident's heel that was previously noted on admission, and in the medical records from the hospital, had come off with some drainage noted. The parameter was red and tender and the bed had yellow and discolored tissue noted. Further, the Provider was made aware of changes to the heel. Review of Resident #18's Wound Evaluation, dated 01/15/2024 at 11:29 AM and signed by the Director of Nursing (DON), revealed the resident had an unstageable pressure ulcer to the right heel, age unknown that was present on admission. Measurements were recorded as, length 4.21 centimeters (cm) X width 2.42 cm. The wound bed was described as 20% (percent) slough and 80% eschar, with slight drainage. Per the evaluation, the treatment order was Betadine, with no dressing to be applied. Continued review revealed the wound was deteriorating and the Nurse Practitioner and Physician were aware. This was the first Wound Evaluation to include an assessment with measurements of the resident's right foot wound, although the resident was admitted with the pressure injury to the right foot on 12/10/2023, thirty-six (36) days earlier. Resident #18's Treatment Administration Record (TAR) for January 2024, revealed there were no orders in place for wound care or monitoring until 01/15/2024. Resident #18's Physician's orders, dated 01/15/2024, revealed an order that read, right heel, paint area with Betadine every shift for one week, then reevaluate every shift for right heel wound. Further review revealed an order that read, check heels for support in place every shift, heels up cushion. This Physician's order dated 01/15/2024, was the first treatment order for this resident's right heel pressure injury since admission (12/10/2023), therefore the resident went thirty-six (36) days without an order for wound treatment and monitoring. Observation of Resident #18's wound assessment performed by LPN #1, on 01/26/2024 at 10:10 AM, revealed the right heel wound was 100% eschar, and measured 2.45 cm length X 3.47 cm width with no drainage noted. Additional review of Resident #18's person-centered care plan for Skin Integrity, dated 12/26/2023, revealed the care plan was not developed and implemented related to specific interventions to protect the resident's right foot wound when the resident was sitting in the wheelchair. Observation of Resident #18 on 01/23/2024 at 10:55 AM, and 2:18 PM; 01/24/2024 at 8:45 AM, 10:00 AM, 1:48 PM, and 4:20 PM; 01/25/2024 at 8:50 AM, 10:25 AM, 11:58 AM, and 3:33 PM; and on 01/26/2024 at 9:45 AM, revealed the resident had just a sock on his/her right foot and his/her right foot was resting directly on the metal wheelchair footrest. There was no heel protector or pressure reducing device in place. During an interview with Certified Nursing Assistant (CNA) #2, on 01/24/2024 at 11:11 AM, he stated he was providing care for Resident #18, but was unaware the resident had a pressure injury, and was unaware of any interventions care planned to provide pressure relief of the resident's right foot when the resident was sitting in the wheelchair. The State Agency Representative requested CNA #2 show her the CNA Kardex (Nurse Aide Care Plan) and there was no information on the Kardex to indicate Resident #18 had a wound to the right foot, nor were there interventions for protection of the right foot wound when the resident was sitting in the wheelchair. Additional observation on 01/26/2024 at 10:50 AM, after the wound assessment, revealed LPN #1 did not replace Resident #18's sock following wound care and evaluation, and his/her bare foot was now resting against the metal wheelchair footrest. Continued observation on 01/26/2024 at 1:48 PM, revealed the resident was sitting up in the wheelchair and the sock to the resident's right foot was noted to be half on and half off and the back of the resident's bare foot was resting on the metal wheelchair footrest. During an interview with LPN #3, on 01/26/2024 at 3:39 PM, she stated she completed Resident #18's admission assessment. She further stated the assessment had been started by another nurse on the previous shift, and she finished the assessment. LPN #3 further stated she documented the resident had discolored thick skin to the right heel that was blackish brown in color and was unstageable, with no open area. However, she confirmed she did not measure the area or obtain any photographs. She further stated she could not recall any treatment orders for the area, but they may have been obtained on the day shift. Further, she stated she did not complete a baseline care plan for the resident on admit, because they were usually completed on day shift. She stated the facility had forty-eight (48) hours to complete the baseline care plan. During interview with the Assistant Director of Nursing, (ADON), on 01/27/2024 at 2:54 PM, she stated she was unsure why she signed Resident #18's admission assessment and she verified she did not observe or assess the resident's foot wound on admission. She confirmed all wounds should be described and measured weekly by her or the floor nurses. She further stated she was unaware of any issues related to Resident #18's right heel until a few weeks ago when the calloused area fell off, and at that time treatment was initiated. During further interview with the ADON, on 01/27/2024 at 2:54 PM, she stated she thought the facility had seventy-two hours to complete the baseline care plan, and verified Resident #18's care plan was not completed timely. Further, she stated the baseline care plan needed to include specific interventions to be implemented in providing care, especially related to wounds. The ADON stated she had not observed Resident #18's foot resting directly on the wheelchair pedal and was unsure if it would make the wound worse or do any more damage. During an interview with the Minimum Data Set (MDS) Coordinator on 01/26/2024 at 3:56 PM, and 01/27/2024 at 12:33 PM, she stated she had documented Resident #18's right foot heel wound as unstageable on the MDS assessment dated [DATE]. She explained there were no measurements or photos of the resident's right heel wound when she completed the assessment, and she did not obtain them. During further interview with the MDS Coordinator, on 01/26/2024 at 3:56 PM, and 01/27/2024 at 12:33 PM, she stated the baseline care plan was to be initiated by the admitting nurse. However, she was unaware the baseline care plan was to be completed within 48 hours. She then stated Resident #18's baseline care plan should have included specific interventions to monitor, treat, and protect the right foot wound. She further stated if appropriate interventions were not in place the wound could deteriorate. Additionally, she stated the facility did not utilize boots, but staff could have used a pillow to relieve pressure for the resident's right foot when the resident was in the wheelchair. During additional interview with the MDS Coordinator, on 01/26/2024 at 3:56 PM, and 01/27/2024 at 12:33 PM, she stated the facility reviewed new admissions daily in the clinical meeting, but she did not recall anything specific about Resident #18. Further, the facility was revamping the Interdisciplinary team meeting (IDT) and there had not been a meeting in a while, nor were there weekly IDT notes available to review. During an interview with the Director of Nursing (DON), on 01/27/2024 at 3:54 PM, she stated the baseline care plan should be initiated at the time of admission by the admitting nurse. She further stated the facility had forty-eight (48) hours to complete the baseline. The DON stated if the admission nurse did not complete the care plan, she would expect the MDS Coordinator to complete it. The DON verified Resident #18's baseline care plan was not completed timely. In further interview with the DON on 01/27/2024 at 3:54 PM, she was questioned if Resident #18's care plan should have been developed with interventions related to weekly wound evaluations and a specific treatment for the wound. She stated wound evaluations should be completed on admission and weekly to include description and measurements, and if a wound was identified a treatment should be obtained and this should be care planned. However, she stated Resident #18's right heel wound was a growth or callous and not a pressure injury on admission and did not require a treatment until 01/15/2024, when the dry area fell off, and a wound was noted underneath. Per interview, a wound evaluation was then completed, and a treatment was obtained. The DON could not explain why the resident's wound was described as an unstageable Deep Tissue Injury (DTI) on admission. The DON was questioned if it was safe for the resident's socked right foot with the pressure injury to be resting directly on the wheelchair pedal, or if there should have been a care plan intervention to be implemented related to pressure relief. She stated the facility did not utilize heel protectors, and a wound such as Resident #18's needed to stay dry, so they would not keep a dressing on the wound all the time. During an interview with the Physician, on 01/26/2024 at 4:35 PM, she stated she was informed Resident #18 had a skin tear on admission, but verified she was not informed of a pressure injury. She stated she was not notified of the pressure injury until 01/15/2024, when she gave an order for treatment. In further interview, she stated it was her expectation to be notified if there were treatment orders needed or changes in condition so orders could be given if needed. Further, the physician stated if the facility did not follow protocols such as offloading the heel, an outcome would be worsening of a wound. In an interview on 01/27/2024 at 6:07 PM, the Administrator stated she thought Resident #18's foot wound had been assessed incorrectly on the admission assessment, as the staff did not know what was underneath the resident's heel growth. However, she stated it was her expectation wounds would be properly assessed and measured on admission and a treatment put in place if applicable. Further, it was her expectation an intervention such as a heel protector or blue boots (device for heel protection) be in place when a resident with a foot/heel wound was sitting in a wheelchair. Additional interview revealed the baseline care plan should be completed timely with appropriate interventions. 2) Review of Resident #195's face sheet revealed the facility admitted the resident on 01/17/2024 with diagnoses to include Malignant Neoplasm of the Bladder, and Urostomy. Observation of Resident #195 on 01/25/2024 at 3:40 PM, revealed the resident had a urostomy with pouch to the Right Quadrant that was connected to urinary tubing and a urinary drainage bag. Review of Resident #195's Admission Minimum Data Set (MDS) Assessment, dated 01/24/2024, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of five (5) out of fifteen (15), indicating severe cognitive impairment. The MDS Assessment was in progress and not fully completed. Review of Resident #195's Baseline Care Plan, dated 01/22/2024, revealed the facility did not develop a Baseline Person-Centered care plan related to Urostomy Care. In an interview with LPN #5, on 01/23/2024 at 9:00 AM, she stated Resident #195 was admitted to the facility on [DATE] with urostomy status post bladder resection, but she was unable to recall if the resident had a baseline care plan in place for the urostomy. She stated she was frequently assigned to the resident, and the resident should have been care planned related to urostomy care. In an interview with the Minimum Data Set (MDS) Nurse, on 01/27/2024 at 12:33 PM, she stated baseline care plans were initiated and set up based on the Admission assessments completed by the nursing staff, and verified Resident #195 did not have a baseline care plan related to urostomy care. She further verified this care plan should have been completed within 48 hours of the resident's admission to the facility. In an interview with the Assistant Director of Nursing (ADON), on 01/27/24 at 3:10 PM, she stated she was not aware Resident #195 was not care planned for urostomy care, and stated the care plan should have included this concern. The ADON stated the facility did not have an actual urostomy procedure or process policy. Further, it was her expectation for the admitting nurse, and MDS Nurse to complete the baseline care plans accurately. She further stated she was aware baseline care plans were to be completed within forty-eight (48) hours. In an interview with the Director of Nursing (DON), on 01/27/2024 at 3:53 PM, she verified Resident#195's baseline care plan should have been initiated within forty-eight (48) hours of the resident being admitted to the facility. Further interview revealed if the admitting nurse did not complete the baseline care plan, she would expect the MDS Nurse to completed it within the forty-eight (48) hour timeframe. In continued interview, the DON stated this resident's baseline care plan should have included the diagnoses of urostomy, with interventions related to urostomy care. 47567

Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to ensure that a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one (1) of three (3) residents reviewed for pressure out of sixteen (16) sampled residents (Resident #18). The facility admitted Resident #18 on 12/10/2023 and assessed the resident on that date as having a right heel unstageable Deep Tissue Injury (DTI). However, there was no documented evidence of a wound evaluation to include further description or a measurement of the right heel pressure injury on admission. Further, there was no documented evidence of a Wound Evaluation again until 01/15/2024, thirty-six (36) days later, when the wound was described as unstageable measuring 4.21 centimeters (cm) length X 2.42 cm. width with 20% (percent) slough and 80% eschar. Additionally, there was no documented evidence of Physician's orders for wound treatment and monitoring for the right heel pressure injury until 01/15/2024, thirty-six (36) days after the resident was admitted with the wound. Observation of a skin assessment on 01/26/2024, revealed the resident's right heel wound was unstageable, and measured 2.45 cm length X 3.47 cm width and was noted to have 100% eschar. Moreover, there were no interventions in place to protect the resident's right foot wound when in the wheelchair. Multiple observations on 01/23/2024, 01/24/2024, 01/25/2024, and 01/26/2026, revealed the resident was sitting in a wheelchair with his/her socked right foot resting directly on the metal wheelchair pedal. The findings include: Review of the facility's policy titled, Skin Integrity and Wound Management, effective date, 07/01/2001, revised 02/01/2023, revealed, a comprehensive, initial, and ongoing nursing assessment of intrinsic and extrinsic factors that influenced skin health, skin wound impairment, and the ability of a wound to heal would be performed. The plan of care for the patient (resident) would be reflective of assessment findings from the comprehensive assessment and wound evaluation. Staff would continually observe and monitor patients (residents) for changes and implement revisions of the care plan as needed; and notify the Medical Director, the Director of Nursing, and Administrator if deviation from protocol was requested. Continued review revealed the purpose was to provide safe and effective care to promote optimal skin health, prevent pressure injuries and promote healing. Review of the facility Wound Care Guidelines from Medline Skin Health, undated, revealed care guidelines were meant as a starting point for treatment based on wound bed characteristics and as a wound evolved, treatment modalities may change as well. Continued review revealed the document showed photos of wounds at different stages. However, the Guidelines did not address wounds with eschar or necrotic tissue. Review of Resident #18's Admission Record revealed the facility admitted the resident on 12/10/2023 with diagnoses including History of Transient Ischemic Attack, with Cerebral Infarction, Acquired Absence of Left Leg below Knee and Type 2 Diabetes Mellitus without complications. Review of the Admission Assessment, dated 12/10/2023 at 3:51 PM, signed by Licensed Practical Nurse (LPN) #3 and co-signed by the Assistant Director of Nursing (ADON), revealed Resident #18 was assessed to have a Braden Score of sixteen (16), indicating the resident was at mild risk for developing pressure injuries. Further review revealed the resident was assessed as having an unstageable Deep Tissue Injury (DTI). However, there was no documented evidence of a wound evaluation to include further description or a measurement of the right heel unstageable DTI on admission. Review of Resident #18's Physician Orders Summary Recap report, dated 12/10/2023, revealed no orders for wound care for Resident #18's right heel pressure injury on admission. Review of Resident #18's Physician's Note, dated, 12/14/2023, revealed Resident #18 was seen by the provider and skin was dry, normal turgor, with no pallor or rash. However there was no reference to Resident #18's right foot wound. Review of Resident #18's Admission Minimum Data Set (MDS) Assessment, dated 12/15/2023, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of fourteen (14) out of fifteen (15), indicating intact cognition. Continued review revealed the facility assessed the resident as having an unstageable pressure injury with suspected deep tissue injury that was present on admission. Review of the weekly Braden Scale Score for Predicting Pressure Sore Risk, dated 12/17/2023, revealed a score of nineteen (19), indicating Resident #18 had no risk of developing pressure injuries. The criteria listed which affected this resident included Sensory Perception, Activity, Mobility, Moisture, Nutrition, and Friction and Shear. Review of the Weekly Skin Check, dated 12/18/2023 12:05 AM, and signed by LPN #3, revealed Resident #18 had a skin injury or wound identified as other. Under location was a typed statement that read necrotic area to heel. However, no other information was provided. Review of the weekly Braden Scale Score for Predicting Pressure Sore Risk, dated 12/24/2023, revealed a score of fifteen (15), indicating Resident #18 was at mild risk for developing pressure injuries. There was no reference to the resident already having a pressure ulcer. Review of Resident #18's Weekly Skin Check dated 12/26/2023 at 9:34 PM, revealed the resident had a skin injury or wound. However, no other information was provided. Review of the weekly Braden Scale Score for Predicting Pressure Sore Risk, dated 12/31/2023, revealed a score of fourteen (14), indicating Resident #18 was at moderate risk for developing pressure injury. Review of Resident #18's Care Plan revealed there was no baseline care plan completed within forty-eight (48) hours to address the resident's skin breakdown. Further, the facility did not develop a person-centered care plan for Skin Integrity until 12/26/2023, sixteen (16) days following admission. (Refer to F655) The care plan dated 12/26/2023, revealed a focus problem that stated the resident was at risk for skin breakdown related to frail fragile skin, incontinence, limited mobility and/or had actual skin breakdown, and had a pressure ulcer to the right heel. The goal dated 12/26/2023, stated the resident would not show signs of skin breakdown through next review, and the maintenance goal dated 12/26/2023, stated the wound would remain free from signs and symptoms of infection through the next review. Interventions dated 12/26/2023, included: offload/float right heel while in bed with pillows or other device; weekly skin check by licensed nurse; provide wound treatment as ordered; observe skin condition daily with care and report abnormalities; apply barrier cream with each cleansing; provide treatment to skin tear per order and observe for signs of infection until healed; provide preventative skin care, lotions, barrier creams as ordered; provide patient (resident) and or health care decision maker education regarding risk factors; and Pat, (do not rub) skin when drying. However, there were no specific interventions listed related to weekly wound evaluations or treatment for the wound. (Refer to F655). Review of the Treatment Administration Record (TAR) for December 2023, revealed there were no orders in place for wound care or monitoring. Review of the Weekly Skin Check dated 01/01/2024 at 5:49 PM, signed by the Director of Nursing (DON), revealed the resident had a new skin injury or wound, and moisture associated skin damage to the coccyx. However, there was no documentation related to Resident #18's wound to the right foot. Review of the Weekly Skin Check dated 01/08/2024 at 8:09 PM, revealed the resident had a wound identified as other wound, necrotic to heel. However, no further information was provided. Review of the Progress Note, completed by the Advanced Practice Registered Nurse (APRN) on 01/12/2024, revealed Resident #18 was alert and oriented to all spheres and had a chronic right heel pressure injury, and an unroofed callus with non-blanchable redness. Continued review revealed Resident #18 had a pressure injury of the skin of the right heel, with unspecified injury, stage. Review of Resident #18's Progress Note, dated 01/14/2024 at 8:29 PM, as a late entry and signed by LPN #3, revealed a change in condition was noted. Continued review revealed the calloused area on the resident's heel that was previously noted on admission, and in the medical records from the hospital, had come off with some drainage noted. The parameter was red and tender and the bed had yellow and discolored tissue noted. Provider was made aware of changes to the heel. Review of the Treatment Administration Record (TAR) for January 2024, revealed there were no orders in place for wound care or monitoring until 01/15/2024. Review of Resident #18's Physician's orders, dated 01/15/2024, revealed an order that read, right heel, paint area with Betadine every shift for one week, then reevaluate every shift for right heel wound. Further review revealed an order that read, check heels for support in place every shift, heels up cushion. This Physician's order dated 01/15/2024 was the first treatment order for this resident's right heel wound since admission (12/10/2023), therefore the resident went thirty-six (36) days without an order for wound treatment and monitoring. Review of the Weekly Skin Checks, dated 01/15/2024 at 9:32 PM, and 01/22/2024 at 8:50 PM, revealed the resident had a skin or wound identified as other wound and a necrotic left heel. {Resident #18 had a Left Below the Knee Amputation (BKA)}. Review of Resident #18's Wound Evaluation, dated 01/15/2024 at 11:29 AM and signed by the Director of Nursing (DON), revealed the resident had an unstageable pressure ulcer to the right heel, age unknown that was present on admission. Measurements were recorded as, length 4.21 centimeters (cm) by width 2.42 cm. The wound bed was described as 20% (percent) slough and 80% eschar, with slight drainage. Per the evaluation, the treatment order was Betadine, with no dressing to be applied. Continued review revealed the wound was deteriorating and the Nurse Practitioner and Physician were aware. This was the first Wound Evaluation to include an assessment with measurements of the resident's right foot wound, although the resident was admitted with the pressure injury to the right foot on 12/10/2023, thirty-six (36) days earlier. Review of the Physician's Note, dated 01/16/2024, revealed Resident #18 had a right heel diabetic wound. Heels were to be offloaded and to continue with Betadine and close monitoring. Review of Resident #18's Wound Evaluation, dated 01/21/2024 at 5:11 PM, completed by the Assistant Director of Nursing (ADON), revealed the resident had an unstageable pressure ulcer to the right heel that was improving, age was unknown, and wound was present on admission. The wound measured 3.11 centimeters (cm) length by 3.82 cm width. Continued review revealed the wound bed was 100% eschar, had moderate drainage and the current treatment was wound cleanser and apply Betadine with no dressing. Review of Resident #18's Physician's orders dated 01/23/2024, revealed an order to clean pressure wound to right heel daily with wound cleanser and apply Betadine every day shift for pressure ulcer to right heel. Review of Resident #18's Wound Evaluation dated 01/23/2024 at 2:46 PM, signed by the ADON, revealed an unstageable pressure ulcer that measured 1.77 cm length X 3.16 cm width. Continued review revealed the wound bed had epithelial tissue at 20% and eschar at 80%. There was moderate drainage, and the treatment remained the same, to cleanse with wound cleanser and apply Betadine. Review of the Nurse Aide Care Plan (Kardex), dated 01/25/2024, under Skin Care, revealed staff was to observe skin condition daily during care and report abnormalities, float heels when in bed with device or pillow as resident would allow, and pat, do not rub skin when drying. There was no documentation on the nurse aide Kardex that indicated Resident #18 had a pressure injury to the right heel, nor was there an intervention in place for protection to the resident's right foot when in the bed or wheelchair. Observation of the wound assessment performed by LPN #1, on 01/26/2024 at 10:10 AM, revealed Resident #18's right heel wound was 100% eschar, and measured 2.45 cm length X 3.47 cm width. Review of Resident #18's Wound Evaluation dated 01/26/2024, at 10:48 AM, completed by LPN #1, revealed the resident had an unstageable pressure injury to the right heel, age unknown, that was present on admission and measured 2.45 cm length by 3.47 cm width. The area was unstageable due to 100% eschar and had no drainage. Further review revealed the treatment order was to cleanse with generic wound cleanser and apply Povidone Iodine. Further review of Resident #18's person-centered care plan for Skin Integrity, dated 12/26/2023, revealed there were no specific interventions to protect the resident's right foot wound when the resident was sitting in the wheelchair. (Refer to F-655) Observation on 01/23/2024 at 10:55 AM, revealed Resident #18 was sitting up in the wheelchair at the bedside. While speaking with Resident #18, the State Survey Agency (SSA) surveyor asked if he/she had any wounds or skin concerns and he/she held up his/her right foot. The resident had just a sock on his/her right foot and his/her right foot was resting directly on the metal wheelchair footrest. There was no heel protector or pressure reducing device in place. Resident #18 had an elevator device on the bed and when asked if he/she used the device, his/her response was, hell no. Continued observation of Resident #18 on 01/23/2024 at 2:18 PM, revealed the resident was sitting in the wheelchair with his/her socked foot resting directly on the metal wheelchair foot rest. Observation on 01/24/2024 at 8:45 AM, revealed Resident #18 was sitting up in the wheelchair with his/her socked foot resting directly against the metal wheelchair pedal. During the observation of Resident #18, on 01/24/2024 at 10:00 AM, the resident's daughter was present in the room and she stated the resident's foot wound had worsened since admission. She further stated there was what looked like a big callous on his/her right foot, and staff told her it fell off a couple of weeks ago. The daughter stated she did not know callouses could just fall off. Resident #18 was observed to be sitting up in the wheelchair with his/her socked foot resting directly against the metal wheelchair pedal. During an interview with Resident #18, on 01/24/2024 at 10:00 AM, the resident stated he/she had something on his/her foot that might be a callous. The resident stated he/she did nothing for it at home and the facility had not provided any treatments until the callous came off a couple of weeks ago. He/she further stated the wound had gotten worse in just a couple of weeks and he/she did not feel like the wound would have deteriorated if the facility had been watching it. During further interview with Resident #18's daughter, on 01/24/2024 at 10:30 AM, she stated the facility should have at least been checking the area to the resident's right foot. During this conversation, the daughter took a photograph of the wound area and shared it with the SSA surveyor. The photograph revealed the right posterior ankle/heel had an area with black eschar. Further observation of Resident #18, on 01/24/2024 at 1:48 PM, and 4:20 PM; and on 01/25/2024 at 8:50 AM, 10:25 AM, 11:58 AM, and 3:33 PM, revealed the resident was up in the wheelchair with his/her right socked foot resting directly against the metal footrest. Observation on 01/26/2024 at 9:45 AM, revealed Resident #18 was sitting up in the wheelchair with just a sock on the right foot which was resting on the metal footrest. The SSA surveyor requested a wound evaluation be completed and measurements obtained. Observation of the wound assessment completed by LPN #1, on 01/26/2024 at 10:10 AM, revealed the right heel wound was 100% eschar, and measured 2.45 cm length X 3.47 cm width. Further observation on 01/26/2024 at 10:50 AM, after the wound assessment, revealed LPN #1 did not replace Resident #18's sock following wound care and evaluation, and his/her bare foot was now resting against the metal wheelchair footrest. Continued observation on 01/26/2024 at 1:48 PM, revealed Resident #18 was up in the wheelchair watching television. The sock to the right foot was noted to be half on and half off and the back of the resident's bare foot was resting on the metal wheelchair footrest. During an interview with Certified Nursing Assistant (CNA) #2, on 01/24/2024 at 11:11 AM, he stated he was providing care for Resident #18, but had no idea the resident had a pressure injury. He stated no one had shared that information with him. The State Agency Representative requested CNA #2 show her the CNA Kardex and there was no information on the Kardex indicating Resident #18 had a wound to the right foot, nor were there interventions for protection of the right foot wound when in the wheelchair. During an interview with CNA #5, on 01/26/2024 at 10:29 AM, she stated she had provided care to Resident #18 in the recent past, but was not aware he/she had a pressure ulcer. She stated Resident #18 had a heel up device when in bed, but he/she had no pressure relieving device to the foot when up in the wheelchair. In an interview with LPN #1, on 01/24/2024 at 9:12 AM, she stated she sometimes provided care for the resident, and could not recall staff ever telling her of any concerns related to the resident's skin, and did not recall performing any kind of treatment for Resident #18 until about two (2) weeks ago. She stated Resident #18 currently had a wound that was black eschar. In an interview with LPN #4, on 01/26/2024 at 3:15 PM, she stated she often provided care to Resident #18. LPN #5 confirmed she had completed weekly skin assessments for Resident #18 and documented the necrotic area to the heel. She stated she could not recall if the resident had a treatment order on admission for the right heel and she did not question it as treatments were usually performed on the day shift. She further stated Resident #18 currently had betadine ordered. When questioned about the resident's right socked foot resting directly on the wheelchair pedal, she stated she did not know what interventions were in place for Resident #18's wounds related to pressure relief. During an interview with LPN #3, on 01/26/2024 at 3:39 PM, she stated she was the nurse who completed Resident #18's admission assessment. She further stated Resident #18 was admitted early in the day and the assessment had been started by another nurse, but she finished the assessment as she worked the following shift. LPN #3 stated she read through Resident #18's hospital paperwork. She further stated she documented that Resident #18 had discolored thick skin to the right heel that was blackish brown in color which was unstageable and was not an open area. LPN #3 stated she did not measure the area or obtain any photographs. She further stated she could not recall any treatment orders for the area, which may have been obtained on the day shift. Per interview, she did not report the area to the Director of Nursing (DON) until the next day, when the DON relieved her for the shift. LPN #3 stated the facility usually monitored unstageable pressure injuries to make sure they did not get worse, and the monitoring would be documented on the treatment record if a physician's order was put in to monitor the area. In an interview with the Assistant Director of Nursing, (ADON), on 01/27/2024 at 2:54 PM, she stated she was an LPN and had been the ADON since 2022, but had been at the facility for twenty-one years. She stated the wound nurse resigned in November 2023, and she (ADON) had been helping with weekly wound assessments. Further, the facility floor nurses provided wound care and wound care was done in-house following the facility's wound protocols. The ADON stated the admitting nurse was to perform the wound assessments on new admissions, unless there was a late admission, and then the floor nurses were to perform the wound assessments. In continued interview, the ADON stated she was unsure why she signed Resident #18's admission assessment. She stated she never observed or assessed the resident's foot on admission. Further, she was not aware of any photos being taken on admission of the resident's wound. The ADON stated she was not aware of any issues with Resident #18's foot until a few weeks ago when the calloused area fell off. She further stated at that time, the facility took photos and initiated a treatment. The ADON stated she was not aware of Resident #18's foot resting directly on the wheelchair pedal and was unsure if it would make the wound worse or do any more damage. When questioned if there should have been a device in place to protect the resident's foot when in the wheelchair, she made no comment. Continued interview confirmed wounds should be described and measured on admit and weekly by her or the floor nurses. In an interview with the Minimum Data Set (MDS) Coordinator, on 01/27/2024 at 12:33 PM, she stated she had documented Resident #18's wound as unstageable on the MDS assessment dated [DATE]. She stated there were no measurements or photos of the wound when she completed the assessment. In further interview, she stated the baseline care plan was initiated by the admitting nurse and completed by the MDS Nurse, and an intervention should have been initiated on admission with interventions related to treatment and protection for the right foot wound. She further stated if interventions were not in place the wound could worsen, and although the facility did not utilize boots, staff could have used a pillow to relieve pressure for the resident's right foot when the resident was in the wheelchair. The MDS Coordinator stated the facility reviewed new admissions daily in the clinical meeting, but she did not recall anything specific about Resident #18. She further stated the facility was revamping the Interdisciplinary team meeting (IDT) and had not had a meeting in a while. She further stated there were no weekly IDT notes available. During an interview with the Director of Nursing (DON), on 01/27/2024 at 3:54 PM, she stated she had been in the position as DON for about a year. She further stated the facility had a wound protocol and she expected that to be followed with any wound care or treatments. The DON stated wound evaluations were to be completed on admission and weekly by the floor nurses, as there was no wound nurse in house at this time. She further stated when she assessed Resident #18's right foot wound prior to 01/15/2024, it was noted as a growth or callous, an extremely dry area, but it was not eschar or a deep tissue injury and did not require a treatment. However, the DON could not state the date of this assessment, nor was the assessment noted in the medical record. She further stated she was unsure why the resident's wound was described as unstageable Deep Tissue Injury (DTI) or necrotic prior to the wound assessment completed on 01/15/2024. The DON stated on 01/15/2024 when the area fell off, there was a wound noted underneath, and a treatment was obtained. When questioned if it was safe for the resident's socked right foot with the pressure injury to be resting directly on the wheelchair pedal, she stated the facility did not utilize heel protectors, and a wound such as Resident #18's needed to stay dry, so they would not keep a dressing on the wound all the time. In an interview on 01/26/2024 at 2:29 PM, with the APRN who signed Resident #18's Progress Note, dated 01/12/2024, she stated she was unaware Resident #18 was admitted with an unstageable wound to the right foot. She further stated she recalled the resident was admitted with a skin tear on the right foot and a foam dressing was in place. Further, she recalled the resident's right heel was red from a foam dressing. In continued interview, she stated she did not recall any sort of wound on admission and would have to check her notes. The APRN stated it was after Christmas before she saw Resident #18 and she was unsure of the date the physician saw him/her. She further stated the facility followed an algorithm for wound care provided by facility corporate staff and she did not give wound care orders. The APRN stated heel protectors/boots were not used as it would contribute to extra pressure on the heel; however, if treatment and pressure relieving interventions were not in place, then a wound would deteriorate. In an interview with the Physician, on 01/26/2024 at 4:35 PM, she stated she was informed Resident #18 had a skin tear on admission, but was not informed of a pressure injury. She stated she was notified of the pressure injury on 01/15/2024. She further stated the facility followed corporate protocol and she expected to be notified if there were treatment orders needed or changes in condition so orders could be given if needed. The physician stated if the facility did not follow protocols such as offloading the heel, an outcome would be worsening of a wound. On 01/26/2024, the Administrator informed the State Agency Representative the facility had taken photographs of Resident #18's right heel on admission and they were trying to obtain those. The facility did provide a photograph dated 12/05/2023 when Resident #18 was admitted to the hospital. However, at exit they facility had not provided facility photographs. During an interview on 01/27/2024 at 6:07 PM, the Administrator stated she believed Resident #18's foot wound had been assessed incorrectly on the admission assessment. She stated the facility did not know what was underneath the resident's heel growth on admission. However, she did state it was her expectation wounds would be properly assessed and measured on admission and a treatment put in place if applicable. Further, it was her expectation an intervention such as a heel protector or blue boots (device for heel protection) be in place when a resident with a foot/heel wound was sitting in a wheelchair.

