Every finding on record at Cumberland Valley Nursing & Rehabilitation Center

Based on observation, interview, and facility policy review, the facility failed to ensure proper food handling practices were followed, which had the potential to affect all residents who received meals from the dietary department. Specifically, two kitchen staff with facial hair (Cook 1 and [NAME] 2) were observed without beard restraints in place while handling food items in the kitchen. Findings included: An undated facility policy titled, Employee Sanitary Practices revealed a section titled, Procedure that specified, All employees will: 1. Wear hair restraints (hairnet, hat, and/or beard restraint) to prevent hair from contacting exposed food. An observation of the kitchen on 09/09/2025 at 10:47 AM revealed that while checking the temperatures of food items [NAME] 1's mustache was not covered by a hair restraint. An additional observation on 09/09/2025 at 11:15 AM revealed [NAME] 2 was observed in the kitchen assisting with food preparation and retrieving items from the refrigerator to place on residents' trays with his mustache uncovered. During an interview on 09/09/2025 at 1:13 PM, [NAME] 1 stated that the facility expected staff to cover their facial hair with beard restraints. [NAME] 1 stated sometimes the beard restraint shifted when he was working a long time, but it should have been covering all of his facial hair. During an interview on 09/10/2025 at 12:46 PM, [NAME] 2 stated that he did not realize that his beard restraint was not covering his mustache, but it was supposed to. During an interview on 09/12/2025 at 10:39 AM, the Assistant Dietary Manager stated kitchen staff with facial hair were expected to use facial hair restraints. During a concurrent interview on 09/12/2025 at 8:56 AM, the Administrator (ADM) and the Director of Nursing (DON) both stated that staff should follow the facility policy regarding beard restraints.

Based on interview, record review, and facility policy review, the facility failed to ensure each resident was treated with dignity and respect for 1 (Resident 74) of 2 sampled residents reviewed for dignity and respect.Findings included: A facility policy titled, Resident Rights, reviewed 08/20/2025, indicated, Policy Statement - All residents have the right to be treated with respect, dignity and in a manner and in an environment that promotes maintenance and enhancement of quality of life. An admission Record indicated the facility admitted Resident(R)74 on 04/24/2024. According to the admission Record, the resident had a medical history that included diagnoses of major depressive disorder and anxiety disorder. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/16/2025, revealed R74 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated the resident was dependent on staff for personal hygiene, moving from lying to sitting on the side of the bed, and chair/bed to chair transfers. R74's Care Plan Report included a focus area, revised 03/20/2025, that indicated the resident had a history of verbally degrading comments to others and a history of yelling at staff. An intervention dated 10/23/2023 directed staff to be reassuring and listen to the resident's concerns. During an interview on 09/10/2025 at 1:04 PM, State Registered Nurse Aide (SRNA) 6 stated that on 03/21/2025 at 1:20 PM she was in the process of getting R74 into their wheelchair, and the resident started screaming at her. SRNA 6 stated she told the resident that having a temper tantrum like a five-year-old was not helping the situation. SRNA 6 stated she knew she should not have said that to the resident. During an interview on 09/09/2025 at 3:38 PM, R 74 stated they did not want to discuss the incident involving SRNA 6, as the incident had already been investigated and resolved. During a follow-up interview on 09/10/2025 at 11:55 AM, R74 stated the incident was old news, as the facility had already handled the situation. R74 stated they had no concerns with facility staff members and indicated SRNA 6 was a great aide and very professional. R74 said he did not recall the SRNA making any unprofessional comments toward them. During an interview on 09/11/2025 at 8:59 AM, the Social Services Director (SSD) stated R74 reported staff were not listening to them, the resident was upset, but the resident did not appear to fear staff or feel unsafe. The SSD stated she learned from other staff members that SRNA 6 had said R74 was throwing a temper tantrum like a five-year-old. The SSD stated she considered the remark inappropriate. During an interview on 09/11/2025 at 9:39 AM, the Administrator stated she expected her staff to treat the residents with respect and dignity.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure staff assisted dependent residents with activities of daily living (ADLs) for 2 (Resident 2 and Resident 74) of 4 sampled residents reviewed for ADLs. Specifically, the facility failed to provide nail care for Resident 2 and Resident 74. Findings included: A facility policy titled, Activities of Daily Living (ADLs), reviewed 08/20/2025, indicated, 5. For those residents who are unable to perform their own activities of daily living, the facility will provide the needed assistance for completion of cares. Some residents based on medical conditions, co-morbidities, and disease processes may have unavoidable decline in ADLs or lack the potential to improve in their ability to be more independent with self-performance of ADLs. 1. An admission Record revealed the facility readmitted Resident (R) 2 on 09/04/2025. According to the admission Record, the resident had a medical history that included diagnoses of type 2 diabetes mellitus with diabetic neuropathy, hemiplegia and hemiparesis following cerebral infarction affecting the left dominant side, and stiffness of the left hand. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/12/2025, revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. The MDS indicated R2 was dependent on staff for personal hygiene. R2's Care Plan Report included a focus area, revised 03/04/2025, that indicated the resident was at risk for complications associated with type 2 diabetes. Interventions directed staff to provide nail care per licensed staff or a podiatrist, revised 03/04/2025. R2's Care Plan Report included a focus area, revised 06/17/2025, that indicated the resident was at risk for a decrease in ADL function related to hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting the left dominant side, convulsions, rheumatoid arthritis, gout, peripheral vascular disease, type 2 diabetes mellitus with diabetic neuropathy, and chronic obstructive pulmonary disease. Interventions directed staff to assist Resident #2 with hygiene, revised 08/06/2025. An observation on 09/08/2025 at 10:41 AM revealed R2 had long fingernails. An observation on 09/09/2025 at 3:38 PM revealed R2 had long fingernails. During an interview on 09/10/2025 at 12:22 PM, Unit Coordinator (UC) 3 stated nail care was provided on the residents' shower days or as needed. UC #3 stated state registered nurse aides (SRNAs) were responsible to clean all residents' nails and trim the non-diabetic residents' fingernails. UC 3 stated residents who had diabetes had their nails trimmed by nurses. During a concurrent observation and interview on 09/11/2025 at 2:19 PM, SRNA 4 stated nail trim/cleaning was a task that was completed every day for all residents. SRNA 4 stated the nurses trimmed the fingernails if the resident was diabetic. SRNA 4 observed R2's fingernails and stated he did not clean the resident's nails that day, and he should have cleaned them. During a concurrent observation and interview on 09/11/2025 at 2:28 PM, UC 3 stated the administration team checked the residents on their assigned units daily to ensure things like personal hygiene which included cleaning and the trimming fingernails were done. UC #3 stated she had completed the rounds (scheduled staff visits) for her unit that day and she had no concerns. However, on observing R2's fingernails UC 3 stated the resident's nails were dirty and long. UC 3 stated she expected her staff to keep the residents' fingernails clean and trimmed. During an interview on 09/11/2025 at 4:40 PM, SRNA 4 stated he had given R2 their bed bath that day and was responsible for making sure the resident's fingernails were clean. SRNA 4 stated he cleaned R2's hands but did not clean the resident's fingernails. SRNA 4 stated cleaning fingernails was part of the SRNA's job duties. SRNA 4 stated he did not offer to clean R2's fingernails that day. During an interview on 09/11/2025 at 4:43 PM, Licensed Practical Nurse (LPN) 5 stated diabetic residents' fingernails were cleaned once a week and as needed. During an observation on 09/11/2025 at 4:48 PM, LPN 5 confirmed R2's fingernails needed to be trimmed. LPN 5 stated the nurses were responsible for trimming the fingernails of the diabetic residents. During an interview on 09/12/2025 at 9:59 AM, the Administrator (ADM) stated she expected her aides to keep the residents' nails clean and trimmed. The Administrator stated the nurses were responsible for trimming the diabetic residents' fingernails. During an interview on 09/12/2025 at 10:05 AM, the Director of Nursing (DON) stated she expected her aides to keep the residents' nails clean and trimmed, and she stated the nurses were responsible to trim the diabetic residents' fingernails. 2. An admission Record indicated the facility admitted R74 on 04/24/2024. According to the admission Record, the resident had a medical history that included diagnoses of type 2 diabetes mellitus and morbid obesity. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/16/2025, revealed R74 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated the resident was dependent on staff for personal hygiene. R74's Care Plan Report included a focus area, revised 08/20/2024, that indicated the resident at risk for impaired ability to perform selfcare related to morbid obesity. Interventions directed staff to provide hygiene, 09/28/2023. R74's Care Plan Report included a focus area, revised 07/15/2024, that indicated the resident was at risk for pressure related skin problems. Interventions directed staff to attempt to keep R74's nails short and clean as the resident allowed, 07/15/2024. During a concurrent observation and interview on 09/08/2025 at 10:47 AM, R74 was observed to have long, dirty fingernails. R74 stated that the staff did not offer to provide nail care. R74 stated they would like their