Based on observation, interview, record review, review of the facility's assessment, and review of the facility's policy, it was determined the facility failed to provide adequate staff to provide nursing and related services. Review of Resident Council Meeting Minutes revealed resident's voiced concern that call lights were not answered timely. Additionally, resident's were concerned there was not enough staff on the night shifts and weekends. The findings include: Review of the facility's policy titled, Nurse Scheduling and Timekeeping Process, revised 07/01/2022, revealed the facility would staff according to budgeted staffing levels and adjust schedules based on census. Budgeting and adjusting staffing levels were based on a combination of senses, acuity levels and regulatory requirements. The purpose was to ensure consistent quality care provided by all service locations and optimal utilization of employees. Review of the facility's policy titled, Staffing Center Plan , revised 08/07/2023, revealed the facility provided qualified and appropriate staffing levels to meet the needs of the resident population. The staffing plan included all shifts, 7 days per week. The facility would assure that appropriate staffing levels were scheduled and maintained. Further. staffing levels were reviewed on an ongoing basis by facility staff to evaluate compliance and provide appropriate levels of care by qualified employees. Review of the Facility's Assessment Population Profile, dated 01/09/2023 through 01/08/2024, Staffing and Personnel, revealed the daily nursing staff included; six (6) licensed nurses which consisted of two (2) nurses on the 7 AM-3 PM shift, two (2) nurses on the 3 PM-11 PM shift, and two (2) nurses on the 11 PM-7 AM shift. Continued review revealed that the facility would have ten (10) Certified Nursing Assistants daily and included; four (4) CNA's on 7 AM-3 PM, four (4) on 3 PM-11 PM, and two to three (2/3) on 11 PM-7 AM shift. Review of the Resident Council Meeting Minutes dated 08/17/2023 at 3:07 PM, revealed residents had nursing concerns that included, it takes a while for call lights to be answered, and residents asked if there could be more staff at night and on weekends. Review of the Resident Council Meeting Minutes dated 09/14/2023 at 3:06 PM, revealed residents voiced concerns that weekend showers were not being done. Further review of the document revealed staff failed to offer some residents the option of getting up on the weekends due to staffing. Review of the Resident Council Meeting Minutes dated 10/19/2023 at 2:23 PM, revealed residents reported they felt there was not enough staff overnight. Review of the Resident Council Meeting Minutes, dated 12/27/2023 at 2:05 PM, revealed residents reported they were being told they could not come to the dining room due to staffing shortages on the weekends. Review of the Resident Council Meeting Minutes dated 01/11/2024 at 3:05 PM, revealed a resident stated that he/she was left alone while taking a shower multiple times and that staff were not offering to get residents up on the weekends. Review of the Resident Council Meeting Minutes dated 01/24/2024 at 3:32 PM, revealed residents reported some of the nursing staff were not worth anything and the residents were not happy on weekends. 1. Review of Resident #17's Admission Record revealed the facility admitted the resident on 09/18/2019 with diagnoses which included Schizophrenia, unspecified, Bipolar Disorder, unspecified and Retention of urine, unspecified. Review of Resident #17's Quarterly Minimum Data Set (MDS) Assessment, dated 12/22/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of eleven (11) out of fifteen (15), indicating the resident was cognitively intact and interviewable. During an interview with Resident #17 on 01/23/2024 at 9:39 AM, he/she stated staff would turn his/her call light off and would never come to his/her room. Resident #17 stated this happened very often and it made him/her upset. 2. Review Resident #145's Admission Face Sheet revealed the facility admitted Resident #145 on 01/09/2024, with diagnoses which included Malignant Neoplasm of Pancreas, unspecified, Malignant Neoplasm of Colon, unspecified, and Malignant Neoplasm of unspecified site of unspecified female breast. Review of Resident #145's Admission MDS Assessment, dated 01/12/2024, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of fourteen (14) out of fifteen (15) which indicated Resident #145 was cognitively intact. During an interview with Resident #145 on 01/23/2024 at 8:49 AM, he/she stated it took staff over an hour to answer his/her call light and this happened often due to the facility being short staffed. Resident #145 stated he/she would have to wait for help to get on the bedside commode and would finally just get up by him/her-self because he/she could not wait any longer. 3. During an interview with Resident #24 on 01/23/2024 at 9:55 AM, he/she stated he/she did not use his/her call light often but staff would tell him/her to turn the call light off. Resident #24 stated if he/she were having a heart attack, he/she might as well be dead. Resident #24 stated the facility did not have enough help. Resident #24 further stated it made him/her feel bad. In an interview with Certified Nursing Assistant (CNA) #1, on 01/25/2024 at 10:43 AM, she stated staffing was always a problem. She stated that not only were there concerns with the number of staffing but the failure of staff members to complete their share of the work. CNA #1 further stated CNA #2 had been out of the facility for several weeks due to medical concerns and the facility had floating staff members to fill-in. She stated sometimes those staff members had offered her assistance on the North Hall and she had been responsible for all residents' care on that hall. In an interview with Certified Nursing Assistant (CNA) #2 on 01/25/24 at 11:15 AM, he stated he had worked in the facility for more than thirty (30) years but had recently been out of the facility due to illness for several weeks. He stated staffing could be challenging at times. He stated he worked day shift on the North Hall. During an interview with CNA #3 on 01/25/2024 at 3:11 PM, she stated she often worked sixteen (16) to eighteen (18) hour shifts due to low staffing. CNA #3 further stated she often worked the entire hall alone which made it difficult when she had several residents that required assistance with feeding or needed two staff to assist with transfers. She stated she would have to go to the other hall and ask for help and then have to wait until the other staff member had time to help her. In an interview with Certified Nursing Assistant (CNA) #3 on 01/26/2024 at 12:20 AM, she stated she has been at the facility less than a year. She stated they were short staffed 01/25/2024, after 3:00 PM and Administrative staff were on the floor helping. CNA #3 stated she worked a total of sixteen hours on 01/25/2024. She further stated that the facility has enough staff members but they just do not schedule them appropriately. CNA #3 stated she has worked as the only CNA in the building numerous shifts. In an interview with CNA #5, on 01/26/2024 at 10:29 AM, she stated she has worked two (2) years at facility, with the majority of it on the South Hall. She stated residents were not getting the care they needed. She stated the residents were not receiving their showers twice a week because some staff did not do their job. CNA #5 stated that two staff members on each side was considered short in her opinion, and day shift staff had pulled the burden of night shift. She stated night shift through the week had one CNA on each hall, and during weekends they had three (3) CNA's. She stated she had made Administration aware of staffing concerns but felt they had made excuses for those who had not performed their job duties. CNA #5 stated what surveyors had observed this week was a show and not how the facility had been normally. She stated residents had to be left in bed on weekends because of staffing issues. In an interview with Certified Nursing Assistant (CNA) #6 on 01/26/2024 at 1:44 PM, she stated she had been at the facility for two (2) years. She stated staffing depended on the census not how much care a resident needed. CNA #6 stated resident care had suffered because of not having enough staff. She stated night shift usually had two licensed staff and two aides. CNA #6 stated she was aware of residents who were not gotten up out of bed due to the shortage of staff. She stated management does not come out and help on the floor. CNA #6 further stated the week of the survey had been an exception. CNA #6 further stated the Director of Nursing (DON) and the Administrator were aware of staffing concerns. She stated they say they would address concerns but staff never see any results. In an interview with Director of Nursing (DON) on 01/27/2024 at 3:51 PM, she stated she had been in her position for a year. She stated she expected staff to answer call lights timely and for administrative staff to assist. The DON stated all staff should work as a team and ensure care was provided. She stated resident outcomes could occur if staff waited too long to provide assistance because residents could fall and/or have incontinent episodes, and resident safety was number one. Additionally, the DON stated the Social Services Director had not made her aware of any concerns from the Resident Council Meetings about staffing. She stated the facility has followed the guidelines for staffing based on the facility's acuity and census. The DON stated the administrative staff fills in and helps to ensure they have a staff manager on duty to help with resident care. She stated administrative staff that can provide direct care as a nurse or aide do so when needed. In an interview with Administrator, on 01/27/2024 at 11:54 AM, she stated she has been in her position since July 2023. She stated staff were expected to answer call lights timely, and provide quality care to the residents. The Administrator stated without staff's timely response and care, potential resident outcomes such as a falls or skin breakdown could occur. During an additional interview with the Administrator on 01/27/2024 at 5:00 PM, she stated she believed the facility to be adequately staffed, and the administrative staff could pitch in and help if needed. She stated staffing was adequate despite what the Payroll Based Journal (PBJ) report reflected. The Administrator stated she was aware of resident concerns about staffing and the resident acuity does not have any effect on the staffing.

Based on interviews, record reviews, and review of facility's policy, it was determined the facility failed to ensure residents had the right to formulate an advance directive for nine (9) of sixteen (16) sampled residents (Residents #7, #8, #15, #17, #145, #195, #32, #295, and #18). Review of the residents' medical records revealed there was no documented evidence to support the facility provided a written description of the facility's policies that would empower the residents to participate in their own health care and decision-making by formulating an advance directive. Additionally, the Director of Social Services and Recreation, who was responsible for discussing whether the residents wished to consider developing an advanced directive, stated she was unaware of the regulatory requirements concerning advanced directives and did not give the residents information on how to formulate an advance directive upon admission. The findings include: Review of the facility's policy titled, Health Care Decision Making, revised on 01/08/2024, revealed it was the right of the resident to participate in their own health care decision making, including the right to formulate or not formulate an advance directive. The facility would provide a written description of the facility's policy to implement advanced directives. Approach a capable resident who did not have an advanced directive upon admission: the patient (resident) would be approached by the Social Worker or another designated staff person on admission, quarterly, and with change in condition, to discuss whether the resident wished to consider developing an advanced directive, and the resident representative, if the patient (resident) was incapacitated at the time of admission as to whether an advanced directive had been completed, executed in accordance with state law, and establish mechanisms for documenting and communicating the patients (residents) choices to the interprofessional team and staff responsible for the patient's (resident's) care. 1. Review of Resident #18's Admission Record revealed the facility admitted the resident on 12/10/2023 with diagnosis to include history of Transient Ischemic Attack, with Cerebral Infarction, Acquired Absence of Left Leg below Knee and Type 2 Diabetes Mellitus. Review of Resident #18's Admission Minimum Data Set (MDS) Assessment, dated 12/15/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fourteen (14) out of fifteen (15), indicating the resident was cognitively intact. Review of Resident #18's Admission orders revealed Resident #18 was a Full Code Status. Review of Resident #18's Electronic Health Record (EHR), revealed there was no documented evidence the resident had been offered the opportunity to formulate an advanced directive. During an interview with Resident #18 on 01/24/2024 at 10:00 AM, he/she stated he/she was a full code and did not know what an advance directive was. Resident #18 stated he/she did not recall anyone speaking to him/her about it. 2. Review of Resident #7's Medical Record revealed the facility admitted Resident #7 on 07/19/2022, with diagnosis to include Chronic Systolic Heart Failure, Gastrostomy Status, and Chronic Obstructive Pulmonary Disease (COPD). Review of Resident #7's Quarterly Review Minimum Data Set (MDS) Assessment, dated 12/15/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of five (5) out of fifteen (15), indicating the resident was non-interviewable. Review of Resident #7 Electronic Health Record (EHR) revealed there was no documented evidence Resident #7 or his/her responsible party, were given information on the option to formulate an advance directive. 3. Review of Resident #15's Facesheet revealed the facility admitted the resident on 08/12/2022 with diagnoses to include Atrial Flutter, Type 2 Diabetes Mellitus, and Long-Term use of Antibiotics. Review of Resident #15's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15), indicating the resident was cognitively intact. Review of Resident #15's Emergency Medical Services (EMS) Form, revealed the resident was a full code, however, there was no documented evidence the resident was given information on formulating an advanced directive. 4. Review of Resident #32's Face Sheet revealed the facility admitted the resident on 05/23/2023 with diagnoses to include Paraxysmal Atrial Fibrillation, Acquired Absence of the Right Leg Above the Knee, and Moderate Protein-Calorie Malnutrition. Review of Resident #32's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15), indicating Resident #32 was cognitively intact. Review of Resident #32's medical record revealed no documented evidence the resident was given information on formulating an advanced directive. 5. Review of Resident #195's Face Sheet revealed the facility admitted Resident #195 on 01/17/2024 with diagnoses to include Malignant Neoplasm of the Bladder, Hypertension, and Anemia. Review of Resident #195's Admission Minimum Data Set (MDS) Assessment, dated 01/24/2024, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of five (5) out of fifteen (15), indicating severe cognitive impairment. Review of Resident #195's medical record revealed no documented evidence the resident was given information on formulating an advanced directive. 6. Review of Resident #295's Face Sheet revealed the facility admitted Resident #295 on 01/18/2024 with diagnoses to include Pneumonia, Malignant Neoplasm of the Stomach, and Parkinson's Disease. Review of Resident #295's Admission Minimum Data Set (MDS) Assessment, dated 01/22/2024, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of thirteen (13) out of fifteen (15), indicating the resident was cognitively intact. Review of Resident #295's medical record revealed no documented evidence the resident was given information on formulating an advanced directive. 7. Review Resident #145's Admission Face Sheet revealed the facility admitted Resident #145 on 01/09/2024, with diagnoses which included Malignant Neoplasm of Pancreas, unspecified, Malignant Neoplasm of Colon, unspecified, and Malignant Neoplasm of unspecified site of unspecified female breast. Review of Resident #145's Admission MDS Assessment, dated 01/12/2024, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of fourteen (14) out of fifteen (15) which indicated Resident #145 was cognitively intact. Review of Resident #145's Electronic Medical Record revealed no documented evidence the resident was given information on formulating an advanced directive. 8. Review of Resident #17's Admission Face Sheet revealed the facility admitted the resident on 09/18/2019, with diagnoses which included Schizophrenia, unspecified, Bipolar Disorder, unspecified, and unspecified Dementia, unspecified severity, without behavioral disturbance. Review of Resident #17's Quarterly MDS Assessment, dated 12/22/2023, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of eleven (11) out of fifteen (15), which indicated Resident #17 was cognitively intact. Review of Resident #17's medical record revealed no documented evidence the resident was given information on formulating an advanced directive. 9. Review of Resident #8's Admission Record revealed the facility admitted the resident on 02/04/2022, with diagnoses which included Acute Kidney Failure, Anemia, and Benign Prostatic Hyperplasia with lower urinary tract symptoms. Review of Resident #8's Quarterly MDS Assessment, dated 01/09/2024, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of thirteen (13) out of fifteen (15), indicating Resident #8 was cognitively intact. Review of Resident #8's Electronic Health Record (EHR) revealed no documented evidence the resident was given information on formulating an advanced directive. During an interview with the Admissions Coordinator on 01/27/2024 at 10:40 AM, she stated the Admission Packet was done at the seventy-two (72) hour meeting, and at that time the resident was asked about formulating an advance directive. She stated the Social Services Director takes care of the advanced directives and collects documentation regarding those. The Admissions Coordinator further stated residents with a low Brief Interview for Mental Status (BIMS) score were not allowed to sign documents. During an additional interview with the Director of Social Services and Recreation on 01/27/2024 at 10:51 AM, she stated that she did not know what the regulatory requirements were concerning advanced directives. She further stated she did not give residents information on how to formulate an advanced directive upon admission. In an interview with the Director of Nursing (DON) on 01/27/2024 at 3:53 PM, she stated she was not aware of the facility's advanced directives policy and would have to review it. During an interview with the Administrator on 01/27/2024 at 5:00 PM, she stated the facility discusses Advanced Directives with the Social Services Director during the seventy-two (72) hour meeting. She stated she had never heard the facility was required to provide assistance or ask residents about formulating an advance directive. The Administrator stated she would have to check the facility policy on this practice. During an additional interview with the Administrator on 01/27/2024 at 5:33 PM, she stated residents and representatives were asked if the residents had an advance directive upon admission. She stated if they had an Advanced Directive the facility would obtain a copy so it could be uploaded into the residents chart. The Administrator further stated she expected the SSD to follow the facility's policy and assist the resident in obtaining an Advanced Directive if they chose to have one. 45914 47567 47798

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility failed to ensure standard and Enhanced Barrier Precautions were followed. Observation during initial tour of the facility, on 01/23/2024 starting at 8:45 AM, revealed there were no residents on Enhanced Barrier Precautions. However, observation on 01/24/2024 starting at 8:50 AM, revealed the North and South Halls, had nineteen (19) resident rooms with EBP signage, and two (2) Personal Protective Equipment (PPE) bins on the halls. The facility failed to follow the Centers for Disease Control (CDC) and Prevention guidelines related to residents with wounds/indwelling medical devices should be on EBP, regardless of MDRO colonization status and if infection or colonization with an MRDO. Additionally, observation on 01/23/2024 at 9:00 AM, and 10:56 AM, revealed Resident #195 was lying in bed with his/her urinary drainage bag touching the floor; and there were no EBP precautions such as signage, or PPE noted. Further observation on 01/24/2024 at 10:00 AM, revealed EBP signage was on Resident #195's door and PPE Bins were noted in the hallway. Continued observation on 01/24/2024 at 1:48 PM, revealed Resident #195 was sitting up in his/her wheelchair at the nurse's station with the urinary drainage bag touching the floor. Furthermore, observation on 01/23/2024 at 9:55 AM, revealed Resident #295 was lying in bed and his/her gastrostomy drainage bag was touching the floor. There were no EBP precautions such as signage, or PPE noted on Resident #295's door. The findings include: Review of the facility's policy titled, Enhanced Barrier Precautions (EBP), revised on 01/08/2024, revealed in addition to standard precautions, EBP would be used when contact precautions did not otherwise apply, for novel or targeted multi-drug resistant organisms (MDRO). EBP was based on the Centers for Disease Control (CDC) and Prevention Guidance Implementation of Personal Protective Equipment (PPE) use in nursing homes to prevent the spread of MDRO's. State regulations would be followed when applicable. In an interview with Kentucky Regional Infection Prevention Program Coordinator on 01/24/2024 at 10:05 AM, she stated CDC expanded EBP to those without a history of infection or colonization; it did not matter if no other residents have an MDRO, those residents with wounds/indwelling devices should be on EBP. She stated that when CDC made recommendations, CMS expected facilities to implement those guidelines. 1) Observation during initial tour, on 01/23/2024 starting at 8:45 AM, revealed there were no residents on Enhanced Barrier Precautions as evidenced by no signage on doors and no Personal Protective Equipment (PPE) bins containing PPE. However, observation on 01/24/2024 starting at 8:50 AM, revealed the North and South Halls, had nineteen (19) resident rooms with EBP signage, and two (2) Personal Protective Equipment (PPE) bins on the halls. Review of the list received from the Infection Preventionist (IP), on 01/24/2024, revealed there were nineteen (19) resident rooms for a total of twenty-five (25) residents who were on EBP precautions. In an interview with Certified Nursing Assistant (CNA) #7, on 01/27/2024 at 10:51 AM, she stated she had noticed the signs now present on resident doors that directed staff on what precautions to take related to Personal Protective Equipment (PPE) when providing care. She verified the signs were new and she had not seen them posted before today, 01/27/2024. In continued interview, she stated she had been educated on EBP by Licensed Practical Nurse (LPN) #1 and the infection control nurse (IP) this morning upon returning to work. Interview with the Infection Preventionist (IP), on 01/27/2024 at 11:35 AM, revealed she had been the IP for about a year. Regarding Enhanced Barrier Precautions, she stated the facility had precautions in place for EBP a few months ago, but the corporate staff had said to discontinue this practice. She further stated the facility initiated EBP on the evening of 01/23/2024, after the State Survey Agency (SSA) inquired about facility practices related to infection control. The IP stated resident records were reviewed, signage was placed on doors, PPE was placed on the hall and education was provided to staff after the survey started. She stated she had provided education daily, coming in early to educate night shift staff to ensure all staff had been educated on EBP. She further stated she had worked on the floor so much that she was not aware of the new guidelines on EBP. In an interview with the Director of Nursing (DON), on 01/27/2024 at 3:53 PM, she stated she did not know EBP was a continuous procedure until she pulled the policy for review. She stated corporate had informed them awhile back that they could remove the precautions. In continued interview, she stated residents were placed in precautions on 01/23/2024 after the survey began. She further stated signage had been placed and she expected staff to read and follow the guidelines. The DON stated education was initiated on the evening of 01/23/2024, after the SSA inquired about facility practices related to infection control. She stated all staff have been educated on EBP. She further stated the facility had plenty of PPE. When questioned about potential outcomes of staff not using EBP precautions, she stated staff could expose or contaminant themselves or other residents. In an interview with the Administrator, on 01/27/2024 at 6:00 PM, she stated the facility had initiated the EBP and corporate had told them to stop so all precautions were stopped. She further stated she was unaware of the newest guidelines and initiated EBP on the evening of 01/23/2024. Further, she stated the IP and DON had placed signs, gathered PPE and educated staff on the precautions. In continued interview, she stated she expected staff to follow the guidelines on the signs at the door. She stated cross contamination could happen if staff were not utilizing the appropriate PPE. 47567 2) Interview with the Assistant Director of Nursing (ADON), on 01/27/24 at 3:10 PM, revealed the facility did not have an actual urostomy procedure or process policy. Review of Resident #195's Admission Record revealed the facility admitted the resident on 01/17/2024 with diagnoses to include Malignant Neoplasm of the Bladder and Urostomy. Review of Resident #195's Admission Minimum Data Set (MDS) Assessment, dated 01/24/2024, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of five (5) out of fifteen (15), indicating severe cognitive impairment. The MDS Assessment was in progress and not fully completed. Observation on 01/23/2024 at 9:00 AM, revealed Resident #195 was lying in bed and his/her urinary drainage bag was touching the floor. Further observation revealed there were no EBP precautions such as signage, or PPE noted. In an interview with Licensed Practical Nurse (LPN) #2, on 01/23/2024 at 9:55 AM, she stated she was assigned to Resident #195. She stated catheter care was provided by the aides. She further stated she checked for leaks, and made sure the urinary drainage bags were clean. In continued interview, she stated she usually had to change Resident #195's urinary drainage bag at least every five (5) days because he/she rolled over it with his/her wheelchair a lot. She further stated the drainage bags should not be touching the floor as this was an infection control issue. Further, she verified there were no EBP precautions in place for this resident at this time. Observation on 01/23/2024 at 10:56 AM, revealed Resident #195's urinary drainage bag continued to touch the floor while the resident was lying in bed. Additional observation on 01/24/2024 at 10:00 AM, revealed EBP signage was on the resident's door and PPE Bins were noted in the hallway. Observation on 01/24/24 at 1:48 PM, revealed Resident #195 was sitting up in his/her wheelchair at the nurse's station with the urinary drainage bag touching the floor. 3) Review of the Admission record revealed the facility admitted Resident #295 on 01/18/2024 with diagnoses to include Pneumonia, Malignant Neoplasm of the Stomach, and Parkinson's Disease, and Gastrostomy. Review of Resident #295's Admission Minimum Data Set (MDS) Assessment, dated 01/22/2024, revealed the facility assessed the resident as having a BIMS score of thirteen (13) out of fifteen (15), indicating intact cognition. Observation on 01/23/2024 at 9:55 AM, revealed Resident #295 was lying in bed and his/her gastrostomy drainage bag was touching the floor. Further observation revealed there were no EBP precautions such as signage, or PPE noted. In an interview with the Director of Nursing (DON), on 01/27/2024 at 3:53 PM, she stated urinary and gastrostomy drainage bags should be kept off the floor to prevent contamination. In an interview with the IP Nurse on 01/27/2024 at 11:34 AM she stated she expected the staff to follow Enhanced Barrier Precautions when providing care for a resident with urostomy or a gastrostomy. Further, drainage bags should not be touching the floor as this was an infection control issue. In an interview with the Administrator, on 01/27/24 at 5:00 PM, she stated it was an infection control issue for medical drainage bags to touch the floor, and staff should ensure this did not happen.

Based on observations, interviews, and review of the facility's policy it was determined the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for three (3) of sixteen (16) sampled residents (Resident's #295, #195, and #17). Observations of Resident #295 and Resident #17, on 01/24/2024 and 01/25/2024, revealed the resident's catheter bags had no dignity cover in place. Observation during a lunch meal on 01/23/2024, revealed Resident #195 waited thirty-two minute for his/her meal tray, while other residents had been served their food in the dining room. The findings include: Review of the facility provided document titled, Resident Rights under Federal Law, dated 11/28/2016, revealed the resident had a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. Further, the resident also had the right to exercise his or her right as a resident of the facility and as a citizen or resident of the United States. Review of facility policy titled, Resident Rights, revised 02/01/2023, revealed residents had the fundamental right to considerate care that safeguarded their personal dignity along with respecting cultural, social, and spiritual values. The purpose of the policy was to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his/her self-esteem and self-worth and to incorporate the resident's goals, preferences, and choices into care. Review of the facility's policy titled, Treatment: Considerate and Respectful, reviewed 08/07/2023, revealed the facility would promote respectful and dignified care for patients (residents) in a manner and in an environment that promoted maintenance or enhancement of their quality of life while recognizing each patient's (resident's) individuality. The facility would refrain from demeaning practices such as keeping urinary catheter bags uncovered. 1. Review of Resident #295's Face Sheet revealed the facility admitted Resident #295 on 01/18/2024 with diagnoses to include Pneumonia, Malignant Neoplasm of the Stomach, and Parkinson's Disease. Review of Resident #295's Admission Minimum Data Set (MDS) Assessment, dated 01/22/2024, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of thirteen (13) out of fifteen (15), indicating the resident was cognitively intact. Observation of Resident #295 on 01/24/2024 at 9:19 AM, revealed the residents Foley drainage bag half full of dark brown colored urine, with no dignity bag in place. Observation of Resident #295 on 01/25/2024 at 9:00 AM, revealed. the residents Foley drainage bag containing dark brown colored urine, with no dignity bag in place. During an attempted interview with Resident #295 on 01/24/2024 at 9:14 AM, he/she declined to be interviewed. 2. Review of Resident #17's Admission Record revealed the facility admitted the resident on 09/18/2019 with diagnoses which included Schizophrenia, unspecified, Bipolar Disorder, unspecified, and Retention of urine, unspecified. Review of Resident #17's Quarterly Minimum Data Set (MDS) Assessment, dated 12/22/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of eleven (11) out of fifteen (15), indicating the resident was cognitively intact and interviewable. Review of Resident #17's Comprehensive Care Plan, revealed he/she was care planned for a catheter due to Neurogenic bladder/suprapubic catheter with interventions to include catheter care every shift and as needed, keep catheter bag off floor and provide a privacy bag. Observations on 01/23/2024 at 9:39 AM and on 01/25/2024 at 9:45 AM, revealed Resident #17's catheter bag was anchored to his/her bed facing the hallway, and did not have a dignity cover in place. During an interview with Resident #17 on 01/23/2024 at 9:39 AM, he/she stated he/she did not like people being able to see his/her urine. During an interview with Certified Nursing Assistant (CNA) #5 on 01/25/2024 at 2:48 PM, she stated Resident #17's catheter should have been covered because it was a dignity issue. During an interview with Licensed Practical Nurse (LPN) #5 on 01/25/2024 at 3:57 PM, she stated Resident #17's catheter should have had a dignity cover on it. During an interview with CNA #6 on 01/26/2024 at 1:44 PM, she stated Resident #17's catheter should have been covered with a dignity bag and she was unsure why it did not have one. During an interview with the Assistant Director of Nursing (ADON) on 01/27/2024 at 3:22 PM, she stated Foley bags should be covered with a dignity bag. During an interview with the Director of Nursing (DON) on 01/27/2024 at 3:53 PM, she stated she expected staff to ensure catheters had a dignity cover on them. During an interview with the Administrator on 01/27/2024 at 5:33 PM, she stated dignity was a big issue and some resident's were non-compliant. She stated staff continued to explain to the resident that it was an infection control and dignity issue. The Administrator stated she expected staff to ensure there was a dignity cover in place for catheters. 3. Review of Resident #195's Admission Record revealed the facility admitted the resident on 01/17/2024 with diagnoses which included Malignant Neoplasm of Bladder, unspecified, weakness, and Benign Prostatic Hyperplasia without lower urinary tract symptoms. Review of Resident #195's Admission Minimum Data Set (MDS) Assessment, dated 01/24/2024, revealed Resident #195 had a Brief Interview for Mental Status (BIMS) score of five (5) of fifteen (15), indicating a severe cognitive deficit. Observation of a lunch meal in the dining room, on 01/23/2024 at 11:31 AM, revealed Resident #195 was not served his/her lunch tray until 12:02 PM which was thirty-two (32) minutes after other residents had received their meals and were eating. During an interview with the Infection Preventionist (IP) on 01/23/2024 at 11:55 AM, she stated when she noticed Resident #195 had not received his/her tray, she asked the kitchen why and was told that his/her tray was being prepared with the hall cart because he/she normally consumed meals in his/her room. The IP nurse stated Resident #195 should have been provided a tray sooner. During an interview with Certified Nursing Assistant (CNA) #5 on 01/25/2024 at 9:51 AM, she stated when resident's decided to go to the dining room rather than eat in their room, she would make sure to notify the kitchen as soon as possible so the resident could get a tray. During an interview with CNA #3 on 01/25/2024 at 3:11 PM, she stated it was the resident's choice on where to eat his/her meals. She stated it was unacceptable for a resident to have to sit and wait a long period of time while others were eating. CNA #3 further stated it should only take ten to fifteen minutes for a tray to be prepared. During an interview with Certified Nursing Assistant (CNA) #7 on 01/27/2024 at 10:51 AM, she stated if a resident had not notified staff ahead of time that they were going to eat in the dining room, she would notify the kitchen so a tray could be provided. She stated a resident should not have to wait any longer than fifteen minutes to be served. During an interview with the Director of Nursing (DON) on 01/27/2024 at 3:53 PM, she stated she expected staff to notify the kitchen immediately if a resident had not received a tray. She stated Resident #195 could have felt socially awkward sitting there while other residents were eating. The DON further stated she hoped the resident was at least offered something to drink. Further, she stated that waiting for over thirty minutes for a tray was unacceptable. During an interview with the Administrator on 01/27/2024 at 5:33 PM, she stated she expected resident's to be served their meals timely and it was not acceptable for a resident to wait twenty (20) or thirty (30) minutes for a tray while others were eating. The Administrator stated she expected staff to get the residents a tray as soon as they came to the dining room and the resident should not have to wait more than five (5) minutes. She stated the resident could feel singled out and may not ever want to go to the dining room again if they had to wait so long while others had been served. 47798

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to review and revise the care plans when changes occurred for one (1) of sixteen (16) sampled residents (Resident #18). On 01/25/2024, Resident #18 was assessed to be unable to transfer independently and was unable to stand or pivot with transfer. It was at that time, the resident required the use of the total body lift with the assistance of two staff for transfers. The facility; however, failed to ensure the resident's Comprehensive Care Plan was updated/revised to reflect the change in the resident's assessed needs. The findings include: Review of the facility's policy titled, Person-Centered Care Plan, revised on 10/24/2022, revealed the facility would develop and implement a Baseline Person-Centered Care Plan within forty-eight (48) hours of admission for each resident that included the instructions needed to provide effective and person-centered care that met professional standards of quality care. Continued review revealed, the care plan would be reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments and as needed to reflect the response to care and changing needs and goals, and it would be documented on the Care Plan Evaluation Note. Review of the facility's policy titled, Safe Resident Handling Program, revised on 04/15/2023, revealed all residents would be assessed upon admission/readmission with significant change in condition and quarterly by licensed nurse for assistance with transfer activities in accordance with Minimum Data Set (MDS) procedures and requirements. Further, assessments would include the need for lift transfer equipment, and gait transfer belt. Mechanical lift devices would be used in accordance with manufacturers recommended capacities. Continued review revealed, staff would follow the nursing policies and procedures related to the use of lifts and transfer positioning devices. Review of Resident #18's Admission Record revealed the facility admitted the resident on 12/10/2023 with diagnoses including History of Transient Ischemic Attack, with Cerebral Infarction, Acquired Absence of Left Leg below Knee and Type 2 Diabetes Mellitus without complications. Review of Resident #18's Admission Minimum Data Set (MDS) Assessment, dated 12/15/2023, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of fourteen (14) out of fifteen (15), indicating intact cognition. Continued review revealed the facility assessed the resident to require substantial or [NAME] assistance for chair to bed transfers. Review of a Lift Transfer Evaluation dated 12/10/2023 and signed by Licensed Practical Nurse (LPN) #3, revealed Resident #18 was able to stand and pivot with transfer and limited to minimal assist. Review of Progress Note dated 01/24/2024 at 8:00 PM, signed by the ADON, revealed, Resident #18 had been lowered to the floor with assistance. Review of a Lift Transfer Evaluation dated 01/25/2024, at 11:09 AM, and completed by the Director of Nursing, revealed that Resident #18 was unable to transfer independently or with supervision and that he/she was unable to stand and pivot with transfer and would now require a total body lift for transfers. Review of the document titled, Visual Bedside Kardex Report, dated 01/25/2024 at 12:08 PM, under Ambulation, Mobility and Transfers, revealed staff were to provide Resident #18 with the assistance of one (1) to two (2) staff for transfers using a walker and gait belt. The Kardex; however, was not revised to include the assessed intervention of utilizing the hoyer lift to transfer the resident, as stated in the Lift Transfer Evaluation. Review of the Progress Note dated 01/25/2024 at 2:37 PM, signed by Licensed Practical Nurse (LPN) #1, revealed Resident #18, when moving from seat to stand position, was not steady but was able to stabilize with staff assist and when transferring from surface to surface. Continued review revealed the resident required a hoyer lift with transfers. Review of Resident #18's Comprehensive Care Plan, dated 12/26/2023, revealed the resident was at risk for falls due to impaired mobility. Continued review revealed there were no interventions on the care plan related to how the resident would be assisted with transfers. Additionally, there was no indication that the care plan had been reviewed and revised on 01/24/2024, when Resident #18 was lowered to the floor with no injuries. Further, the facility failed to revise the resident's care plan to include transfers utilizing the hoyer lift, as assesed on 01/25/2024. Continued review of Resident #18's care plan for Activities of Daily Living (ADL), dated 12/26/2023, revealed the resident was at risk for decreased ability to perform ADL's with bed mobility, transfer, locomotion, and toileting related to impaired balance, dizziness and limited mobility. Interventions included staff were to provide extensive assist of one (1) to two (2) for transfers using a walker and gait belt. In an interview with Certified Nursing Assistant (CNA) #2 on 01/24/2024 at 11:11 AM, he stated Resident #18 was a total body lift for transfers and had been for a while. He stated he would have expected the intervention of utilizing the hoyer lift with the resident's transfers would have been added to the Kardex (CNA's Care plan), but it was not. In an interview with CNA #7 on 01/27/2024 at 10:51 AM, she stated she used the Kardex to review instructions on how to provide care for a resident. She stated if she had questions, she would communicate with the nurse. She stated changes were communicated on a form that was discussed during shift change and that nurses would communicate any relevant concerns with all staff at the nurses station. In an interview with the Director of Nursing (DON) on 01/27/2024 at 3:54 PM, she stated she expected care plans to be revised when there were changes with the resident's care. She stated the nurse who completed Resident #18's change in condition was responsible for updating the care plan. The DON further stated she had completed a lift transfer evaluation and the intervention for Resident #18 being lowered to the floor was to initiate a total body lift for transfers. The DON stated she informed the staff that Resident #18's assistance with transfers was now a lift and assist of two (2) staff. The DON stated she did not update Resident #18's care plan to include the use of a total body lift for Resident #18's transfers, but should have. In an interview with the Administrator on 01/27/2024 at 6:07 PM, she stated the MDS Coordinator reviewed and revised the residents care plans. She stated she expected the care plans to be updated timely, with new interventions as needed, when resident changes occurred.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to provide the necessary care and services to ensure the residents had an effective communication system for one (1) of sixteen (16) sampled residents (Resident #30). Observation and an attempted interview with Resident #30, who was a Non-English speaking resident, on 01/23/2024 at 9:00 AM, revealed the resident was unable to communicate with the State Survey Agency (SSA) Surveyor due to not having access to a functioning communication system/device. The findings include: Review of the facility's policy titled Resident Rights Under Federal Law, revised 02/01/2023, revealed residents had the fundamental right to considerate care that safeguard their personal dignity along with respecting cultural, social, and spiritual values. The policy further revealed the facility must ensure that information was provided to each resident in a form and or manner the resident can access and understand, including in an alternative format or in a language that the resident could understand. Record review revealed the facility admitted Resident #30 on 05/21/2021, with diagnoses to include Cerebral Infarction, Aphasia following Cerebral Infarction, and Flaccid Hemiplegia affecting the Right dominant side. Review of Resident #30's Quarterly Minimum Data Set (MDS) Assessment, dated 11/14/2023, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of ninety-nine (99), indicating the interview was not conducted. Review of a facility form titled, Interpreter Request Form, dated 05/21/2021, revealed Resident #30's legal representative signed an interpreter request form for the resident to have interpreter services twenty-four (24) hours each day that was to be provided free of charge by the facility. Review of Resident #30's Admission Minimum Data Set Assessment for Section A: Identification Information dated 05/22/2021, revealed Resident #30 requested interpreter services. Review of Resident #30's Quarterly Minimum Data Set Assessment for Section A: Identification Information dated 11/14/2023, revealed it was unable to determine if Resident #30 needed interpreter services. Review of Resident #30's Comprehensive Care Plan revealed a problem area/focus of impaired communication as evidenced by difficulty making self understood (expressive), difficulty understanding others (receptive) related to Cerebral Vascular Accident (CVA) with the goal that Resident #30 would express needs through nonverbal communication as tolerated daily, with interventions to include obtaining a translator for simple head nod yes, head shake no questions responses as needed. Observation on 01/23/2024 at 9:00 AM, revealed Resident #30 had difficulty communicating with the SSA Surveyor when approached for an interview. At this time, Certified Nursing Assistant (CNA) #10 walked by Resident #30's doorway and stated He/she doesn't speak English, but comprehends it. Continued observation revealed Resident #30 did not have access to a functional communication system or interpreter device. Observation on 01/23/2024 at 10:47 AM, revealed Resident #30 being asked by Certified Nursing Assistant (CNA) #10 if he/she was ready to get up. Resident #30 observed to give CNA #10 a blank stare with no response. During an interview with Resident #30's family member on 01/24/2024 at 9:00 AM, he stated the resident would smile or use hand gestures, but can not speak because he/she had a stroke prior to facility placement a few years ago. Resident #30's family member stated the resident never spoke English and the facility never offered any interpreter services upon admission. During an interview with Certified Nursing Assistant (CNA) #10 on 01/23/2024 at 9:00 AM, she stated the resident communicates his/her needs with facial expressions with smiling or frowning. CNA #10 stated the resident could understand everything staff stated. She further stated that if one was to work with the resident long enough then, you just kind of know. In an interview with CNA #5 on 01/26/2024 at 10:29 AM, she stated she was told Resident #30 did not speak English, and she just learned to communicate with the resident by talking to him/her. She further stated the Bosnian employees would try to speak to him/her in their native language but Resident #30 would not respond. CNA #5 stated Resident #30 has aphasia and she was aware that residents were supposed to be asked if they want an interpreter. She stated she knew this because she had worked at another facility and learned it there. In an interview with CNA #6 on 01/26/2024 1:50 PM, she stated the facility had two (2) staff members who spoke Bosnian and translated for Resident #30 when they worked. She stated when those staff members were not working they would use a translator app on a tablet or iPad that was kept up front in the administration office, to communicate with Resident #30. CNA #6 further stated Resident #30 appeared to understand what staff communicated to him/her but he/she was unable to talk. She stated when she cared for Resident #30, she would utilize Google translate to communicate with the resident. CNA #6 stated to her knowledge staff had access to a translator app but she had not witnessed any of the staff members using it. In an interview with Registered Nurse (RN) #1 on 01/26/2024 at 10:41 PM, she stated Resident #30 came to the facility after he/she had a stroke. Staff were never really able to determine how well he/she communicated in his/her own language. RN #1 stated the resident appeared to understand what staff were communicating to him/her. She further stated the facility used to have a language interpreter line but they do not use it. During an interview with the Minimum Data Set (MDS) Nurse on 01/27/2024 at 12:33 PM, she stated Resident #30 made attempts to communicate with family when they called or came to visit. The facility had two Bosnian speaking employees who communicated with Resident #30 but the resident does not respond. The MDS Nurse stated the resident's Quarterly Minimum Data Set Assessment, (MDS) Section A was coded as unable to determine if interpreter was needed. She stated the facility does have access to interpreter services if they were needed, but did not believe the service was needed to communicate with Resident #30. During an interview with the Director of Social Services and Recreation (DSSR) on 01/25/2024 at 11:49 AM, she stated she had not experienced any non-English speaking residents. She stated the facility currently had two residents that were Bosnian descent and they both spoke English. The DSSR stated Resident #30 appeared to understand what staff were communicating to him/her, but was unable to speak as a result of his/her stroke. She further stated the facility had two aides that spoke Bosnian, but when they were not here, they would have the family interpret for the residents or they would obtain an interpreter if needed. She stated she completed an assessment called an social determinants of health, and in the assessment she would ask the resident if he/she wanted an interpreter or not. She stated it was noted, Resident #30 was unable to respond to the question. She further stated that when she wanted to communicate with the resident, she would ask for the assistance of an aide to translate for her, to help her understand the resident. The DSSR stated she would not know for certain that what was communicated to the aide was translated in a way that would express the needs of the resident. In an interview with the Speech Pathologist on 01/26/2024 at 4:19 PM, she stated she had been with the facility since 10/25/2023 and had not evaluated any non-English speaking residents. She stated she conducted evaluations on new admits that do not speak English as a part of her job duties. During an interview with the Assistant Director of Nursing (ADON) on 01/27/2024 at 3:10 PM, she stated staff should communicate with residents that do not speak English by using the interpreter line, or the app on the iPad. She stated staff could also use picture boards if necessary. The ADON stated there were two Bosnian employees which help translate for the Bosnian speaking residents. The ADON stated Resident #30 could understand English. She further stated she has used the telepad (a tablet or iPad that contains the translator app) and called families to talk to them that way. In an interview with the Director of Nursing (DON) on 01/27/2024 at 3:53 PM, she stated staff used the interpreter line to communicate with the non-English speaking residents. She stated the nursing staff should document if they used the translator. The DON stated because Resident #30 was non-verbal they used picture boards to communicate. She stated she was not for sure why staff were not using any interpreter devices when caring or communicating with Resident #30. During an interview with the Administrator on 01/27/2024 at 5:00 PM, she stated they have a translator app and the interpreter line to communicate with residents who do not speak English. She further stated the other non-English speaking residents were non-verbal, so they do not have to use the translator services for those residents. The Administrator further stated she was not sure if nursing staff documented their use of the translator services.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to develop and implement an effective discharge planning process that focuses on the resident's discharge goals for one (1) of three (3) closed records (Resident #43). Review of Resident #43's closed record revealed there was no documentation to support the facility had developed a discharge plan for the resident upon admission. Further, the Social Service Director (SSD) stated she did not know how the resident's discharge plan was missed. The findings include: Review of the facility policy titled, Discharge Planning Process, revised 11/15/2022, revealed the facility must develop and implement an effective discharge planning process that focuses on the resident's discharge goals, effectively transition them to post-discharge care, and reduce the factors leading to preventable readmissions. The policy further revealed within seventy-two (72) hours of admission the post admission family conference will be held with the resident, resident representative, care team, and community providers as available. Discharge Plan documentation would be as early as admission and no later than seven days prior to patient (resident) discharge. Nursing or Social Services would be responsible for initiating the discharge, communicating the discharge date to the resident or resident representative, and prepare the resident for transition. The policy further revealed once the discharge plan documentation was completed a discharge transition plan would be generated, reviewed with and given to the resident and or resident representative along with the discharge packet upon discharge from the facility. Closed record review revealed the facility admitted Resident #43 on 10/22/2023, with diagnoses which included Unspecified Fracture of Left Ulna, Type 2 Diabetes Mellitus, and Chronic Kidney Disease Stage 3. Review of Resident #43's Five (5) Day Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of thirteen (13) out of fifteen (15) indicating the resident was cognitively intact. In an interview with Resident #43 on 01/25/2024 at 8:15 AM, he/she stated that he/she requested to be discharged from the facility a few days after his/her arrival because he/she was unhappy with his/her care. Resident #43 stated he/she had complained to staff about urinary issues and he/she felt like they did not care. Resident #43 stated that he/she set up Home Health Services with the help of his/her primary care physician. Resident #43 stated the facility called later in the week after he/she was home and offered to set up Home Health but declined because he/she had already made his/her own arrangements. In an interview with the Social Services Director (SSD) on 01/25/2024 at 11:49 AM, she stated she could not recall Resident #43. She stated when a resident was ready for discharge, she contacted the physician and asked for a discharge order, met with the family and the resident to find out what type of equipment was needed, if any. The SSD stated that if a resident needed equipment she would obtain an order from the Medical Director, and made referrals to outside sources such as Home Health or Hospice, if needed. Further, she stated she would then complete the resident's discharge summary. During a second interview with the Social Services Director on 01/27/2024 at 10:51 AM, she stated she could not locate the resident's discharge plan since the resident's admission. Further, she stated she did not know how this got missed. The SSD stated discharge planning for short term residents was discussed upon admission and Resident #43 left before his/her time was up. Per the interview, she stated she contacted Resident #43 after he/she was discharged home and received an update of his/her discharge plans. In an interview with the Assistant Director of Nursing (ADON) on 01/27/2024 at 3:10 PM, she stated that discharge planning starts upon admission. She stated she expected nursing staff to have everything in place for a resident's discharge and that the process would be the same regardless if the discharge was planned or unplanned. During an interview with the Director of Nursing (DON) on 01/27/2024 at 3:53 PM, she stated she could not recall Resident #43, but that discharge planning begins upon admission. In an interview with the Administrator on 01/27/2024 at 5:00 PM, she stated that Resident #43 went out for a doctor's appointment, requested to be discharged while out, and never returned to the facility. She stated the resident called her and stated he/she would not be back to the facility. The Administrator further stated upon admission, staff should have asked the resident about his/her discharge goals, and if needed, obtained an order from the doctor, to assist in setting up outside services such as Home Health, if needed. The Administrator stated it was Social Services responsibility to begin the discharge planning for the residents.