fingernails to be clean and trimmed. During a concurrent observation and interview on 09/09/2025 at 12:03 PM, R74 was observed to have long, dirty fingernails. R74 stated no staff had offered to trim their fingernails, and they would like them to be trimmed. During a concurrent observation and interview on 09/10/2025 at 12:14 PM, R74 was observed to have long, dirty fingernails. R74 stated they had not asked the staff to trim their fingernails, but they wished the staff would trim and clean their fingernails when the staff had time. During an interview on 09/10/2025 at 12:22 PM, Unit Coordinator (UC) 3 stated nail care was provided on the residents' shower days or as needed. UC 3 stated State Registered Nurse Aides (SRNA) were responsible to clean all residents' nails and trim the non-diabetic residents' fingernails. UC 3 stated residents who had diabetes had their nails trimmed by nurses. During a concurrent observation and interview on 09/11/2025 at 2:19 PM, SRNA 4 stated nail trim/cleaning was a task that was completed every day for all residents. SRNA 4 stated the nurses trimmed the fingernails if the resident was diabetic. SRNA 4 observed R74's fingernails and stated he did not clean the resident's nails that day, and he should have cleaned them. During a concurrent observation and interview on 09/11/2025 at 2:28 PM, UC 3 stated the administration team checked the residents on their assigned units daily to ensure things like personal hygiene, which included cleaning and the trimming fingernails, were done. UC 3 stated she had completed the rounds (scheduled staff visits) for her unit that day and she had no concerns. However, on observing R74's fingernails UC 3 stated the resident's nails were dirty and long. UC 3 stated she expected her staff to keep the residents' fingernails clean and trimmed. During an interview on 09/11/2025 at 3:16 PM, R74 stated they had already had their bed bath for the day, and staff had not cleaned or trimmed their fingernails. A concurrent observation of R74's fingernails revealed the resident's nails were long and dirty. During an interview on 09/11/2025 at 4:40 PM, SRNA 4 stated he had given R74 their bed bath that day and was responsible for making sure their fingernails were clean. SRNA 4 stated R74 was moving their hands, and he did not clean the resident's fingernails that day. SRNA 4 stated cleaning fingernails was part of the SRNA's job duties, but he had not offered to clean R74's fingernails that day. During an observation on 09/11/2025 at 4:50 PM, LPN 5 confirmed 74's fingernails were long and dirty and should have been trimmed and cleaned by staff. LPN 5 stated the SRNAs were responsible for cleaning the residents' fingernails, and the nurses were responsible for trimming the diabetic residents' fingernails. During an interview on 09/12/2025 at 9:59 AM, the Administrator (ADM) stated she expected her aides to keep the residents' nails clean and trimmed. The Administrator stated the nurses were responsible for trimming the diabetic residents' fingernails. During an interview on 09/12/2025 at 10:05 AM, the Director of Nursing (DON) stated she expected her aides to keep the residents' nails clean and trimmed, and she stated the nurses were responsible to trim the diabetic residents' fingernails.

Based on observation, interview, and record review, the facility failed to develop and implement a Comprehensive Person-Centered Care Plan for each resident that included measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs for 3 of 27 sampled residents, Residents (R) 14, R33, and R58. On 08/10/2023, facility staff observed R33 in R14's room with his hands under R14's shirt. However, the facility failed to develop R33's Comprehensive Care Plan (CCP) to include interventions to address supervision and monitoring of the resident. On 09/01/2023, facility staff observed R33 in R58's room with his hand on R58's breast. Again, the facility failed to develop interventions for R33's inappropriate sexual behaviors in his CCP. On 04/27/2024, facility staff found R33 in R58's room with his hands inside R58's open brief, and her night clothing pulled up to expose her breasts. The facility again failed to develop a CCP for R33 which addressed his inappropriate sexual behavior and need for supervision and monitoring him in order to protect other residents. Immediate Jeopardy (IJ) was identified on 10/16/2024 at 42 CFR 483.21 Develop and Implementation of a Comprehensive Person-Centered Care Plan (F656) at a Scope and Severity (S/S) of a J. The IJ was determined to exist on 08/10/2023. The facility was notified of the IJ on 10/16/2024. An acceptable Immediate Jeopardy Removal Plan was received on 10/19/2024, which alleged removal of the IJ on 04/30/2024. The State Survey Agency (SSA) validated the IJ was removed on 04/30/2024. Refer to 689 The findings include: 1(a). Review of R14's Admission Record revealed the facility admitted the resident on 12/13/2017, with diagnoses of Parkinsonism, dementia, anxiety disorder, and heart disease. Review of R14's Annual MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS' score of seven out of 15, indicating severe cognitive impairment. Review of R14's CCP dated 08/04/2023, revealed the facility identified a problem for the resident as at risk for feelings of isolation. 