Based on observation, interview, and Reivew of the facility's policy, it was determined the facility failed to ensure residents were able to exercise their right to view the results of the facility's State Survey results and Plan of Correction. Additionally, the facility failed to ensure residents and/or family members were aware of the location of the survey results and/or the results were not easily accessible to them. Observations on 01/23/2024 through 01/26/2024, revealed the survey results were not readily accessible to residents, family members, and legal representatives of the residents. The survey result binder was located in the facility's front lobby but was not accessible to residents without staff assistance. The findings include: Review of the facility's policy titled, Resident Rights Under Federal Law, dated 11/28/2016, revealed the resident had the right to exercise his/her rights as a resident of the facility and as a citizen of the United States, to the fullest extent possible without interference, coercion, discrimination, or reprisal. The State Survey Agency (SSA) Surveyor requested the facility's policy related to the posting of the Federal and State survey results; however, no policy was provided. Observation of the facility's front lobby on 01/23/2024 at 9:45 AM, revealed a sign posted stating, KRS (Kentucky Revised Statutes) 217.54 required state inspection reports on this facility to be made available to you upon request. Observation on 01/23/2024 at 1:40 PM revealed the results of the Federal and State survey binder were not readily accessible to the residents and/or the public. Continued observations revealed the survey inspection binder could not be located and the results of the most recent survey and/or plans of corrections the facility may have implemented was not available for the public to view. In an interview with the Administrator, on 01/27/2024 at 6:07 PM, she stated the State Survey Inspection binder was located in her office. During a Resident Group Interview, on 01/24/2024 at 3:15 PM, with ten (10) facility residents, Resident #10 stated he/she would have to ask for the survey results in order to view them. Residents #20, #2 and #25 stated they were unaware they could view the latest survey inspection results. Additionally, the residents stated they did not know where the results were kept. Record review revealed the facility assessed Resident #20 as having a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15), indicating intact cognition on the most recent Annual Minimum Data Set (MDS) Assessment, dated 11/04/2023. In an interview with Resident #20, on 01/24/2024 at 2:55 PM, he/she stated he/she was not sure where the survey book was located and had never examined the survey book. Record review revealed the facility assessed Resident #10 as having a BIMS score of fifteen (15) out of fifteen (15), indicating intact cognition on the most recent Quarterly MDS Assessment, dated 01/08/2024. In an interview with Resident #10, on 01/24/2024 at 3:02 PM, he/she stated she had examined the survey book and was not sure where it was located but knew he/she had to ask for it. In an interview with the Director of Nursing (DON) on 01/27/2024 at 3:54 PM, she stated the Survey Results binder was on a bookcase in the front lobby and was assessable to all visitors and staff. She further stated residents would not have to ask for the binder. In an interview with the Administrator on 01/27/2024 at 6:07 PM, she stated the Survey Results binder was located in the lobby area in the corner on a table. The Administrator stated the binder was accessible to the residents; however, she had to remove the binder as a resident had torn pages out of the binder sometime this week (week of January 22-27 2024). Per the interview, she stated she had the binder in her office to replace the torn pages. The Administrator stated she was aware the Survey binder should be available and within reach of residents, staff, family and visitors.

Based on interview, record review, and review of facility policy, it was determined the facility failed to ensure an allegation of abuse was thoroughly investigated and documented for one (1) of nine (9) sampled residents (Resident #8). An incident on 03/25/2022, of alleged abuse involving Resident #8, was not thoroughly investigated and documented. This deficient practice increases the risk that abuse may continue without being investigated and without implementing appropriate interventions to protect the residents vulnerable to abuse. The findings include: Review of the facility's policy titled, Abuse Prohibition, revised 04/09/2021, revealed to initiate an investigation within twenty-four (24) hours of the allegation of abuse .The investigation would be thoroughly documented with the Risk Management System (RMS). Ensure that documentation of witnessed interviews was included. All documentation related to allegation of abuse would be maintained at the Center for not less than three (3) years .Only an investigation can rule out abuse, neglect, or mistreatment. Review of Resident #8's medical record revealed the facility admitted the resident on 09/06/2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #8's Annual Minimum Data Set (MDS) Assessment, dated 03/17/2022, revealed the resident was assessed as non-interviewable with a Brief Interview for Mental Status (BIMS) score of four (4), which indicated he/she had severe cognitive impairment. MDS Section E200, regarding behaviors-Sexual indicate there were no sexual behaviors observed during the look back period. Review of Resident #7's medical record revealed the facility admitted the resident on 10/22/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #7's Annual Minimum Data Set (MDS) Assessment, dated 01/18/2022, revealed the resident was assessed as non-interviewable with Brief Interview for Mental Status (BIMS) score of zero zero (00), which indicated the resident had severe cognitive impairment. Review of a Progress Note for Resident #8, dated 03/25/2022 at 7:00 PM, revealed the nurse came out of another resident's room on South Hall and was walking towards the nurse's station, when the nurse saw Resident #8 coming out of room belonging to a female resident (Resident #7). When the nurse got closer. he/she saw the resident had his/her hand in his/her pants, with an erection and it was hanging out of the flap of his pants. Further review of the progress note, revealed the nurse asked the resident what he/she was doing and why he/she was on the opposite side of the building in a female's room. Resident #8 started to laugh and said, You can't prove that I did anything to her. The nurse immediately redirected the resident and told him/her the resident needed to go back to his/her room on the North Hall. Additionally, the nurse told the resident he/she could not come back down here. Continued review of the progress note, revealed the nurse immediately notified the Assistant Director of Nursing (ADON) and the Administrator of the situation and Resident #8 was placed on one (1) on one (1) supervision. The physician was notified of the incident the next day and was involved in the care conference about the incident. Resident #8 was placed on 1:1 supervision at the time of the incident, removed the next day after CED observation and consultation with the Physician, family and the Ombudsman. Review of Resident #8's care plan initiated in January with the first incident and update in March with this incident. Review of a Progress Note for Resident #7, dated 03/25/22, revealed he/she was assessed by the nurse and no signs of assault or skin issues were identified. Resident #7 was not interviewable due to his/her severe cognitive impairment. Interview with the Assistant Director of Nursing (ADON), on 09/07/2022 at 3:00 PM, revealed she recounted the event and confirmed the Administrator was notified. She further confirmed it was a potential abuse incident and needed to be investigated. Interview with the Administrator, on 09/08/2022 at 11:45 AM, revealed he was not able to access the files from the previous Administrator. He further stated he was unable to locate the documentation and evidence the SA had been notified of the incident on 03/25/2022, involving Resident #7's demonstrated inappropriate behavior. Additionally, he stated the facility's Risk Management System (RMS) lacked documentation of the event.

Based on interview, record review, and review of the facility investigation, and review of the facility policy, it was determined the facility failed to ensure the initial report of an allegation of abuse was reported to the State Agency (SA) within the two (2) hour period for one (1) of nine (9) sampled residents (Resident #8). An incident on 03/25/2022, of alleged abuse involving Resident #8, was not reported to the SA within the two (2) hour period. Additionally, the facility failed to ensure an outcome report of the abuse allegation was submitted to the SA within five (5) days of the incident. This deficient practice increases the risk that all allegations of abuse are not investigated by the SA, placing other residents at risk of abuse. The findings include: Review of the facility's policy titled, Abuse Prohibition, revised 04/09/2021, revealed upon immediately receiving information concerning a report of suspected or alleged abuse the Administrator would enter the allegation into the Risk Management System (RMS). The policy further stated the Administrator would report allegations involving abuse no later than two hours after the allegation was made to the appropriate state and local authorities. Review of Resident #8's medical record revealed the facility admitted the resident on 09/06/2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #8's Annual Minimum Data Set (MDS) Assessment, dated 03/17/2022, revealed the resident was assessed as non-interviewable with a Brief Interview for Mental Status (BIMS) score of four (4), which indicated he/she had severe cognitive impairment. MDS Section E200 Regarding Behaviors-Sexual, revealed there were no behaviors were observed in the look back period. Review of a Progress Note for Resident #8, dated 03/25/2022 at 7:00 PM, revealed the nurse came out of another resident's room on South Hall and was walking towards the nurse's station, when the nurse saw Resident #8 coming out of room belonging to a female resident (Resident #7), when the nurse got closer saw the resident had his/her hand in his/her pants, with an erection and it was hanging out of the flap of his pants. Further review of the progress note revealed the nurse asked the resident what he/she was doing and why he/she was on the opposite side of the building in a females room. Resident #8 started to laugh and said, You can't prove that I did anything to her. The nurse immediately redirected the resident and told him/her the resident needed to go back to his/her room on the North Hall. Additionally, the nurse told the resident he/she could not come back down here. Continued review of the progress note, revealed the nurse immediately notified the Assistant Director of Nursing (ADON) and the Administrator of the situation and Resident #8 was placed on one (1) on one (1) supervision. The 1:1 supervision was removed the following day after CED observation consultation with Physician and and family and the Ombudsman. The care plan was updated after the incident. Review of a Progress Note for Resident #7, dated 03/25/22, revealed he/she was assessed by the nurse and no signs of assault or skin issues were identified. Resident #7 was not interviewable due to his/her severe cognitive impairment. Review of Resident #7's medical record revealed the facility admitted the resident on 10/22/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #7's Annual Minimum Data Set (MDS) Assessment, dated 01/18/2022, revealed the resident was assessed as non-interviewable with a Brief Interview for Mental Status (BIMS) score of zero zero (00), which indicated the resident had severe cognitive impairment. Interview with the Assistant Director of Nursing (ADON), on 09/07/2022 at 3:00 PM, revealed she recounted the event and confirmed the Administrator was notified and confirmed it was a potential abuse incident. The ADON further stated the incident needed to be reported to the SA and be investigated. Interview with the Administrator, on 09/08/2022 at 11:45 AM, revealed he had not been able to access the files from the previous Administrator. He stated he was unable to locate the documentation and evidence the SA had been notified of the incident on 03/25/2022 involving Resident #7's demonstrated behavior. The Administrator further stated the former Administrator stated the SA was notified but was unable to find documentation the incident was reported. He stated review of the facility's Risk Management System (RMS) revealed no documentation of the event.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of four (4) sampled residents (Resident #1) received adequate supervision and monitoring to prevent elopement (exit the facility unsupervised). Resident #1 had a history of wandering and exit seeking behavior, which increased in the evening. On 10/21/2020, the facility assessed the resident required a wanderguard (system used to monitor the resident's location) due to the resident exhibiting behaviors of [CONDITION(S)], delusional behavior, and wandering that placed the resident at significant risk. On 11/18/2020, Resident #1 exhibited behaviors of wandering in other rooms and was redirected several times, however, the facility failed to increase the resident's supervision. On 11/18/2020 at approximately 9:50 PM, staff could not locate the resident in his/her room and noted the resident's window was open and the window screen was gone. Resident #1 crawled out an unsecured window in his/her room and went to a neighboring hotel. The hotel was located behind the facility near a busy four (4) lane highway between (2) two intersections, in a high traffic area. The resident was last seen at the facility at approximately 9:10 PM and staff found resident at the hotel after 10 PM. The facility's failure to ensure adequate supervision/monitoring for a resident exhibiting exit seeking behaviors has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 02/11/2021 and determined to exist on 11/18/2020. The facility was notified of the Immediate Jeopardy on 02/11/2021. An acceptable Allegation of Compliance (AoC) was received on 02/22/2021. The State Survey Agency validated the AoC and determined Immediate Jeopardy was removed on 02/25/2021. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility policy titled, Elopement of Patient, last revised May 2014, revealed residents would be evaluated for elopement risk upon admission, readmission, quarterly and with a change in condition, as part of the nursing assessment process. Those determined to be at risk would receive appropriate interventions to reduce risk and minimize injury. Further review of the policy revealed residents identified as at risk would have an elopement care plan developed with individual risk factors, patterns identified, and addressed within the care plan. Review of the facility policy titled, Enhanced Patient Supervision: Continuous 1:1, last revised 11/01/2019, revealed the whereabouts and well-being of residents was part of routine nursing supervision; however, a patient may require a temporary period of enhanced supervision in order to maintain his/her safety and the safety of others. Further review revealed enhanced supervision was an integral part of a therapeutic plan and ensured the safe and sensitive monitoring of the patient's physical and psychological well-being (including his/her conduct and mental health). The purpose was to provide a consistent approach in the planning and implementation for enhanced patient supervision and support for patients, who pose a potential or actual risk to themselves or others, and to provide a safe environment for patients. The nurse in charge of each shift was responsible to allocate staff to carry out continuous 1:1 supervision. Record review revealed the facility admitted Resident #1 on 10/16/2020 with diagnoses, which included Unspecified Dementia without Behavioral Disturbance, Unspecified [CONDITION(S)] not due to a substance or know Physiological Condition, Major Depressive Disorder Recurrent Unspecified, Cognitive Communication Deficit, Muscle Weakness, Weakness, and Unsteadiness on Feet. Review of Resident Admission Referral completed, on 10/09/2020, and faxed to facility on 10/13/2020, revealed Resident #1 had a wanderguard in place with a history of wandering and exit seeking that increased in evening. Review of Admission Assessment, dated 10/16/2020, revealed the facility assessed Resident #1's cognition was moderately impaired, his/her daily decision-making skills were poor for daily routine and he/she required reminders, cues, and supervision. Review of Nursing Note, dated 10/19/2020 at 8:24 AM by Licensed Practical Nurse (LPN) #2, revealed Resident #1 was wandering up to (5) five days a week. However, review of Resident #1's behavior monitoring and interventions sheets for October 2020, revealed there was no documented evidence these episodes occurred, what interventions were used, and if effective or not. Review of Nursing Notes, dated 10/21/2020 at 10:20 AM by LPN #2, revealed Resident #1 had a wanderguard placed. Review of Resident #1's Comprehensive Care Plan for Elopement related to wandering/exit seeking, initiated 10/21/2020, revealed a goal for resident not to have an elopement episode through next review. Further review of the care plan, revealed interventions to approach resident with redirection in a calm manner, be alert for any behaviors related to exit seeking, give verbal cues using resident details such as his/her daughter's name and using his/her full name and city/county location to assist with reassurance of safe belonging, and redirect resident when needed related to cognition level/confusion. Further review of the plan also revealed interventions for a symbol/clip art picture of resident choice placed at resident room and on door to reorient resident to his/her room, and wanderguard in place per orders. Review of an Elopement Assessment, dated 10/22/2021, revealed the facility assessed Resident #1 had a history of actual elopement or attempted elopement with expression of desire to leave; and behaviors of shadowing staff/other patients, frustrations, restlessness and/or agitation, and boredom. Review of an Admission Minimum Data Set (MDS) assessment, dated 10/23/2020, revealed the facility assessed Resident #1's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of three (3) which indicated the resident was not interviewable. Further review of the MDS revealed the resident had signs and symptoms of [CONDITION(S)], inattention, difficulty in focusing attention, and disorganized thinking that fluctuated. In addition, the resident had behaviors of delusions and wandering that placed the resident at significant risk of getting to a potentially dangerous place, with a wanderguard used daily. Review of Nursing Notes, dated 11/03/2020 at 9:30 AM documented by LPN #1, revealed Resident #1 was moderately impaired in decision making skills for daily routine; and wandered daily or almost daily. Further review revealed the Resident was experiencing agitation/restlessness, anxiety about surroundings, sleep cycle issues up to 5 days a week; and, exhibited behaviors of [CONDITION(S)] (e.g. restless walking patterns), and seeking companionship (e.g. looking for a loved one). At 5:30 PM, LPN #1 documented Resident #1 was moderately impaired in decision making skills for daily routine; was experiencing agitation/restlessness, anxiety about surroundings, and seek companionship (e.g. looking for a loved one). Review of Nursing Note, dated 11/04/2020 at 9:30 AM documented by LPN #2, revealed Resident #1 was confused and moderately impaired in decision-making skills for daily routine. Resident #1 wandered daily or almost daily, had sleep cycle issues up to 5 days a week, and exhibited behavior [CONDITION(S)] (e.g. restless walking patterns). At 5:30 PM, Registered Nurse (RN) #1 documented Resident #1 was experiencing agitation/restlessness. Review of Nursing Notes dated 11/05/2020, revealed LPN #2 documented Resident #1 was severely impaired in decision making skills for daily routine, and wandered daily or almost daily; and was experiencing agitation/restlessness, anxiety about surroundings, and impulsive behaviors. Resident #1 had sleep cycle issues daily or almost daily, and exhibited behavior [CONDITION(S)] (e.g. restless walking patterns). At 5:30 PM, LPN #1 documented Resident #1 was severely impaired in decision making skills for daily routine, wandered daily or almost daily, and posed significant risk and or intruded on others; and experienced agitation/restlessness, and anxiety about surroundings. Resident #1 had sleep cycle issues daily or almost daily, and exhibited behavior of [CONDITION(S)] (e.g. restless walking patterns). Review of Resident #1's behavior monitoring and interventions sheets for November 2020, revealed there were check boxes for wandering, yelling, and pacing; however, none of the boxes had been checked to indicate the behavior had occurred, what interventions were used, and if effective or not. Review of a Nursing Note, dated 11/18/2020 at 10:30 AM, revealed Resident #1 was transferred to another room. Review of a Nursing Note, dated 11/18/2020 at 10:22 PM, documented by Registered Nurse (RN) #1, revealed Resident #1 had Dementia, and he/she lifted the window in his/her room to create space to get out and was found sitting on a bench at the building next to the facility. The Resident had no injury, and vital signs were within normal limits. Review of a facility investigation, dated 11/18/2020, revealed staff identified Resident #1 was not in his/her room at approximately 9:50 PM, and noted the resident's window was open and the screen was gone from window. Further review of the investigation revealed Resident #1 was last seen around 9:00 PM, had eloped through an unsecured window, and was found at a facility (hotel) next door. Review of timeanddate.com website, revealed the temperature was 36 degrees Fahrenheit, and clear, on 11/18/2020 at 9:15 PM - 9:35 PM, and 42 degrees and clear at 9:55 PM. Observation on 01/27/2021, of the hotel that Resident #1 was found at on 11/18/2020, revealed the hotel was a six minute walk from the LTC facility. The building was located near a very busy four (4)-lane highway between two (2) busy intersections in a high traffic area. In addition, there was an enclosed gate housing an in-ground covered pool. Attempts to interview CNA #15 (prior shift CNA) on 01/29/2021 at 12:48 PM and 02/04/21 at 12: 09 PM, were unsuccessful due to statement of voicemail not set up. Interview on 02/23/2021 at 4:58 PM, with the Administrator, revealed the number provided was the only available number for CNA #15 and the CNA was no longer employed at the facility. Interview with Certified Nurse Aide (CNA) #1, on 01/29/2021 at 10:48 AM and on 02/01/2021 at 8:38 AM, revealed she received shift report on the evening of 11/18/2020 at around 9:00 PM, from CNA 15. CNA #1 stated CNA #15 reported to her that Resident #1 was incontinent earlier in the evening, had urinated on self, did not understand he/she was in a nursing home, and was asleep. She further revealed after receiving report she obtained Resident #1's vitals around 9:05 PM - 9:10 PM and resident was in bed. Continued interview revealed around 9:45 PM-10:00 PM, CNA #3 and herself began their first round (incontinent care of residents), and when they opened Resident #1's room door, they observed the resident was not in the bed or in the bathroom. She stated they noticed the window was open and screen was out, so they informed RN #1. CNA #1 further revealed Resident #1 wandered around the facility and entered other resident rooms. She stated sometimes the CNA's would sometimes sit with him/her a while until relaxed and periodically checked on the resident; but at that time the resident was in another room and staff were able to see the resident. She stated Resident #1 had times when he/she did not remember things, would not talk, and would get up, wander around, and say something about going to the store to go buy food or groceries. Interview on 02/23/2021 at 8:35 PM, with CNA #3, revealed Resident #1 had sundowners and wandered around the night of 11/18/2020 and she had redirected resident to his/her room. CNA #3 stated the resident was scared that day due to his/her roommate being sent out and had stated he/she had to get out of there and the resident was moved to the room that he/she had eloped from. Interviews with RN #1, on 01/27/2021 at 3:03 PM, and on 02/01/2021 at 2:28 PM, revealed on the day Resident #1 eloped, the Resident was going in/out of rooms and she had redirected resident to his/her room several times that night while she was passing medication. She stated Resident #1 told staff he/she thought he/she was in jail. RN #1 stated the resident was known to put on coat and shoes in the past, and stated he/she wanted to go to church. Further interview with RN #1 on 02/24/2021 at 4:28 PM, revealed she was not aware that Resident #1 had been upset that day. She stated the Resident was wandering around and she had to redirect him/her several times that night. She revealed she was made aware the window in Resident #1's room was raised and Resident #1 was missing. RN #1 stated the staff searched for the resident and went outside calling his/her name. She revealed staff brought the resident back to the facility when he/she was found, the resident was placed on 1:1, and she informed the DON and Administrator of the elopement. RN #1 stated the resident was wearing long sleeves, and sneakers and it was cold outside. RN #1 further stated the resident had sundowners, wandered every day and was sometimes easy to direct and sometimes not, would be upset one day then not the next, and wandered in/out of resident rooms. Interview with CNA #4, on 01/29/2021 at 11:23 AM, revealed she worked with Resident #1 and the resident had dementia and is sometimes there and sometimes not. CNA #4 stated the resident wandered a lot, and would state he/she had to go places, do things, and would pack things and gather belongings. CNA #4 further revealed Resident #1 would get frustrated with staff when redirected because he/she looked at it as being told what to do. Continued interview revealed the resident would have to be redirected two to three (2-3) times a day and would pack his/her things when adamant that he/she had to go somewhere and would put on his/her jacket, shoes and head to the door. CNA #4 stated this would mainly happen when there was a lot of commotion going on such as tray pass at mealtime. Interview with Licensed Practical Nurse (LPN) #1, on 01/29/2021 at 11:39 AM and 12:07 PM; and, on 02/11/2021 at 10:47 AM, revealed Resident #1 would get very confused not knowing date, time, and location. LPN #1 stated the resident would try to go out the door to go home, and tried to leave thinking his/her room was his/her apartment. LPN #1 further stated the resident would bag things up, set bag by the door, and come to the nurse's station and say he/she was going somewhere. LPN #1 stated Resident #1 wanted to leave all the time, to go to the store, to his/her daughters and that kind of thing. She revealed the resident had tinkered with the windows prior to elopement. LPN #1 stated staff would redirect the resident and reiterate where his/her room was located when these behaviors occurred. Interview with LPN #2, on 01/30/2021 at 9:50 AM, revealed Resident #1 would say that he/she was going to his/her car, and would have a coat on and staff would have to remind the resident that he/she was staying at the facility. She stated the resident had sundowners. LPN #2 further stated when the resident was first admitted to the facility he/she would put a coat on to leave. She stated if a resident was exit seeking, the resident was always put on 1:1 till the behavior ended. Interviews with RN #3, on 01/31/2021 at 8:17 AM, 02/01/2021 at 12:30 PM, and 02/10/2021 at 9:44 AM, revealed Resident #1 would pack/unpack belongings when first admitted to the facility but did not think he/she had done it since the elopement. RN #3 stated every day around 3:00 PM, Resident #1 would get his/her jacket, hat, and shoes then make a statement that he/she was leaving, and had to go home, and staff would have to redirect the resident, and sometimes he/she said he/she was going somewhere else or going to apartment. Interview on 01/27/2021 at 11:40 and 4:00 PM, with the Maintenance Director, revealed the window Resident #1 had crawled out of had been placed in August 2020. He stated the window flipped open and could be raised as well but had not been secured shut, till after the 11/18/2020 elopement. He revealed there were some windows that had faulty adhesive in securing the window to the framework of the window. Further interview with Maintenance Director revealed the distance to the neighboring hotel when stepped off with a size 11 men's shoe was approximately 330 feet from where Resident #1 crawled out of his/her window. Interview with Assistant Director of Nursing (ADON), on 01/29/2021 at 12:38 PM, revealed the management of behaviors to include exit seeking was dependent on what distracted a resident. She stated the facility expected staff to place a resident on 1:1 if exit seeking, and should stay on 1:1 until discussed with DON, herself and physician. Additionally, the ADON stated staff called Resident #1's family so he/she could hear a familiar voice and calm him/her. She further revealed if a resident was packing things up, Administrative staff should be notified because they need to be alerted, so resident could be assessed to find out why exit seeking. Interview on 02/25/2021 at 12:41 PM, with Director of Nursing (DON), revealed all residents were checked every two hours (q2h) or more if needed. She stated if the resident was a resident that was up and moving, they should be in eye sight to see what they need. Interview with the Administrator, on 02/25/2021 at 8:25 AM, revealed staff were to be alert for any changes in residents and report the change and follow-up per company policy. **The facility implemented the following to remove the Immediate Jeopardy: 1. Review of General Note, dated 11/18/2020 at 10:22 PM by RN #1, revealed Resident #1 placed on 1:1 following elopement from window. 2. The Licensed Nurse completed a head count of residents in the facility at 10:05 PM on 11/18/2020. All residents (39 of 39) were accounted for. 3. All exit doors and windows were checked, on 11/18/2020 between 10:05 PM and midnight, by the Licensed Nurse and the Certified Nurse's Assistant and all doors/windows were working properly. 4. All windows were secured by screw to open 2 inches on 11/19/2020 by the Maintenance Director. 5. On 11/18/2020 at 10:22 PM, the RN completed an assessment of Resident #1 to include vital signs taken, BP 140/80, P 90, RR 22, T 96.8, Pulse Ox 96% which were in usual range for Resident #1. Resident was noted by the RN to be able to move all extremities without complaints of pain or discomfort. 6. The Physician was notified at 12:36 AM on 11/19/20, and Responsible Party was notified at approximately 10:00 PM on 11/18/2020; by RN #1. 7. On 11/19/2020 at 11:31 AM, Resident was removed from 1:1 after the IDT had met and a virtual appointment with the resident's Nurse Practitioner and a Psychiatric consult deeming resident to be safe to remove from 1:1. 8. The Social Service Director completed a BIMS assessment on 11/19/2020. The BIMS at that time was a 13. 9. The Center Executive Director (CED) completed an updated Elopement Evaluation for Resident #1 on 11/19/2020. 10. Resident #1's care plan/Kardex was updated on 11/18/2020 by Center Nurse Executive (CNE) to include review of elopement evaluation and one to one (1:1) supervision. 11. All residents residing in the center (39 of 39) were reassessed for elopement risk starting on 11/18/2020 and completed on 11/19/2020 by the Center Nurse Executive to identify any new elopement risks and the care plan were revised at that time. The Elopement Risk Evaluations for at risk residents, care plans and Kardexes (5 of 5) were revised and updated by the licensed nurse with no additional residents identified to be an elopement risk. 12. The Center Nurse Executive, the Assistant Director of Nursing, the Business Office Manager, Therapy Manager and Human Resource Manager were reeducated by the Center Executive Director on 11/19/2020. The education consisted of center elopement policies and procedures to include prevention and management, supervision and redirection of residents at risk for elopement, and following and revision of the care plan with any occurrences. A posttest was completed to validate understanding of 100%. 13. On 11/19/2020, the Assistant Director of Nursing, Center Nurse Executive, Center Executive Director, Business office Manager, Therapy Manager and Human Resources re-educated all other staff. Re-education included Center policies on elopement prevention & management, supervision needs including redirection of residents assessed at risk for elopement, the facility policy for following each resident's person-centered plan of care/Kardex regarding residents at risk for elopement to include revision of care plan with occurrences if necessary. 14. Staff and contract employees not available would be provided reeducation and complete posttest upon day of return to work before providing resident care by Center Nurse Executive, Resource Nurse, Unit Managers and or License Nurses. 15. All newly hired employees and contract employees would have elopement education and complete posttest during orientation by the Center Nurse Executive, Resource Nurse, Unit Managers and or License Nurses. 16. Elopement drills were completed one (1) per day times (x) three (3) days with no concerns identified and ongoing thereafter as determined by the Quality Assurance Performance Improvement (QAPI) Committee. 17. Window audits were initiated on 11/25/2020, by the Maintenance Director. Window audits were completed once daily x 2 weeks, then 3 x per week for 2 weeks, then weekly x 8 weeks, then every other week x 8 weeks, then monthly x 1 month, then ongoing thereafter as determined by QAPI committee. Further need for continued audits will be reviewed and determined by the monthly QAPI Committee. 18. Interviews of three (3) staff members regarding interventions on care plan regarding residents who were at risk for elopement would be completed by CNE, CED, charge nurses, Unit Managers daily x 2 weeks including weekends and holidays, then 3 times per week x 2 weeks, then weekly x 8 weeks, then every other week x 8 weeks, then monthly x 1 month, then ongoing thereafter, as determined by QAPI committee. 19. An AdHoc Quality Assurance Performance Improvement Committee was held on 11/19/2020, with the Medical Director for recommendations in developing the action plan including audits, reeducation, and compliance monitors for residents at risk for elopement and prevention methods. 20. Results of elopement audits/drills, staff interviews and care plan revisions of newly identified residents at risk would be reviewed daily x 2 weeks including weekends, then 3 times per week x 2 weeks, then weekly x 8 weeks, then every other week x 8 weeks, then monthly x 1 month, then ongoing thereafter as determined by QAPI committee by the Administrator, Center Nurse Executive or Assistant Director of Nursing. 21. Elopement audits/drills, staff interviews and care plan revision review audits would be brought to the Quality Assurance Performance Improvement Committee by the Center Nurse Executive or Assistant Director of Nursing, Center Executive Director monthly x 6 months for any additional follow up and/or in-servicing until the issue was resolved and ongoing thereafter as determined by the QAPI committee which includes Administrator, Director of Nursing, Assistant director of Nursing, Admissions and Marketing Coordinator, Activities Director, Social Services Director, Clinical Reimbursement Manager, Maintenance Director, Nurse Practice Educator, and Nutrition Services Director. **The State Survey Agency validated the corrective action taken by the facility as follows: 1. Interview with CNA #2 on 01/28/2021 at 6:22 AM revealed he provided 1:1 supervision of Resident #1, till 9:00 AM on 11/19/2020, following the resident's elopement on 11/18/2020. Interview with RN #1, on 02/24/2021 at 4:34 PM, revealed she designated CNA #2 to provide 1:1 supervision of Resident #1 following his/her elopement from the facility on 11/18/2020. 2. Review of a facility listing of residents signed by RN #1, dated 11/18/2020 at 10:05 PM, revealed all residents were counted and accounted for. Interview with ADON, on 02/25/2021 at 3:32 PM, revealed a head count of residents was completed after the elopement of Resident #1, on the night of 11/18/2020. 3. Review of a signed document, dated 11/18/2020 by CNA #3 and 11/19/2020 at midnight, by RN #3, revealed all windows in the facility were secure. Interview on 02/25/2021 at 12:41 with DON, revealed windows were checked for security immediately following the elopement. 4. Review of census sheet of residents, dated 11/19/2020 revealed all windows in proper working order and secure per Maintenance Director. Interview on 01/27/2021 on 11:40 and 4:00 PM, with the Maintenance Director revealed the windows were secured on the morning of 11/19/2020. 5. Review of Progress Notes, dated 11/18/2020 at 10:22 PM by RN #1, revealed an assessment of Resident #1 revealed vital signs were BP 140/80, P 90, RR 22, T 96.8, and Pulse Ox 96%, which were in usual range for Resident #1. Resident was noted by the RN to be able to move all extremities without complaints of pain or discomfort. Review of Skin Assessment, dated 11/18/2020 at 10:15 PM, revealed no skin injury or wounds after elopement. Interview on 02/24/2021 at 4:28 PM with RN #1, revealed she had assessed Resident #1 when he/she returned to the facility after elopement. 6. Review of Nursing Notes dated 11/19/2020, revealed the Nurse Practitioner and Psych Physician were notified of Resident #1's elopement on 11/19/2020. 7. Review of a Progress Note revealed that IDT had met, on 11/19/2020, and decided to remove Resident #1 from 1:1. Review of Behavioral Health Psychiatric Consult, dated 11/19/2020, revealed consult with psychiatrist. 8. Review of 11/19/2020 Section C -Cognitive Patterns of Resident #1 completed by Social Service Director, revealed the resident had a BIMS of thirteen (13). Interview on 02/23/2021 at 5:50 PM, with the SSD, revealed he had completed Resident #1's follow-up BIMS on 11/19/2020. He stated the resident scored 13 (cognition intact). 9. Record review revealed an elopement assessment was completed on Resident #1 on 11/19/2020. 10. Review of Resident#1's Care Plan/Kardex revealed they were updated, on 11/18/2020 by the DON, to include review of elopement evaluation and one to one (1:1) supervision. 11. Review of AOC binder revealed documentation that all residents in the facility were reassessed for elopement risk starting on 11/18/2020 and completed on 11/19/2020 by the DON. Interview on 02/25/2021 at 12:41, with the DON, revealed all resident were reassessed for elopement risks. 12. Review of the facility education and listing of staff revealed the Center Nurse Executive, the Assistant Director of Nursing, the Business Office Manager, Therapy Manager and Human Resource Manager were reeducated by the Center Executive Director, on 01/19/2021, regarding the center elopement policies and procedures to include prevention and management, supervision and redirection of residents at risk for elopement, and following and revision of the care plan with any occurrences. In addition, further review revealed a posttest was completed to validate understanding of 100%. Interviews on 02/25/2021 with Therapy Director, at 9:41 AM, DON at 12:41 PM, and ADON at 3:32 PM, revealed they were educated on the center elopement policies and procedures to include prevention and management, supervision and redirection of residents at risk for elopement, and following and revision of the care plan with any occurrences. They stated they completed a posttest and scored 100%. 13. Review of a list of staff with names marked out, revealed 36 of 38 Active Genesis employees, 6 of 6 Rehab employees, 5 of 5 Housekeeping employees, and 7 of 7 Dietary employees, received the above education and were administered posttests, by CED, CNE, ADON, Therapy Manager, and Account Manager on 11/18/2020-11/24/2020. Interviews on 02/25/2021 with Therapy Director at 9:41 AM, DON at 12:41 PM, and ADON at 3:32 PM, revealed they started educating staff the night of the elopement on 11/18/2020 and continued on 11/19/2020. Interviews on 02/23/2021 with LPN #2, at 10:46 AM, LPN #4 at 3:31 PM; LPN #1 at 4:45 PM, CNA #3 at 8:35 PM; on 02/24/21 with CNA #8 at 2:20 PM , Hospitality Aide #1 at 2:25 PM , CNA #12 at 2:45 PM, CNA #13 at 2:45 PM, Business Office Manager (BOM) at 2:35 PM , CNA #14 at 2:40 PM, Account Manager of Housekeeping at 3:00 PM, Night Cook at 3:15 PM, and Medical Records Personnel at 3:10 PM; and, on 02/25/21 with Account Manager of Dietary at 11:09 AM and CNA #10 at 12:16 PM; revealed they were educated on Center policies on elopement prevention & management, supervision needs including redirection of residents assessed at risk for elopement, the facility policy for following each resident's person-centered plan of care/Kardex regarding residents at risk for elopement to include revision of care plan with occurrences if necessary. They stated they also completed a post-test. 14. Review of listing of residents revealed all staff were educated with the exception of one (1) that was on leave of absence (LOA). 15. The facility list of new hires revealed there were six (6) new employees and none of them had started to work at this time. 16. Review of the AOC binder revealed an elopement drill was completed on 11/18/2020, by the Administrator, Director of Nursing and Assistant Director of Nursing. Review of AOC binder revealed a calendar with documentation drills were completed daily time three days and monthly in November and December 2020, and January and February 2021, on varying shifts. There were no concerns identified. Interviews on 02/23/2021 with CNA #3 at 8:35 PM, LPN #4 at 8:31 AM, MDS Coordinator at 4:34 PM, LPN #1 at 4:45 PM, and on 02/25/2021 with CNA #10 at 12:16 PM, revealed elopement drills were completed at the facility after the elopement of Resident #1 on 11/18/2020. 17. Review of window audits revealed audits were completed by Maintenance Director, and Director of Nursing (DON) per the AOC from 11/25/2020 to 02/23/2021 with no identified concerns identified. Interview on 02/25/2021 at 11:00 AM, with Maintenance, revealed he checked the alarms battery to see if in working order and raised the windows. 18. Review of AOC binder revealed interviews of staff regarding care plans for residents at risk questionnaires were completed by staff daily x 2 weeks including weekends and holidays, then 3 times per week x 2 weeks, then weekly x 8 weeks, and had completed the first set of interviews for every other week, on 02/13/2021. Interviews on 02/23/2021 with CNA #3 at 8:35 PM and LPN #4 at 8:31 PM; and, on 02/25/2021 with Director of Therapy at 9:41 AM, revealed interviews of staff regarding risk questionnaires were completed by administrative staff. 19. Review of AOC binder revealed an ad Hoc meeting was held on 11/19/2020 to discuss recommendations in developing an action plan including audits, reeducation, compliance monitors for residents at risk for elopement and prevention methods after the elopement from the facility by Resident #1 on 11/18/2020. Interviews on 02/25/2021 with Administrator at 3:00 PM and Medical Director at 12:57 PM revealed they had an Ad Hoc meeting on 11/19/2021 to develop an action plan which included [TRUNCATED]

Based on interview, record review, and facility policy review, it was determined the facility failed to review and revise the comprehensive care plan for one (1) of three (3) sampled residents (Residents #1). Resident #1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/22/2020, the facility assessed the resident to be at risk for elopement and used a Wanderguard device for the resident, which was initiated on 10/21/20. Resident #1 had behaviors of trying to go out the door, packing his/her items and sitting by door; and voicing he/she wanted to leave/go home. In addition, staff had to redirect the resident several times due to going in and out other residents' rooms on 11/18/2020, prior to the elopement. However, the facility failed to revise the resident's care plan to increase his/her supervision. On the evening of 11/18/2020, staff could not locate Resident #1 in his/her room at approximately 9:50 PM. Staff noted Resident #1's window was open and the window screen was gone. Resident #1 had crawled out an unsecured window in his/her room and went to a neighboring hotel. The hotel was located near a busy four (4) lane highway between (2) two intersections, in a high traffic area. The resident was last seen at the facility at approximately 9:10 PM. Staff found Resident #1 at the hotel after 10 PM. The facility's failure to review and revise the care plan for a resident exhibiting exit seeking behaviors to ensure the resident received adequate supervision and monitoring has caused or was likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 02/11/2021 and determined to exist on 11/18/2020. The facility was notified of the Immediate Jeopardy on 02/11/2021. An acceptable Allegation of Compliance (AoC) was received on 02/22/21. The State Survey Agency validated the AoC and determined Immediate Jeopardy was removed on 02/25/21. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility policy titled, Elopement of Patient, last revised May 2014 revealed residents would be evaluated for elopement risk upon admission, readmission, quarterly and with a change in condition. Residents determined to be at risk would receive appropriate interventions to reduce risk and minimize injury. Residents identified, as at risk would have an elopement care plan developed with individual risk factors, and patterns identified and addressed within the care plan. Review of the facility policy titled, Person Centered Care Plan last revised 07/01/2019, revealed the care plan would be reviewed and revised as needed to reflect the response to care and the changing needs and goals. Record review revealed the facility admitted Resident #1 on 10/16/2020 with diagnoses, which included Unspecified Dementia without Behavioral Disturbance, Unspecified [CONDITION(S)] not due to a substance or known Physiological Condition, Major Depressive Disorder, Recurrent Unspecified;, Cognitive Communication Deficit, Muscle Weakness, Weakness, and Unsteadiness on Feet. Review of an Admission Minimum Data Set (MDS) assessment, dated 10/23/2020 revealed staff assessed Resident #1's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of three (3) which indicated the resident was not interviewable. Further review of the MDS revealed the resident had signs and symptoms of [CONDITION(S)], inattention, difficulty in focusing attention, and disorganized thinking that fluctuated. In addition, the resident had behaviors of delusions and wandering that placed the resident at significant risk of getting to a potentially dangerous place, with a wanderguard used daily. Review of Resident #1's Comprehensive Care Plan for Elopement related to wandering/exit seeking, initiated 10/21/2020, revealed interventions to approach resident with redirection in a calm manner, be alert for any behaviors related to exit seeking, give verbal cues using resident details such as his/her daughter's name and using his/her full name and city/county location to assist with reassurance of safe belonging, and redirect resident when needed related to cognition level/confusion. Further review revealed interventions for a symbol/clip art picture of resident choice placed at resident room and on door to reorient resident to his/her room, and wanderguard in place per orders. Interviews Certified Nurse Aide (CNA) #1, on 02/01/2021 at 8:38 AM; CNA #4 on 01/29/2021 at 11:23 AM; Licensed Practical Nurse (LPN) #1, on 01/27/2021 at 3:08 PM; and, with Registered Nurse (RN) #1, on 02/01/2021 at 2:28 PM; revealed staff were aware Resident #1 would pack things and leave by the door, dress to leave facility, state he/she was going somewhere, wander in/out of rooms, and tinker with the windows. However, further review of the care plan with staff revealed there were no revisions to the care plan to show the resident was known to having these behaviors and what action the staff were supposed to take if any of these behaviors occurred. In addition, review of care plan with staff revealed there was no documented evidence the resident was supposed to receive any increased supervision, when any of these behaviors occurred. Review of a Nursing Note, dated 11/18/2020 at 10:22 PM; facility investigation dated 11/18/2020; and, interviews with CNA #1, on 01/29/2021 at 10:48 AM and on 02/01/2021 at 8:38 AM; CNA #3 on 02/23/2021 at 8:35 PM; and, RN #1 on 01/27/2021 at 3:03 PM and on 02/01/2021 at 2:28 PM; revealed Resident #1 was wandering in and out of resident rooms on 11/18/20, and was last seen by staff in bed asleep at 9:00 PM. The staff identified Resident #1 was not in his/her room at approximately 9:50 PM and the Resident had lifted the unsecured window in his/her room to create space to get out, knocked out the screen, and eloped from the facility. The Resident was found sitting on a bench at the building (hotel) next door to the facility. The Resident had no injuries and vital signs were within normal limits. Interview on 02/08/2021 at 1:40 PM, with Licensed Practical Nurse (LPN #4), revealed nurses were able to put interventions in place for residents and interventions were gone over in the morning meeting. She stated if there was an elopement, the Director of Nursing (DON) and Administrator were notified and the DON or MDS nurse modified or corrected interventions. Interview on 02/06/2021 at 4:33 PM, with MDS Coordinator, revealed during the morning meetings the resident's nurse provided information to determine if any revisions to the care plan were needed. She stated they discussed interventions to put in place to minimize risks if a resident had any sort of special needs or anything out of the ordinary happened. MDS Coordinator revealed she made rounds on the hall and spoke to the staff about resident concerns and she was responsible for placing interventions on the care plan. She revealed if there was a shift in the activity of the resident, the floor nurse was able to place an intervention. Interview on 02/02/2021 at 9:52 AM, on 02/08/2021 at 1:52 PM and on 02/09/2021 at 2:59 PM with the Director Of Nursing (DON), revealed any floor nurse may place interventions on the care plan and the Administrative team (DON, ADON, MDS, Administrator, and therapy) went over care plans in the clinical morning meeting. The DON stated the care plan was resident specific, and the purpose of the care plan was to ensure continuity of care-so that staff would know the care for each resident. She further revealed if the resident was exhibiting exit specific behavior, the resident should be redirected, and if not successful, then placed on 1:1. She stated the resident would be on 1:1 supervision until the IDT (interdisciplinary team) met. Interview on 02/25/2021 at 8:25 AM, with the Administrator, revealed nurses were able to update and revise care plans and then the revision information went to the Administrative Team through the 24-hour report for morning meeting. The Administrator stated the Interdisciplinary team (IDT), which included the Administrator, DON, and ADON, reviewed the revisions. The Administrator further revealed MDS validated the care plan was accurate and if there were any changes that needed to be made, MDS made them at that time. **The facility implemented the following to remove the Immediate Jeopardy: 1. Review of General Note, dated 11/18/2020 at 10:22 PM by RN #1, revealed Resident #1 placed on 1:1 following elopement from window. 2. The Licensed Nurse completed a head count of residents in the facility at 10:05 PM on 11/18/2020. All residents (39 of 39) were accounted for. 3. All exit doors and windows were checked, on 11/18/2020 between 10:05 PM and midnight, by the Licensed Nurse and the Certified Nurse's Assistant and all doors/windows were working properly. 4. All windows were secured by screw to open 2 inches on 11/19/2020 by the Maintenance Director. 5. On 11/18/2020 at 10:22 PM, the RN completed an assessment of Resident #1 to include vital signs taken, BP 140/80, P 90, RR 22, T 96.8, Pulse Ox 96% which were in usual range for Resident #1. Resident was noted by the RN to be able to move all extremities without complaints of pain or discomfort. 6. The Physician was notified at 12:36 AM on 11/19/20, and Responsible Party was notified at approximately 10:00 PM on 11/18/2020; by RN #1. 7. On 11/19/2020 at 11:31 AM, Resident was removed from 1:1 after the IDT had met and a virtual appointment with the resident's Nurse Practitioner and a Psychiatric consult deeming resident to be safe to remove from 1:1. 8. The Social Service Director completed a BIMS assessment on 11/19/2020. The BIMS at that time was a 13. 9. The Center Executive Director (CED) completed an updated Elopement Evaluation for Resident #1 on 11/19/2020. 10. Resident #1's care plan/Kardex was updated on 11/18/2020 by Center Nurse Executive (CNE) to include review of elopement evaluation and one to one (1:1) supervision. 11. All residents residing in the center (39 of 39) were reassessed for elopement risk starting on 11/18/2020 and completed on 11/19/2020 by the Center Nurse Executive to identify any new elopement risks and the care plan were revised at that time. The Elopement Risk Evaluations for at risk residents, care plans and Kardexes (5 of 5) were revised and updated by the licensed nurse with no additional residents identified to be an elopement risk. 12. The Center Nurse Executive, the Assistant Director of Nursing, the Business Office Manager, Therapy Manager and Human Resource Manager were reeducated by the Center Executive Director on 11/19/2020. The education consisted of center elopement policies and procedures to include prevention and management, supervision and redirection of residents at risk for elopement, and following and revision of the care plan with any occurrences. A posttest was completed to validate understanding of 100%. 13. On 11/19/2020, the Assistant Director of Nursing, Center Nurse Executive, Center Executive Director, Business office Manager, Therapy Manager and Human Resources re-educated all other staff. Re-education included Center policies on elopement prevention & management, supervision needs including redirection of residents assessed at risk for elopement, the facility policy for following each resident's person-centered plan of care/Kardex regarding residents at risk for elopement to include revision of care plan with occurrences if necessary. 14. Staff and contract employees not available would be provided reeducation and complete posttest upon day of return to work before providing resident care by Center Nurse Executive, Resource Nurse, Unit Managers and or License Nurses. 15. All newly hired employees and contract employees would have elopement education and complete posttest during orientation by the Center Nurse Executive, Resource Nurse, Unit Managers and or License Nurses. 16. Elopement drills were completed one (1) per day times (x) three (3) days with no concerns identified and ongoing thereafter as determined by the Quality Assurance Performance Improvement (QAPI) Committee. 17. Window audits were initiated on 11/25/2020, by the Maintenance Director. Window audits were completed once daily x 2 weeks, then 3 x per week for 2 weeks, then weekly x 8 weeks, then every other week x 8 weeks, then monthly x 1 month, then ongoing thereafter as determined by QAPI committee. Further need for continued audits will be reviewed and determined by the monthly QAPI Committee. 18. Interviews of three (3) staff members regarding interventions on care plan regarding residents who were at risk for elopement would be completed by CNE, CED, charge nurses, Unit Managers daily x 2 weeks including weekends and holidays, then 3 times per week x 2 weeks, then weekly x 8 weeks, then every other week x 8 weeks, then monthly x 1 month, then ongoing thereafter, as determined by QAPI committee. 19. An AdHoc Quality Assurance Performance Improvement Committee was held on 11/19/2020, with the Medical Director for recommendations in developing the action plan including audits, reeducation, and compliance monitors for residents at risk for elopement and prevention methods. 20. Results of elopement audits/drills, staff interviews and care plan revisions of newly identified residents at risk would be reviewed daily x 2 weeks including weekends, then 3 times per week x 2 weeks, then weekly x 8 weeks, then every other week x 8 weeks, then monthly x 1 month, then ongoing thereafter as determined by QAPI committee by the Administrator, Center Nurse Executive or Assistant Director of Nursing. 21. Elopement audits/drills, staff interviews and care plan revision review audits would be brought to the Quality Assurance Performance Improvement Committee by the Center Nurse Executive or Assistant Director of Nursing, Center Executive Director monthly x 6 months for any additional follow up and/or in-servicing until the issue was resolved and ongoing thereafter as determined by the QAPI committee which includes Administrator, Director of Nursing, Assistant director of Nursing, Admissions and Marketing Coordinator, Activities Director, Social Services Director, Clinical Reimbursement Manager, Maintenance Director, Nurse Practice Educator, and Nutrition Services Director. **The State Survey Agency validated the corrective action taken by the facility as follows: 1. Interview with CNA #2 on 01/28/2021 at 6:22 AM revealed he provided 1:1 supervision of Resident #1, till 9:00 AM on 11/19/2020, following the resident's elopement on 11/18/2020. Interview with RN #1, on 02/24/2021 at 4:34 PM, revealed she designated CNA #2 to provide 1:1 supervision of Resident #1 following his/her elopement from the facility on 11/18/2020. 2. Review of a facility listing of residents signed by RN #1, dated 11/18/2020 at 10:05 PM, revealed all residents were counted and accounted for. Interview with ADON, on 02/25/2021 at 3:32 PM, revealed a head count of residents was completed after the elopement of Resident #1, on the night of 11/18/2020. 3. Review of a signed document, dated 11/18/2020 by CNA #3 and 11/19/2020 at midnight, by RN #3, revealed all windows in the facility were secure. Interview on 02/25/2021 at 12:41 with DON, revealed windows were checked for security immediately following the elopement. 4. Review of census sheet of residents, dated 11/19/2020 revealed all windows in proper working order and secure per Maintenance Director. Interview on 01/27/2021 on 11:40 and 4:00 PM, with the Maintenance Director revealed the windows were secured on the morning of 11/19/2020. 5. Review of Progress Notes, dated 11/18/2020 at 10:22 PM by RN #1, revealed an assessment of Resident #1 revealed vital signs were BP 140/80, P 90, RR 22, T 96.8, and Pulse Ox 96%, which were in usual range for Resident #1. Resident was noted by the RN to be able to move all extremities without complaints of pain or discomfort. Review of Skin Assessment, dated 11/18/2020 at 10:15 PM, revealed no skin injury or wounds after elopement. Interview on 02/24/2021 at 4:28 PM with RN #1, revealed she had assessed Resident #1 when he/she returned to the facility after elopement. 6. Review of Nursing Notes dated 11/19/2020, revealed the Nurse Practitioner and Psych Physician were notified of Resident #1's elopement on 11/19/2020. 7. Review of a Progress Note revealed that IDT had met, on 11/19/2020, and decided to remove Resident #1 from 1:1. Review of Behavioral Health Psychiatric Consult, dated 11/19/2020, revealed consult with psychiatrist. 8. Review of 11/19/2020 Section C -Cognitive Patterns of Resident #1 completed by Social Service Director, revealed the resident had a BIMS of thirteen (13). Interview on 02/23/2021 at 5:50 PM, with the SSD, revealed he had completed Resident #1's follow-up BIMS on 11/19/2020. He stated the resident scored 13 (cognition intact). 9. Record review revealed an elopement assessment was completed on Resident #1 on 11/19/2020. 10. Review of Resident#1's Care Plan/Kardex revealed they were updated, on 11/18/2020 by the DON, to include review of elopement evaluation and one to one (1:1) supervision. 11. Review of AOC binder revealed documentation that all residents in the facility were reassessed for elopement risk starting on 11/18/2020 and completed on 11/19/2020 by the DON. Interview on 02/25/2021 at 12:41, with the DON, revealed all resident were reassessed for elopement risks. 12. Review of the facility education and listing of staff revealed the Center Nurse Executive, the Assistant Director of Nursing, the Business Office Manager, Therapy Manager and Human Resource Manager were reeducated by the Center Executive Director, on 01/19/2021, regarding the center elopement policies and procedures to include prevention and management, supervision and redirection of residents at risk for elopement, and following and revision of the care plan with any occurrences. In addition, further review revealed a posttest was completed to validate understanding of 100%. Interviews on 02/25/2021 with Therapy Director, at 9:41 AM, DON at 12:41 PM, and ADON at 3:32 PM, revealed they were educated on the center elopement policies and procedures to include prevention and management, supervision and redirection of residents at risk for elopement, and following and revision of the care plan with any occurrences. They stated they completed a posttest and scored 100%. 13. Review of a list of staff with names marked out, revealed 36 of 38 Active Genesis employees, 6 of 6 Rehab employees, 5 of 5 Housekeeping employees, and 7 of 7 Dietary employees, received the above education and were administered posttests, by CED, CNE, ADON, Therapy Manager, and Account Manager on 11/18/2020-11/24/2020. Interviews on 02/25/2021 with Therapy Director at 9:41 AM, DON at 12:41 PM, and ADON at 3:32 PM, revealed they started educating staff the night of the elopement on 11/18/2020 and continued on 11/19/2020. Interviews on 02/23/2021 with LPN #2, at 10:46 AM, LPN #4 at 3:31 PM; LPN #1 at 4:45 PM, CNA #3 at 8:35 PM; on 02/24/21 with CNA #8 at 2:20 PM , Hospitality Aide #1 at 2:25 PM , CNA #12 at 2:45 PM, CNA #13 at 2:45 PM, Business Office Manager (BOM) at 2:35 PM , CNA #14 at 2:40 PM, Account Manager of Housekeeping at 3:00 PM, Night Cook at 3:15 PM, and Medical Records Personnel at 3:10 PM; and, on 02/25/21 with Account Manager of Dietary at 11:09 AM and CNA #10 at 12:16 PM; revealed they were educated on Center policies on elopement prevention & management, supervision needs including redirection of residents assessed at risk for elopement, the facility policy for following each resident's person-centered plan of care/Kardex regarding residents at risk for elopement to include revision of care plan with occurrences if necessary. They stated they also completed a post-test. 14. Review of listing of residents revealed all staff were educated with the exception of one (1) that was on leave of absence (LOA). 15. The facility list of new hires revealed there were six (6) new employees and none of them had started to work at this time. 16. Review of the AOC binder revealed an elopement drill was completed on 11/18/2020, by the Administrator, Director of Nursing and Assistant Director of Nursing. Review of AOC binder revealed a calendar with documentation drills were completed daily time three days and monthly in November and December 2020, and January and February 2021, on varying shifts. There were no concerns identified. Interviews on 02/23/2021 with CNA #3 at 8:35 PM, LPN #4 at 8:31 AM, MDS Coordinator at 4:34 PM, LPN #1 at 4:45 PM, and on 02/25/2021 with CNA #10 at 12:16 PM, revealed elopement drills were completed at the facility after the elopement of Resident #1 on 11/18/2020. 17. Review of window audits revealed audits were completed by Maintenance Director, and Director of Nursing (DON) per the AOC from 11/25/2020 to 02/23/2021 with no identified concerns identified. Interview on 02/25/2021 at 11:00 AM, with Maintenance, revealed he checked the alarms battery to see if in working order and raised the windows. 18. Review of AOC binder revealed interviews of staff regarding care plans for residents at risk questionnaires were completed by staff daily x 2 weeks including weekends and holidays, then 3 times per week x 2 weeks, then weekly x 8 weeks, and had completed the first set of interviews for every other week, on 02/13/2021. Interviews on 02/23/2021 with CNA #3 at 8:35 PM and LPN #4 at 8:31 PM; and, on 02/25/2021 with Director of Therapy at 9:41 AM, revealed interviews of staff regarding risk questionnaires were completed by administrative staff. 19. Review of AOC binder revealed an ad Hoc meeting was held on 11/19/2020 to discuss recommendations in developing an action plan including audits, reeducation, compliance monitors for residents at risk for elopement and prevention methods after the elopement from the facility by Resident #1 on 11/18/2020. Interviews on 02/25/2021 with Administrator at 3:00 PM and Medical Director at 12:57 PM revealed they had an Ad Hoc meeting on 11/19/2021 to develop an action plan which included audits, reeducation, and compliance monitors, for residents at risk for elopement and prevention methods. 20. Review of the documentation of the reviews of the elopement drills, audits/drills, staff interviews and care plan revisions of newly identified residents at risk revealed the reviews were completed per the AOC. Interviews on 02/25/2021 with Administrator/Center Executive Director (CED) at 3:00 PM, DON (CNE) at 12:41 PM, and ADON at 3:32 PM, revealed the audits/drills and care plans were reviewed daily in the morning meeting. In addition, interview on 02/23/21 at 4:34 PM with MDS Coordinator revealed a review of the care plans was completed in the daily meeting. 21. Interview on 02/25/2021 with Administrator/Center Executive Director (CED) at 3:00 PM, DON (CNE) at 12:41 PM, and ADON at 3:32 PM; and, on 02/25/2021 with Medical Director at 12:57 PM revealed they would go over the components of the AOC during the monthly meetings that were held in November, October, and December of 2020 and January 2021. Review of QAPI Note, dated 02/23/2021, related to windows, window alarms, and audits/follow-up revealed: 1. to leave window alarms on all windows unable to be screwed to prevent from opening and increase alarm checks to twice daily. 2) remove all window alarms from window that are secured from opening up 2 and opening inside the room by 02/24/2021. 3) increase audit of alarm/window frequency to twice daily beginning 02/23/2021. In addition, additional procedures initiated for window security on 02/24/2021 were for concrete screws to be placed in questioned windows by maintenance with monitoring/alert discontinued per QAPI as all windows were secured X2 to not open more than 2 in or moved up more than 2.

Based on observation, interview, record review, Personal Protective Equipment placard review, and facility policy review, it was determined the facility failed to ensure staff wore the appropriate Personal Protective Equipment (PPE) and disposed of used PPE appropriately, to prevent the spread of COVID 19. Observations revealed a staff member entered a resident's room who was on contact and airborne precautions without utilizing the required PPE, per facility policy. In addition, further observation revealed a staff member exited a resident's room, who was on contact and airborne precautions with a rolled up gown in hand. However, there was no trash bin outside of the resident's room, to prevent the staff having to walk down the hall to dispose of the gown. The findings include: Review of the facility's policy titled, Infection Control Policies and Procedures, dated 12/21/2020, revealed in addition to standard precautions, contact and airborne precautions will be implemented for patients suspected or confirmed to have COVID-19, based on the Centers for Disease Prevention and Control (CDC) guidance to prevent the development and transmission of COVID-19. Review of the facility's policy titled, Personal Protective Equipment, dated 11/09/2020, revealed different PPE was used depending on patient/resident health status and unit type. Please refer to Which PPE Do I Use? poster/handout for selecting the correct PPE for each setting. Review of the facility's Which PPE Do I Use? poster, not dated revealed staff should wear gown (patient specific), N95/KN95 respirator, and a face shield in residents' rooms. A universal mask may be worn for the shift, and face shield may be changed to goggles outside of the room and worn throughout the shift. Review of Personal Protective Equipment (PPE) Placard, on the doors of residents who go out to [MEDICAL TREATMENT], and/or were new admits revealed the following PPE was required for staff to wear upon entering room: N95/approved KN95 respirator, gown, face shield, and gloves upon entering their room. Further review revealed to change gown after each patient contact. 1. Observation on 01/28/2021 at approximately 9:40 AM, revealed Certified Nursing Assistant (CNA) #7 came out of a [MEDICAL TREATMENT] resident's room which had the PPE Placard, only wearing goggles and mask. CNA #7 was not wearing a gown, or gloves. Interview with CNA #7, on 01/28/2021 at 9:45 AM revealed she did not think about PPE when the resident asked her for something, and she just went in the room and provided it to the resident. CNA #7 stated she was educated to wear the necessary PPE into the room upon entering but she had not. 2. Observation on 01/28/2021 at 10:40 AM, revealed CNA #5 exited a resident's room which had a PPE Placard. The resident was a new admission. CNA #5 exited with a bundled up gown in her hands. Further observation revealed there was no trash can outside of the resident's room. CNA #5 was observed to walk down the hall to a [MEDICAL TREATMENT] resident's room and place the gown in the trash can outside of that room. Interview with CNA #5, on 01/28/2021 at 10:40 AM revealed there was no trash can available at the new admission resident's room so she had to take the gown down the hall to the other trash can. CNA #5 stated she had not been told of any outcome for going down the hall to another trash can. Interview, with the Assistant Director of Nursing/Infection Control Nurse (ADON/IFCN), on 01/27/2021 at 1:32 PM revealed staff should wear mask, goggles, face shield, gloves, gown, and N95 mask, when they enter residents' rooms, on contact/airborne precautions. She stated when staff exit the room, they should remove their gloves, and gown, then place them in the bin beside the door. Further interview revealed the face shield should be removed and sanitized. She stated there should have been a bin outside of the resident's door but housekeeping had taken them to sanitize and not replaced them during that time frame. Post survey interview with the ADON/IFCN, on 02/03/2021 at 9:41 AM revealed staff should have on an N95 mask anytime they go into an isolation room and it should be worn the entire shift regardless of the room. The ADON/IFCN stated the outcome of not wearing PPE in a room or going down the hall with a previously worn gown from a new admit room could cause the spread of COVID from resident to staff or staff to resident. The ADON/IFCN further revealed that cross contamination could be the outcome of a staff member going down the hall with a previously worn gown. She stated the nurses, DON, and she ensured PPE was being worn as needed. Further interview revealed they would do walk troughs periodically to ensure staff were wearing the appropriate PPE. Interview (Post Survey) on 02/03/2021 at 9:34 AM, with the Director of Nursing (DON) revealed the outcome for staff going into a room without PPE on and for staff walking up the hall with a previously worn gown in hand, was the transmission of an infection/disease to staff or other residents. Interview (Post Survey) on 02/03/2021 at 9:58 AM, with the Administrator revealed staff not wearing the appropriate PPE when entering residents' rooms, who were on transmission precautions, or carrying a gown down the hall that had been worn in one of those resident's rooms, could result in the transmission of infection.

Based on observation, interview and review of the facility's policies, it was determined the facility failed to store foods in accordance with professional standards for food service safety. Observations of the kitchen on 06/11/19 revealed frozen food products, refrigerator food product, and dry storage food products, outside original boxes without labels with food names, received dates, or use by dates. The findings include: Review of the facility's policy titled Refrigerated/Frozen Storage, revised 06/15/18; revealed food should be maintained in a safe and sanitary manner to prevent damage, spoilage, and contamination of products. Additional review revealed all refrigerated foods should be labeled with name of product and the date received and use by date once opened. Further, frozen food was to be kept in original containers, if removed from the original container, food was to be labeled with the name of the product and use by date. A requested policy related to Dry Food Storage was not made available to State Investigator. Observations of the outside standing freezer, on 06/11/19 at 1:07 PM revealed one (1) bag of frozen stuffed manicotti shells with no food name label or use by date. Additional observations revealed two (2) blocks of sliced cheese and one (1) half bag of shredded carrots, in the kitchen refrigerator with no food name, date received or use by date label. Further observations revealed three (3) bags of vanilla wafer cookies, on the dry storage shelf with no food name, date received or use by date label. Interview with Cook #1, on 06/11/19 1:20 PM revealed he and the Director of Dietary were responsible for ensuring food was labeled appropriately in the kitchen. Additionally, a sharpie marker was used to write the date the food product was delivered, the use by date, and the food name on packages if removed from the original box. Continued interview revealed the facility also had sticker labels that were used at times. Further interview revealed, it was important to label and date food products with common food names, received dates and use by dates to know what the food products were and how long they were good to use safety. Interview with the Dietary Director, on 06/13/19 at 12:42 PM, revealed she had been in her current position for one (1) week. Additional interview revealed she was not aware food products should be labeled with food names when out of an original package. However, she expected the facility policy to be followed; all food products should be labeled with food name and use by dates when removed from their original package. Per interview, it was the responsibility of all dietary staff to ensure facility policies related to labeling and dating food products were followed. Further interview revealed, it was important that food products have labels per the facility policy to ensure everyone knew what the food product was and to ensure residents receive an accurate food to meet their nutritional needs and choices. Per interview, she had not yet established an audit process to ensure food labeling was maintained. Interview with the Director of Nursing (DON), on 06/13/19 at 12:59 PM revealed she expect food products to be labeled per the facility policy. Additionally it was important to label foods with names and dates to ensure the food was safe for the residents. Further, labeling ensured proper diets and nutritional needs were met for residents. Per interview, the Dietary Director was responsible to ensure food products were labeled appropriately. Interview with Administrator, on 06/13/19 at 3:19 PM revealed she had worked at the facility for five (5) years. Additionally, food should be stored in accordance with professional standards for food service safety in the kitchen refrigerator, freezer and dry storage with labels including food names, receive by dates, and use by dates. Per interview, she conducted kitchen walk through to validate audits completed by the Dietary Director, to ensure labels on food products were in accordance to facility Food Storage policy. However, she could not state dietary staff or she had not identified why the food items observed on 06/11/19 without labels. Further, it was important for food product labels included food names, use by dates, and received dates to ensure food was safe for residents.

The facility failed to ensure each resident had a person-centered Comprehensive Care Plan (CCP) developed and implemented to address the resident's medical, physical, mental and psychosocial needs for one (1) of fifteen (15) sampled residents, (Resident #142). Review of Resident #142s physician's orders [REDACTED]. The findings include: Review of the facility's Person Centered Care Plan Policy, revised 03/01/18, revealed the facility would develop and implement a person centered care plan for each patient to include instruction to provide effective care to meet professional standards of quality care. Additionally, the CCPs purpose was to attain or maintain the patient's highest practicable physical, mental and psychosocial wellbeing; and to promote optimized clinical outcomes. Further, the CCP would be reviewed ongoing and changed to meet the needs of the patient. Review of Resident #142's medical record revealed facility admitted the resident on 05/17/19 with [DIAGNOSES REDACTED]. Review of Physician Orders, dated (MONTH) 2019, revealed an order for [REDACTED]. Review of Resident #142's Admission Minimum Data Set (MDS) Assessment, dated 05/21/19, revealed the facility assessed the resident as having a Brief Interview for Mental (BIMS) score of fifteen (15) out of fifteen (15) indicating the resident was cognitively intact. Additional review revealed the resident had no presence of mood or behavioral symptoms. Per Assessment, the Resident received hypnotic medication two (2) days during the look back period and a Gradual Dose Reduction was not required. Review of the Admission Care Area Assessment (CAA); [MEDICAL CONDITION] Drug Use, dated 05/27/19, revealed [MEDICAL CONDITION] Drug use was triggered; however, the Care Plan decision was NO, related to the hypnotic medication being discontinued per the Nursing orders and the MAR. However, review of Resident #142's medical record revealed there was no documented evidence of a CCP related to the use of Ambien, a [MEDICAL CONDITION] medication was developed. Interview with the Director of Nursing (DON), on 06/13/19 at 12:59 PM revealed the previous days, interdisciplinary notes, physician orders, changes in condition, and Activities of Daily Living ( ADL) were reviewed in the clinical meetings, which included the DON, the Administrator, the Assistant Director of Nursing (ADON), the MDS Coordinator, the Social Worker and therapy staff. Per interview, upon review, revisions were made as necessary to CCP. Additionally, the MDS Coordinator was responsible to update the CCP with new orders, including orders for medications such as Ambien. Continued interview revealed there was no further audit process in place to ensure CCPs were developed to include new order for [MEDICAL CONDITION] medications other than the MDS Coordinator reviewing care plans when completing scheduled MDS Assessments. Per the DON, the development on the CCP for Resident #142'[MEDICATION NAME] missed because it was prn and not scheduled. However, there should have been a CCP, for Resident #142 developed and implemented related to his/her hypnotic medication use when ordered on [DATE]. Further, it was important to have a CCP developed to guide resident care to meet the residents care needs through individualized monitoring and interventions. Interview with MDS Coordinator, on 06/13/19 at 1:32 PM, revealed she reviewed each resident's physician's orders [REDACTED]. Additionally, [MEDICAL CONDITION] medications should have a CCP developed and implemented when a new order was received from the provider. Per interview, the nurse who took Resident #142's order for [MEDICATION NAME] responsible to initially develop the CCP to include use of [MEDICAL CONDITION] drug use. Further, she was responsible to oversee the implementation of the CCP, and a CCP should have been developed for Resident #142's [MEDICAL CONDITION] drug use; however she was not [MEDICATION NAME] a [MEDICAL CONDITION] medication. Per interview, during scheduled MDS Assessments, the MDS Coordinator would review the CCP to ensure it accurately reflected the resident and care needs. Continued interview revealed it was important to develop and implement a CCP related to use of [MEDICAL CONDITION] drug use, Ambien, related to hypnotic medications having many side effects that could affect the resident and to ensure monitoring was in place to ensure the medication was therapeutic. Interview with LPN #2, on 06/13/19 at 2:06 PM revealed she was Resident #142's assigned nurse on 05/22/19 and received [MEDICATION NAME]. Additional interview revealed the nurse receiving orders for [MEDICAL CONDITION] medication was responsible to ensure the CCP was developed to include [MEDICAL CONDITION] drug use. The CCP should include assessment and evaluation for side effects/behaviors, physician orders [REDACTED]. Per interview, there was a [MEDICAL CONDITION] drug use template in the Electronic Medical Record. Further, it was important for resident to have CCP for [MEDICAL CONDITION] drug use , to ensure monitoring for adverse reactions and therapeutic medication effects for the resident. Further, she should have implemented a CCP for [MEDICAL CONDITION] drug use for Resident #142 on 05/22/19. Interview with Administrator, on 06/13/19 at 3:19 PM revealed each resident should have a person-centered CCP developed and implemented to address the resident's medical, physical, mental and psychosocial needs per the facility policy. Additionally she expected Resident #142's CCP to include Use of [MEDICAL CONDITION] Drug use with the new order received [MEDICATION NAME] 05/22/19. Continued interview revealed the facilities clinical meeting failed to identify Resident #142's CCP was not implemented to include the use of [MEDICAL CONDITION] Drug use. However, the MDS Coordinator was responsible for review of the CCP and implementing the CCP as appropriate. Further, implementation of the CCP to include use of a [MEDICAL CONDITION] medication was important to ensure the Resident was provided the best care and ongoing monitoring was in place.

Based on interview, record review and Allegation of Compliance (AoC) review, it was determined the Immediate Jeopardy (IJ) identified during the abbreviated survey, concluded on 06/02/11, had been removed. However, non-compliance continued to exist as the facility's Quality Assessment and Assurance Committee (QAAC) had not fully implemented a plan of correction to prevent recurrence of the deficient practice related pain management. The findings include: A review of the facility's acceptable Allegation of Compliance (AoC), received on 06/21/11, revealed the Director of Nurses (DON) or charge nurse would conduct daily reviews of pain documentation to identify the effectiveness of the pain intervention each day of the week. Any identified issues would be corrected and re-education/disciplinary action would be provided, as indicated by the DON or the Assistant Director of Nurses (ADON). Interviews with the DON, on 06/27/11 at 10:50 AM and 06/28/11 at 10:44 AM, and review of the AoC, revealed the facility had begun implementing action per their AoC; however, the facility had not completely implemented a plan of correction for the deficient practice identified. The DON revealed that during her daily audits, she identified two incidents when staff failed to document a follow-up assessment for "as needed (prn)" pain medication. She stated she provided in-services for the staff involved regarding the pain management program. During the inservices, she discussed the need to assess the resident before and after administration of the medication. If the medication was not effective in controlling the resident's pain, the nurse should notify the physician. If a resident had a PRN medication for pain, then the nurse should document on the PRN Pain Flow Sheet. If a resident had a routine pain medication, the nurse was responsible for answering the three pain criteria questions. She stated she identified through the audits problems had occurred, on 06/13/11, 06/20/11 and 06/27/11. At the time of the interviews, she had completed education and disciplinary action with staff involved, with the exception of the weekend supervisor. An interview with the Administrator, on 06/28/11 at 4:13 PM, revealed he was to ensure the facility staff carried out quality assurance activities per the AoC (daily audits of pain documentation). He was responsible for audits he conducted and he reviewed the DON's audits. He discussed them in their Quality Improvement (QI) meetings on a weekly basis. The Administrator stated the DON made him aware of the issues regarding documentation of follow-up pain assessments and the weekend supervisor failure to complete daily reviews of the pain documentation for the weekend of 06/18-19/11 and 06/25-26/11. The administrator stated, "Each case we followed the steps and completed re-education as we alleged. If we have problem with the audits, then we would come back to the Performance Improvement (PI) team to track and trend. We would have to make adjustments and we may have to adjust who completes the weekend audits".

Based on interview and record review, it was determined the facility failed to identify issues for which quality assessment and assurance activities were necessary, and failed to develop and implement appropriate plans of action to correct identified quality deficiencies related to referrals for services and the facility's Pain Management Program. On [DATE], Resident #1 complained of pain which involved the ears and the temporal areas on the sides of the forehead. The resident continued to complain of pain and was unable to close his/her mouth which affected the resident's ability to eat and swallow liquids. On [DATE] and [DATE], the Speech Pathologist observed Resident #1 and submitted recommendations for Resident #1 to receive a medical/dental evaluation to rule out possible abnormality of the lower jaw. However, the facility failed to ensure implementation of the consultation with a Dentist and/or a physician and the resident's ability to close his/her mouth did not improve. A CAT-Scan, conducted on [DATE], thirteen days after the resident's onset of symptoms, revealed Resident #1 had a bilateral mandibular (jaw) dislocation. The resident was hospitalized and underwent manipulation of the jaw under anesthesia; however, the resident's jaw remained aligned only temporarily, due to a muscle problem. The resident was discharged from the hospital to a Hospice facility on [DATE] and expired on [DATE]. (Refer to F224 and F309) Based on the above findings it was determined the facility failed to have an effective system to identify quality of care issues to ensure residents were free from neglect and received quality of care, which was likely to cause serious injury, harm, impairment or death. Immediate Jeopardy was identified on [DATE] and was determined to exist on [DATE], and is ongoing. The findings include: Review of the facility's policy and procedures entitled "Performance Improvement Program", dated ,[DATE], revealed it was the policy of the organization that is services would be delivered to care for residents and would be provided in a manner so as to optimize physical and psychosocial functioning in a supportive and caring environment. 1. Based on interview and record review it was determined the facility failed to provide services necessary to avoid physical harm and mental anguish for Resident #1, who experienced pain, loss of ability to eat or drink and the ability to speak clearly. The facility failed to to ensure referrals for medical/dental consultation was communicated and implemented related to Resident #1's inability to close his/her mouth. Interviews with the Administrator, DON, ADON and the ,[DATE] shift Charge Nurse (CN), on [DATE] at 12:45 PM, revealed it was the CN's responsibility to gather information that was discussed in morning meeting, transcribe it onto the 24 hour report and process any follow-up. The facility had no documented policy related to the therapy screening process and no monitoring was conducted to ensure referrals were acted upon. 2. Based on interview and record review it was determined the facility failed to ensure four of seven sampled residents (Residents #1, #4, #5 and #7) received pain medication on an as needed (PRN) basis. Record reviews and interviews with licensed staff revealed the residents were not provided pain assessments to determine the source, type and extent of their pain prior to administration of medication and were not re-evaluated for effective pain relief. A review of the facility's policy and procedures entitled, " Pain Management Program," dated [DATE] and revised [DATE], revealed the program's components were as follows: identifying residents with pain, developing an individual pain management program, implementing the program and monitoring and evaluating the effectiveness of the program. Interviews with the Administrator, DON, and the ADON, on [DATE] at 12:45 PM, revealed the ADON conducted random audits, continuing education and verbal counseling to assure pain assessments were completed according to facility policy and stated, "It was an ongoing process."

Based on interview, record review, and review of facility policy and procedures it was determined the facility failed to be administered in a manner which enabled it to use it's resources effectively and efficiently to attain or maintain the highest practicable, physical, mental and psychosocial well-being for four residents (Residents #1, #4, #5, and #7), in the selected sample of seven. The facility failed to have an effective system in place to to ensure referrals for medical/dental consultation was communicated and implemented timely. The facility failed to have an effective system in place to ensure the facility's pain management program was implemented to assess, monitor, and re-evaluate residents' complaints of pain. (Refer to F224 and F309) On [DATE], Resident #1 complained of pain which involved the ears and the temporal areas on the sides of the forehead and was unable to close his/her mouth. Record review, from [DATE] through [DATE], revealed the resident continued to complain of pain and was unable to close his/her mouth, resulting in difficulty with speech and decreased ability to swallow and consume food and drink. On [DATE] and [DATE], the Speech Pathologist evaluated Resident #1 and made two recommendations for a medical/dental evaluation to rule out possible abnormality of the lower jaw. However, the facility failed to ensure implementation of the consultation with a Dentist and/or a physician. On [DATE], the resident's Power of Attorney (POA) requested an X-ray or a CAT-Scan (Computerized Axial Tomography) to determine the cause of the resident's condition. The CAT-Scan, conducted on [DATE], thirteen days after the resident's onset of symptoms, revealed Resident #1 had a bilateral mandibular (jaw) dislocation. The resident was hospitalized and underwent manipulation of the jaw under anesthesia; however, the resident's jaw remained aligned only temporarily, due to a muscle problem. The resident was discharged from the hospital to a Hospice facility on [DATE] and expired on [DATE]. Based on the above findings it was determined the facility failed to ensure the facility was administered effectively and efficiently which was likely to cause serious injury, harm, impairment or death. Immediate Jeopardy was identified on [DATE] and was determined to exist on [DATE], and is ongoing. The findings include: 1. Review of the facility's policy and procedures entitled "Abuse and Neglect Prohibition Program" revealed the facility's program focused on preventing "abuse, neglect or misappropriation of resident property through increase awareness; and managing events that do occur, including a root-cause analysis to determine how to minimize future risk." The policy defined neglect as "failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Each resident has the right to be free from mistreatment, neglect and misappropriation of property". An interview with the Speech Pathologist, on [DATE] at 4:50 PM, and record review revealed she screened Resident #1 on [DATE] and [DATE] and made two written recommendations for a medical/dental evaluation to rule out possible abnormality of the lower jaw. Per interview, Resident #1 was discussed on two different occasions during the facility morning meetings and her concerns were reported to the Administrator. However, there was no documented evidence these recommendations had been acted upon. An interview with the Director of Nursing (DON), on [DATE] at 5:25 PM, revealed she did not know why the Speech Pathologist's recommendations were missed. She became aware of the documented recommendations during the survey. The DON stated the facility had no policy and/or procedure related to the process of the morning meeting. An interview on [DATE] at 3:25 PM, with the ARNP who was seeing Resident #1, revealed she was unaware of recommendations made by the Speech Pathologist. An interview with the Administrator, on [DATE] At 4:25 PM, revealed he was unaware of the therapy recommendations for a Physician/Dental consult. Further interview with the Administrator, on [DATE] at 12:45 PM, revealed it was the Charge Nurse's responsibility to gather information that was discussed in morning meeting, transcribe it onto the 24 hour report and process any follow-up. The facility had no documented policy related to the therapy screening process. 2. A review of the facility's policy and procedures entitled, " Pain Management Program," dated [DATE] and revised [DATE], revealed the pain management program was an interdisciplinary program that utilized the "APIE" (assess, plan, implement, and evaluate) approach to care giving. The program's components were as follows: identifying residents with pain, developing an individual pain management program, implementing the program, and monitoring and evaluating the effectiveness of the program. A review of the facility's process revealed the resident's pre and post pain assessment was completed on the Pain Management Flow Sheet. The resident's pain was rated on a ,[DATE] pain scale before the pain medication was administered and re-evaluated one hour after administration. Residents #1, #4, #5 and #7 received pain medication on an as needed (PRN) basis. Record reviews and interviews with licensed staff revealed the residents were not provided pain assessments to determine the source, type and extent of their pain prior to administration of medication and were not re-evaluated for effective pain relief. Interviews with RN #1, on [DATE] at 8:45 AM, LPN #3 on [DATE] at 7:15 PM, RN #4 on [DATE] at 8:35 AM, RN# 2, on [DATE] at 10:15 AM LPN #7 on [DATE] at 10:20 AM, and LPN #1 on [DATE] at 11:05 AM revealed they were responsible to assess the residents' pain before and after pain medication was administered, to rate the resident's pain, and document the effectiveness of the pain medication. Interviews revealed they were aware to complete the PRN Pain Management Flow Sheet; however, all failed to do so. An interview with the Assistant Director of Nursing (ADON), on [DATE] at 12:45 PM, revealed she was responsible for conducting inservicing and training on "Pain Management and Assessment" for staff in the facility. However, the DON did most of the training of the new hires and a good portion was done on the computer through "Sun University." Interviews with the Administrator and the DON on [DATE] at 12:45 PM, revealed the DON was responsible for the oversite of implementation of programs, policies and procedures.

Based on interview, record review, and Allegation of Compliance (AoC) review, it was determined the Immediate Jeopardy (IJ) identified during the abbreviated survey, concluded on 06/02/11, had been removed. However, non-compliance continued to exist as the facility's Quality Assessment and Assurance Committee (QAAC) had not fully implemented a plan of correction to prevent recurrence of the deficient practice related pain management. The findings include: Review of the facilities acceptable Allegation of Compliance (AoC), received on 06/21/11, revealed the Director of Nurses (DON) verbally conducted re-education on the facility's pain management program. Nurses were re-educated on assessing pain using 0-10 pain scale on the pain evaluation form, on assessing pain before and after administration of pain medications, and documenting the effectiveness of the pain medication on the pain management flow sheet. The DON or charge nurse would conduct daily reviews of pain documentation to identify the effectiveness of the pain intervention each day of the week. Any identified issues were to be corrected and re-education/disciplinary action, as indicated by the DON or the Assistant Director of Nurses (ADON), would be completed. A review of the policy entitled, "Pain Management Program" dated January 2008 and revised July of 2010, revealed for regularly scheduled or routine doses of pain medication ordered by the physician, the nurse dispensing the medication would document the following on the Medication Administration Record (MAR); pain intensity (using the 0-10 scale); signs of sedation; and side effects. Soon after the medication was administered, the licensed nurse would return to the resident and question them about their pain and how they would rate it. The response would be documented on the MAR and any comments or concerns would be documented on the back of the MAR. If, for some reason, the medication was not effective in controlling pain, the licensed nurse would address the specifics with the physician immediately. Interviews with the DON, on 06/27/11 at 10:50 AM and 06/28/11 at 10:44 AM, and review of the AoC, revealed the facility had begun implementing action per their AOC; however, the facility had not completely implemented a plan of correction for the deficient practice identified. The DON revealed during her daily audits, she identified two incidents when staff failed to document a follow-up assessment for "as needed (prn)" pain medication. She stated she provided in-services for the staff involved regarding the pain management program. During the inservices, she discussed the need to assess the resident before and after administration of the medication. If the medication was not effective in controlling the resident's pain, the nurse should notify the physician. If a resident had a PRN medication for pain, then the nurse should document on the PRN Pain Flow Sheet. If a resident had a routine pain medication, the nurse was responsible for answering the three pain criteria questions. She stated she identified through the audits problems had occurred, on 06/13/11, on 06/20/11, and on 06/27/11. Per interview she had also identified the audits were not completed for the weekend of 06/18-19/11 and 06/25-26/11. At the time of the interviews, she had completed education and disciplinary action with staff involved, with the exception of the weekend supervisor. An interview with the Administrator, on 06/28/11 at 4:13 PM, revealed he was to ensure the facility staff completed the actions as detailed in their AoC (daily audits of pain documentation). He stated he was responsible for the audits he conducted and discussed them in their Quality Improvement meetings weekly. The Administrator stated the DON made him aware of the issues found related to pain documentation not being followed up on and the weekend supervisor's failure to complete the daily review of the pain documentation for the weekend of 06/18-19/11 and 06/25-26/11. He stated the DON informed him, on 06/27/11, of the results of her audit. He stated , "Each case we followed the steps and completed re-education as we alleged. If we have problem with the audits, then we may have to adjust who completes the weekend audits".

Based on interview, record review and facility policy review it was determined the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being for four residents (Residents #1, #4, #5 and #7), in the selected sample of seven. The facility failed to ensure there was an effective pain management system in place to assess, monitor, and re-evaluate residents' complaints of pain. On [DATE], Resident #1 complained of pain which involved the ears and the temporal areas on the sides of the forehead and was unable to close his/her mouth. Record review, from [DATE] through [DATE], revealed the resident continued to complain of pain and was unable to close his/her mouth, resulting in difficulty with speech and decreased ability to swallow and consume food and drink. On [DATE] and [DATE], the Speech Pathologist evaluated Resident #1 and made two recommendations for a medical/dental evaluation to rule out possible abnormality of the lower jaw. However, the facility failed to ensure implementation of the consultation with a Dentist and/or a physician (Refer to F224). On [DATE], the resident's Power of Attorney (POA) requested an X-ray or a CAT-Scan (Computerized Axial Tomography) to determine the cause of the resident's condition. The CAT-Scan, conducted on [DATE], thirteen days after the resident's onset of symptoms, revealed Resident #1 had a bilateral mandibular (jaw) dislocation. The resident was hospitalized and underwent manipulation of the jaw under anesthesia; however, the resident's jaw remained aligned only temporarily, due to a muscle problem. The resident was discharged from the hospital to a Hospice facility on [DATE] and expired on [DATE]. Residents #4, #5 and #7 received pain medication on an as needed (PRN) basis. Record review and interview with licensed staff revealed the facility failed to assess the residents for pain to determine the source, type and extent of their pain prior to the administration of medication and failed to re-assess the residents for effective pain relief. Based on the above findings it was determined the facility failed to ensure there was an effective pain management system in place to ensure residents were assessed, monitored and re-evaluated for complaints of pain which was likely to cause serious injury, harm, impairment or death. Immediate Jeopardy was identified on [DATE] and was determined to exist on [DATE], and is ongoing. The findings include: 1. A review of the facility's policy and procedures entitled, " Pain Management Program," dated [DATE] and revised [DATE], revealed the pain management program was an interdisciplinary program that utilized the "APIE" (assess, plan, implement, and evaluate) approach to care giving. The program's components were as follows: identifying residents with pain, developing an individual pain management program, implementing the program, and monitoring and evaluating the effectiveness of the program. A review of the facility's process revealed the resident's pre and post pain assessment was completed on the Pain Management Flow Sheet. The resident's pain was rated on a ,[DATE] pain scale before the pain medication was administered and re-evaluated one hour after administration. A closed record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the annual Minimum Data Set (MDS) assessment, dated [DATE], revealed the facility assessed Resident #1 as severely impaired cognitively and required extensive assistance of one staff member with meals. At the time of the assessment, Resident #1 ate a Regular fortified diet and fed his/herself with follow up assistance from staff. A review of the Comprehensive Care Plan for "Risk for alteration in Nutrition and Dehydration", dated [DATE] and revised on [DATE], revealed the resident's diet was changed from Regular to a Pureed consistency diet with honey thickened liquids and the resident was fed by staff. Review of the care plan for "comfort measures only", dated [DATE], revealed revisions dated [DATE], which included "Pain R/T facial temporal pain, difficulty closing mouth" and an intervention for "[MEDICATION NAME] (pain medication) as ordered". A review of the Nurse's Notes, dated [DATE] at 7:30 AM, revealed Licensed Practical Nurse (LPN) #1 noted the resident was holding both sides of his/her face and temple area and stated, " I cannot close my mouth". The resident was described as alert and answering questions. The resident was able to slowly close his/her mouth, but complained of pain in the head, temple area and ears. The resident's face was described as flushed. The physician was notified and an order was received for "[MEDICATION NAME] 7XXX,[DATE] mg (pain medication) to be given as a "now" dose. At 8:30 AM, on [DATE], Resident #1 stated, "Feels better but still hurts". Further review of the Nurse's Notes, dated [DATE] at 2:30 PM, revealed the Advance Registered Nurse Practitioner (ARNP) diagnosed Resident #1 with Acute Sinusitis/[MEDICAL CONDITION] and prescribed [MEDICATION NAME] (an antibiotic) 875 mg by mouth twice a day for ten days and [MEDICATION NAME]-APAP 7XXX,[DATE] mg by mouth every six hours as needed for pain. An interview with CNA #1, on [DATE] at 9:45 AM and on [DATE] at 9:25 AM, revealed Resident #1 had informed him his/her mouth hurt. He described the resident's mouth as "drooped' and the resident's eyes as "squinted". He immediately informed LPN #1. CNA #1 stated he had never seen Resident #1 in that condition previously. He described the resident as usually smiling, but after that day, the resident "looked sick" every time care was provided. An interview with LPN #1, on [DATE] at 3:30 PM, revealed she was summoned to Resident #1's room by CNA #1, who reported something was wrong with the resident. She stated Resident #1 could only close his/her mouth a little bit and squinted his/her eyes and rubbed his/her nose and eyes. LPN #1 informed the Assistant Director of Nursing (ADON). An interview with the ADON, on [DATE] at 10:05 AM, revealed she was summoned to Resident #1's room on [DATE] and the resident acted like he/she had a migraine, rubbing his/her temples and the resident's cheeks were observed reddened. The resident was unable to close his/her mouth and complained of a headache. The ADON stated she looked inside the resident's mouth and ears and the resident's cheeks looked "puffy". She checked orders for pain medication and called the ARNP and received an order for [REDACTED]. The ADON stated the resident was never able to totally close his/her mouth. An interview with the ARNP, on [DATE] at 3:25 PM, revealed she assessed Resident #1 on [DATE]. The resident had red swollen cheeks, her month was open and she could close it with no misalignment. The resident complained of pain behind her eyes and in her cheeks. She treated the resident for an infectious process with antibiotics. She ordered [MEDICATION NAME] ([MEDICATION NAME]-APAP) for pain in addition to [MEDICATION NAME] Patch ( pre-existing order). On [DATE], Resident #1 continued with difficulty closing his/her mouth and she ordered laboratory tests and held the resident's medication [MEDICATION NAME] ( for [MEDICAL CONDITION]) and [MEDICATION NAME] (for [MEDICAL CONDITION]). The resident's Sedimentation Rate (Sed Rate) was elevated, indicating inflammation and steroids were ordered. On [DATE], the resident could not close his/her mouth and could not swallow. Per interview, the resident's family was present and she told them a definitive answer could be gotten with a CAT-Scan. The next day the resident's Power of Attorney (POA) agreed and the CAT Scan was ordered. The CAT Scan revealed the resident had a dislocated mandible. The ARNP stated she did not see the resident after [DATE] and the resident was never evaluated by the primary physician. An interview with the resident's POA, on [DATE] at 9:10 AM, revealed he was informed on [DATE], that Resident #1 was unable to close his/her mouth and the cause was unknown. During the next visit, on [DATE], the resident's mouth remained open and he asked nursing staff if the jaw was dislocated. He was told they did not think that was the problem and the resident received steroids and an antibiotic and the treatment should put him/her on the the right path. He stated that during a visit on [DATE], the resident was in severe pain and crying. A review of the Nurse's Notes, dated [DATE] through [DATE], revealed the resident's clinical status declined. The resident's mouth remained open, resulting in difficulty with speech and the ability to swallow and consume food and drink. The resident's face was swollen and tender and the lower jaw was described as rigid and hard when palpated. A review of Resident #1's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] AM, on [DATE] at 7:00 AM, on [DATE] at 12:10 AM, on [DATE] at 1:20 AM, on [DATE] at 9:00 AM and on [DATE] at 1:15 AM. Documentation revealed Registered Nurse (RN) #1 administered six of the eleven doses of the pain medication. However, review of the resident's Pain Management Flow Sheet revealed RN #1 failed to assess Resident #1 to determine what type of pain the resident experienced, the extent of the pain, and whether the administration of the medication relieved the resident's pain on [DATE] at 1:50 AM, on [DATE] at 4:00 AM, on [DATE] at 1:00 AM, on [DATE] at 12:10 AM, on [DATE] at 1:20 AM, and on [DATE] at 1:15 AM. An interview with RN #1, on [DATE] at 8:45 AM, revealed she realized she was responsible to assess the resident and complete the pain management PRN flow sheet. However, she did not and had no explanation for not doing so. An interview with the resident's primary physician, on [DATE] at 1:00 PM, revealed she did not personally follow Resident#1, but was informed by the ARNP the resident's cheeks were red and swollen. She was aware the resident was treated with antibiotics and steroids. She stated she did not think she would have diagnosed Resident #1 with a dislocation of the jaw, because the resident was initially able to close his/her mouth with no misalignment, per the evaluation of the ARNP. 2. A record revealed Resident # 4 was admitted to the on [DATE] a [DIAGNOSES REDACTED].) of other Bone. A review of the MAR, dated ,[DATE]-,[DATE], revealed Resident #4 was administered thirteen doses of [MEDICATION NAME]-APAP 7XXX,[DATE] mg as needed (PRN) for pain on [DATE] at 12:40 PM, on [DATE] at 2:00 PM, on [DATE] at 11:25 PM, on [DATE] at 3:30 AM, [DATE] at 11:50 PM, on [DATE] at 3:30 AM, on [DATE] at 1:00 PM, on [DATE] at 11:30 PM, on [DATE] at 12:00 AM, on [DATE] at 4:00 AM, on [DATE] at 1:00 PM, on [DATE] at 12:00 AM, and on [DATE] at 4:25 AM. Review of the PRN Pain Management Flow Sheet revealed no assessment had been conducted to determined the resident's type of pain, the extent of the pain, and whether the administration of the medication relieved the resident's pain. Registered Nurse (RN) #1 administered nine of the twelve doses and LPN #1 administered three of the doses. An interview with RN #1, on [DATE] at 8:45 AM, revealed she realized she was responsible to assess the resident and complete the pain management PRN flow sheet. However, she did not and had no explanation for not doing so. She stated she was aware of the Pain Management Policy and was inserviced on assessments by the facility. An interview with LPN #1, on [DATE] at 11:05 AM, revealed she was aware of the Pain Management Program and the PRN Pain Management Flow Sheet and stated she was inserviced on pain assessments by the the facility and was unaware of the the missed assessments. 3. A record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the MAR, dated ,[DATE]-,[DATE], revealed Resident #5 was administered twenty-two doses of [MEDICATION NAME]-APAP for pain as needed (PRN). Review of the PRN Pain Management Flow Sheet revealed no assessment had been conducted to determined the resident's type of pain, the extent of the pain, and whether the administration of the medication relieved the resident's pain for three of the doses administered on [DATE] at 12:30 PM, on [DATE] at 9:15 AM, and on [DATE] at 12:30 PM. Review of the MAR indicated [REDACTED]. An interview with LPN# 7, on [DATE] at 10: 20 AM, revealed she was aware of the Pain Management policy and was inserviced and stated she usually assessed residents pain; however, she did not remember why she did not document the assessments on Resident #5. 4. A record review revealed Resident #7 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of the MAR, dated ,[DATE]-,[DATE], revealed Resident #7 was administered seventy-eight [MEDICATION NAME]-APAP for pain as needed (PRN). Review of the PRN Pain Management Flow Sheet revealed no assessment had been conducted to determined the resident's type of pain, the extent of the pain, and whether the administration of the medication relieved the resident's pain for twenty-six doses received on [DATE] at 7:30 PM, on [DATE] at 12:20 AM, on [DATE] at 11:50 PM, on [DATE] at 12:10 AM, on [DATE] at 11:50 PM, on [DATE] at 10:00 PM, on [DATE] at 7:30 PM, on [DATE] at 7:25 PM, on [DATE] at 12:15 AM, on [DATE] at 11:40 PM, on [DATE] at 7:30 PM, on [DATE] at 11:30 PM, on [DATE] at 10:15 PM, on [DATE] at 5:00 PM on [DATE] at 12:30 AM, on [DATE] at 6:30 PM on [DATE] at 10:45 PM on [DATE] at 1:00 PM, on [DATE] at 5:00 PM, on [DATE] at 7:15 PM, on [DATE] at 12:AM, on [DATE] at 10:10 PM, on 05/ ,[DATE] at 11:30 PM, on [DATE] at 12:00 AM, on [DATE] at 7:15 PM, and [DATE] at 11:55 PM. Twelve of those times the medication was administered by the Certified Medication Technician (CMT)#1; nine times by RN#1; three times by RN# 4; once by RN #2; and, once by LPN# 3. An interview with CMT #1, on [DATE] at 7:20 PM, revealed she was aware of pain management policy, but as a CMT she did not assess residents. She stated she alerted the unit nurse when a resident complained of pain and waited to be told if the resident was in need of medication. An interview with RN #1, on [DATE] at 8:45 AM, revealed she realized she was responsible to assess the resident and complete the pain management PRN flow sheet. However, she did not and had no explanation for not doing so. She stated she was aware of the Pain Management Policy and was inserviced on pain assessments by the facility. An interview with RN #4, on [DATE] at 8:35 AM, revealed she was familiar with the Pain Management Policy and assessed the residents per policy. She stated she missed documenting the assessments and she did not know what happened. An interview with LPN #3, on [DATE] at 7:15 PM, revealed that she was inserviced on pain assessments by the facility and was aware of the Pain Management Policy. She stated she assessed and documented the assessments per policy. An interview with RN# 2, on [DATE] at 10:15 AM, revealed she was inserviced on pain assessments by the facility and was aware of the pain management policy and stated if she missed an assessment, it was due to human error. Interview with the Administrator, DON, and ADON on [DATE] at 12:45 PM, revealed the DON was responsible for the oversite of implementation of programs, policies and procedures. The ADON conducted random audits, continuing education, and verbal counseling to assure pain assessments were completed according to facility policy.

Based on interview, record review, and Allegation of Compliance (AoC) review, it was determined the Immediate Jeopardy (IJ) identified during the abbreviated survey, concluded on 06/02/11, had been removed. However, non-compliance continued to exist as the facility's Quality Assessment and Assurance Committee (QAAC) had not fully implemented a plan of correction to prevent recurrence of the deficient practice related pain management. The findings include: A review of the facility's acceptable Allegation of Compliance (AoC), received on 06/21/11, revealed the Director of Nurses (DON) or charge nurse would conduct daily reviews of pain documentation to identify the effectiveness of the pain intervention each day of the week. If issues were identified, corrective action would include re-education and/or disciplinary action, as determined by the DON or the Assistant Director of Nurses (ADON). An interview with the DON, on 06/28/11 at 8:05 AM & 10:44 AM, and review of the AoC, revealed the facility had begun implementing action per their AoC; however, the facility had not fully implemented a plan of correction for the deficient practice identified. The DON stated the weekend supervisor failed to conduct the audits the weekend of 06/18-19/11 and 06/25-26/11. The DON informed and educated the weekend supervisor, regarding the nurse's responsibility for completion of audits. The DON further revealed she discovered the weekend supervisor failed to identify lack of documentation for routine pain medication. The DON revealed she had not completed disciplinary action for the staff involved. An interview with the Administrator, on 06/28/11 at 4:13 PM, revealed he was to ensure the facility staff completed the actions as detailed in their AoC (daily audits of pain documentation). He stated he was responsible for the audits he conducted and discussed them in their Quality Improvement meetings weekly. The Administrator stated the DON made him aware of the issues found related to follow-up for pain and the weekend supervisor's failure to complete the daily review of the pain documentation, for the weekend of 06/18-19/11 and 06/25-26/11. He stated the DON informed him, on 06/27/11, of the results of her audit. He stated , "Each case we followed the steps and completed re-education as we alleged. If we have problem with the audits, then we may have to adjust who completes the weekend audits".

Based on interview, record review, and facility policy review it was determined the facility failed to provide services necessary to avoid physical harm and mental anguish for one resident (#1), in a selected sample of seven, who experienced pain, loss of ability to eat or drink and the ability to speak clearly. The facility failed to to ensure referrals for medical/dental consultation was communicated and implemented related to an inability to close his/her mouth. On [DATE], Resident #1 complained of pain which involved the ears and the temporal areas on the sides of the forehead and was unable to close his/her mouth. Record review, from [DATE] through [DATE], revealed the resident continued to complain of pain and was unable to close his/her mouth, resulting in difficulty with speech and decreased ability to swallow and consume food and drink (Refer to F309) On [DATE] and [DATE], the Speech Pathologist evaluated Resident #1 and made two recommendations for a medical/dental evaluation to rule out possible abnormality of the lower jaw. However, the facility failed to ensure implementation of the consultation with a Dentist and/or a physician. On [DATE], the resident's Power of Attorney (POA) requested an X-ray or a CAT-Scan (Computerized Axial Tomography) to determine the cause of the resident's condition. The CAT-Scan, conducted on [DATE], thirteen days after the resident's onset of symptoms, revealed Resident #1 had a bilateral mandibular (jaw) dislocation. The resident was hospitalized and underwent manipulation of the jaw under anesthesia; however, the resident's jaw remained aligned only temporarily, due to a muscle problem. The resident was discharged from the hospital to a Hospice facility on [DATE] and expired on [DATE]. Based on the above findings it was determined the facility failed to provide services necessary to avoid physical harm and mental anguish for Resident #1, who experienced pain, the loss of ability to eat or drink and the ability to speak clearly. The facility failed to to ensure referrals for medical/dental consultation was communicated and implemented related to an inability to close his/her mouth which was later diagnosed as a bilateral jaw dislocation. Immediate Jeopardy was identified on [DATE] and was determined to exist on [DATE], and is ongoing. The findings include: Review of the facility's policy and procedures entitled "Abuse and Neglect Prohibition Program" revealed the facility's program focused on preventing "abuse, neglect or misappropriation of resident property through increase awareness; and managing events that do occur, including a root-cause analysis to determine how to minimize future risk." The policy defined neglect as "failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Each resident has the right to be free from mistreatment, neglect and misappropriation of property". A closed record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the annual Minimum Date Set (MDS) assessment, dated [DATE], revealed the facility assessed Resident #1 as severely impaired cognitively and required extensive assistance of one staff member with meals. At the time of the assessment, Resident #1 consumed a Regular fortified diet and fed his/herself with follow-up assistance from staff. A review of the Comprehensive Care Plan for "Risk for alteration in Nutrition and Dehydration", dated [DATE], revealed interventions were revised on [DATE]. The resident's diet was changed from Regular to a Pureed consistency diet with honey thickened liquids and the resident was fed by staff. A review of the care plan for "Comfort Measures Only", dated [DATE], revealed revisions dated [DATE], which included "Pain R/T facial temporal pain, difficulty closing mouth" and an intervention for "[MEDICATION NAME] (pain medication) as ordered". A review of the Nurse's Notes, dated [DATE] at 7:30 AM, revealed Licensed Practical Nurse (LPN) #1 was summoned to Resident #1's room by a Certified Nurse Aide (CNA) #1 and noted the resident was holding both sides of his/her face and temple area and stated, " I cannot close my mouth". The resident was described as alert and answering questions. The resident was able to slowly close his/her mouth, but complained of pain in the head, temple area and ears. The resident's face was described as flushed. The physician was notified and an order was received for "[MEDICATION NAME] 7XXX,[DATE] mg (pain medication) to be given as a "now" dose. Further review of the Nurse's Notes, dated [DATE] at 2:30 PM, revealed the Advance Registered Nurse Practitioner (ARNP) diagnosed the resident with Acute Sinusitis/[MEDICAL CONDITION] and prescribed [MEDICATION NAME] (an antibiotic) 875 mg by mouth twice a day for ten days and [MEDICATION NAME]-APAP 7XXX,[DATE] mg by mouth every six hours as needed for pain. A review of the Nurse's Notes, dated [DATE] through [DATE], revealed the resident's clinical status declined without a definitive cause identified. The resident's mouth remained open, which resulted in difficulty with speech and the ability to swallow and consume food and drink. The resident's face was swollen and tender and the lower jaw was described as rigid and hard when palpated. An interview with the Speech Pathologist, on [DATE] at 4:50 PM, revealed she received a request on [DATE] from nursing staff to look at Resident #1, related to jaw pain. During her observation of the resident, she identified Resident #1 experienced difficulty with swallowing and closing his/her mouth with a complaint of pain. She stated she immediately reported her findings to the Administrator, on [DATE]. She documented her findings and recommendation on the Multidisciplinary Screening Form (MSF) and placed a copy in the clinical record, under the therapy section. She stated she attended the morning meeting, on [DATE], and discussed her findings and recommendation for consult with a Dentist with clinical staff. She felt the resident required an evaluation that was not within her scope of practice. An interview with the Administrator, on [DATE] At 4:25 PM, revealed he was unaware of the therapy recommendations for a Physician/Dental consult. Further interview with the Speech Pathologist, on [DATE] at 4:50 PM, revealed on [DATE] she received a second request from nursing staff to look at the resident, due to the resident's inability to move the jaw and decreased ROM. She stated that her observation, on [DATE], revealed the resident informed her he/she was in pain. She stated the resident's jaw appeared dislocated. After the observation, she stated she attended the morning meeting with the clinical staff and presented her recommendation for the resident to be evaluated by a Physician and/or Dentist to determine whether the resident's jaw was dislocated. She did not know if the resident was evaluated as recommended. An interview with the Social Worker and the Admissions Coordinator on [DATE] at 5:20 PM, revealed they remembered the Speech Pathologist recommending a Dentist look at the resident's jaw during a morning meeting. An interview with the Director of Nursing (DON), on [DATE] at 5:25 PM, revealed she was not aware of the documented recommendations until surveyor intervention. Per interview, the MSFs were used when a recommendation was made and communicated in Clinical Stand-up Meetings (morning meeting). She stated she did not know why the Speech Pathologist's recommendations were missed. The DON stated "typically" an order would be written on the Physician order [REDACTED]. Also, it would be written on the white board in the DON's office. The DON stated the facility had no policy and/or procedure related to the process of the morning meeting. A review of the MSF, dated [DATE], revealed the resident was screened by the Speech Pathologist, related to increased jaw pain. A recommendation was made for a Dental consult, due the resident's increased pain and decreased range of motion (ROM) in the jaw and voiced complaints of headache. A review of the MSF, dated [DATE], revealed the resident was screened a second time by the Speech Pathologist, related to inability to move the lower jaw and decreased range of motion (ROM). A recommendation was made for a Medical/Dental consult to determine whether the resident had a jaw abnormality. An interview with the ARNP, on [DATE] at 3:25 PM, revealed she was unaware of recommendations made by the Speech Pathologist. Further interview on [DATE] at 1:00 PM, with the ARNP, revealed she assessed Resident #1 on [DATE]. The resident had red swollen cheeks, her month was open and she could close it with no misalignment. The resident complained of pain behind her eyes and in her cheeks. She treated the resident for a infectious process with antibiotics and ordered [MEDICATION NAME] ([MEDICATION NAME]-APAP) for pain in addition to [MEDICATION NAME] Patch ( pre-existing order). On [DATE], Resident #1 continued with difficulty closing his/her mouth and she ordered laboratory tests and held the resident's medication [MEDICATION NAME] ( for [MEDICAL CONDITION]) and [MEDICATION NAME] (for [MEDICAL CONDITION]). The resident's Sedimentation Rate (Sed Rate) was elevated, indicating inflammation and steroids were ordered. On [DATE], the resident could not close his/her mouth and could not swallow. Interviews with CNA's #2, #3, #4, #5 and #6, on [DATE] at 6:25 PM, on [DATE] at 6:20 PM, on [DATE] at 4:10 PM, on [DATE] at 6:56 PM and on [DATE] at 7:00 PM, respectively, revealed Resident #1 was able close his/her mouth to some degree initially, but not totally and eventually Resident #1 was unable to close his/her mouth at all. Further interview with CNA #6 revealed that Resident #1 pointed to his/her temple areas and when asked if he/she hurt, Resident #1 replied "Yes". Continued interview with the ARNP, on [DATE] at 3:25 PM, revealed on [DATE] she discussed obtaining a CAT-Scan with the resident's family. She stated on [DATE] the resident's POA agreed and the CAT-Scan was ordered. The CAT Scan revealed the resident had a dislocated mandible. The ARNP stated she did not see the resident after [DATE] and the resident was never evaluated by the primary physician. An interview with the resident's primary physician, on [DATE] at 1:00 PM, revealed she did not personally follow Resident#1, but was informed by the ARNP the resident's cheeks were red and swollen. She was aware the resident was treated with antibiotics and steroids. Per interview, when there was no response to the treatment, the ARNP offered the family a CAT-Scan. She stated she did not think she would have diagnosed Resident #1 with a dislocation of the jaw, because the resident was initially able to close his/her mouth with no misalignment, per the evaluation of the ARNP. An interview with the family member/Power of Attorney (POA), on [DATE] at 9:10 AM, revealed he was informed on [DATE], that Resident #1 was unable to close his/her mouth and the cause was unknown. On [DATE], staff informed him that Resident #1 had a sinus infection and antibiotics would be administered for ten days. During the next visit, on [DATE], the resident's mouth remained open and he asked nursing staff if the jaw was dislocated. However, he was told they did not think that was the problem and the resident received steroids and an antibiotic and the treatment should put him/her on the the right path. On [DATE], and was informed the resident only consumed 10% of his/her food and the antibiotics and steroids were not working. He stated that during the visit on [DATE], the resident was in severe pain and crying. He stated CNA#1 offered the resident fluids from a spoon and the resident was not able to swallow. He asked the nurse what was wrong with the resident, and she replied she did not know, but the ARNP would see the resident on [DATE]. He met with the ARNP on Monday, [DATE], and asked what was going with the resident and was told the antibiotics and steroids were not working and she did not know what was going on, she was "stumped". He asked if the jaw was dislocated and was told she did not think that was the problem and wanted to order laboratory tests. The POA stated he was concerned regarding the cause of the pain and on [DATE], after discussion with his spouse, he called the facility and requested an X-ray or CT-scan. Per interview, the scan was completed, on [DATE], and the facility informed him the resident's jaw was dislocated. He stated Resident #1 had no history of dislocation of the jaw previously.

Based on interview, record review and Allegation of Compliance (AoC) review, it was determined the Immediate Jeopardy (IJ) identified during the abbreviated survey, concluded on 06/02/11, had been removed. However, non-compliance continued to exist as the facility's Quality Assessment and Assurance Committee (QAAC) had not fully implemented a plan of correction to prevent recurrence of the deficient practice related pain management. The findings include: Review of the facility's acceptable Allegation of Compliance (AoC), received on 06/21/11 revealed, the Director of Nurses (DON) or charge nurse would conduct daily reviews of pain documentation to identify the effectiveness of the pain intervention each day of the week. Any identified issues were to be corrected and re-education/disciplinary action, as indicated by the DON or the Assistant Director of Nurses (ADON) would be completed. An interview, on 06/27/11 at 10:50 AM, with the DON revealed she discovered two incidents of staff failing to document a follow-up to an as needed (prn) pain medication on a resident. On the morning of 06/20/11 (a Monday) following the weekend (06/18/11 & 06/19/11) she discovered the weekend supervisor had not completed the daily pain audit. The DON stated she informed and educated the weekend supervisor that she was responsible for conducting the daily audits of pain documentation, from 3:00 PM on Friday until the end of her shift on Sunday night at 9:00 PM. The DON revealed she discovered the issues regarding the failure to complete the daily audits, on 06/27/10. The DON revealed she had not completed disciplinary action for the staff involved. An interview with the weekend supervisor, on 06/28/11 at 11:06 AM, revealed she received counseling earlier that morning. She stated the DON talked with her about the daily audits not conducted on 06/17/11. She stated, "The DON said it was just a miscommunication about the daily pain audits". An interview, on 06/28/11 at 4:13 PM, with the facility's Administrator revealed he was responsible to ensure the facility staff carried out activities per the AoC (daily audits of pain documentation). The DON made him aware of the issues found regarding follow-up pain assessment documentation, for dates 06/13/11 and 06/17/11) and the weekend supervisor not completing the daily review of the pain documentation for the weekend of 06/18-19/11 and 06/25-26/11. The Administrator stated, "Each case we followed the steps and completed re-education as we alleged. If we have problem with the audits, then we may have to adjust who completes the weekend audits".