1(b). Review of R33's Admission Record revealed the facility admitted the resident on 09/11/2015 with diagnoses which included aphasia, cerebral infarction, osteoarthritis, and hemiplegia and hemiparesis. Review of R33's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of 99, which indicated he was unable to complete the interview. Further review revealed the facility also assessed R33 to have modified independence with making decisions. Review of the facility's investigation, dated 08/10/2023, revealed at 3:20 PM, the Administrator was notified that the Activity Director had walked into R14's room and found R33 with his hand up R14's shirt. The facility placed R33 on increased monitoring for eight (8) hours with no issues identified. Review of R33's (CCP), revealed the facility developed a problem for mood/behaviors dated 08/11/2023 (the day after the sexually inappropriate incident). Per review, the facility developed the problem with mood/behaviors related to a history of socially inappropriate/disruptive behavior and noncompliance with medications and care. Continued review of the mood/behavior care plan revealed R33 had a history of wandering into (other) residents' rooms uninvited, and had a history of sexually inappropriate behaviors towards other residents. Further review revealed the interventions the facility developed for R33 included administering medications as ordered; monitoring the resident for pocketing medications, and removing him from public areas when his behavior was disruptive or inappropriate. However, additional review of R33's CCP revealed no documented evidence the facility developed interventions such as: removing R33 from other residents' rooms; monitoring him for sexual behaviors; and/or monitoring or supervising the resident to prevent further incidents. In interview on 10/19/2024 at 2:05 PM, the Regional [NAME] President of Operations (VPO) stated the facility's intent for the (CCP) intervention of removal of R33 from public areas when his behavior was disruptive/inappropriate was to watch him while in the hallway to keep him from going into other residents' rooms. She stated she considered residents' rooms as public areas. In interview on 10/19/2024 at 5:25 PM, the Social Services Director (SSD) stated she updated R33's CCP for removing him from public areas when his behavior was disruptive/inappropriate. The SSD further stated she did not consider other residents' rooms as public areas. In interview on 10/16/2024 at 4:51 PM, R14's family member stated the facility placed a Velcro stop sign over the resident's door entrance. Per R14's family member, the facility explained the stop sign placed over R14's door entrance as due to her having a urinary infection and required the stop sign. In continued interview on 10/19/2024 at 5:25 PM, the SSD stated she updated R14's CCP to include the stop sign. 2. Review of R58's Admission Record revealed the facility admitted the resident on 08/17/2023, with diagnoses of Alzheimer's Disease, femur fracture, and anxiety. Review of 58's Admission MDS assessment dated [DATE], revealed the facility assessed the resident as having a BIMS' score of 99, indicating the resident had not been able to complete the interview. Further review revealed the facility assessed R58's cognitive skills for decision making as severely impaired. Review of R33's progress note dated 09/01/2023 at 11:56 AM, documented by Licensed Practical Nurse (LPN) 4, revealed staff found R33 in R58's room with her shirt pulled up and him touching R58's breast. Further review revealed the facility placed R33 on one to one (1:1) monitoring. Review of the facility's investigation, dated 09/01/2023, revealed at 10:35 AM, a Certified Nursing Assistant (CNA) notified the SSD, who notified the Administrator, that the CNA walked into R58's room and saw R33 sitting in his wheelchair with his hand up R58's shirt, touching her breast. R33 was placed on 1:1 monitoring and was referred to the hospital's behavioral health unit. R33 and R58 were placed on acute 72-hour charting to identify any signs or symptoms of psychosocial decline. However, review of R33's CCP revealed no revisions to the resident's mood/behavior care plan immediately following the incident on 09/01/2023. Review of R33's CCP revealed a psychotropic medication care plan initiated 09/08/2023, for the resident's risk for adverse medication effects. Per review of the psychotropic medication care plan, the facility initiated interventions for administering R33's medications as ordered, and to monitor and document R33's target behaviors. Further review of R33's CCP revealed no documented evidence the facility care planned R33 for 1:1 monitoring. Review of R58's CCP revealed no evidence the facility developed the resident's CCP, following the incident on 09/01/2023, to include interventions for her protection from further sexual abuse by other residents. In interview on 10/16/2024 at 1:36 PM, Licensed Practical Nurse (LPN) 7 stated R33 had been placed on 1:1 monitoring at the time of the 09/01/2023 incident and, after the 1:1 monitoring was completed, all staff knew they were to keep an eye on R33. The LPN stated the task for keeping an eye on R33 had not been assigned to anyone specifically. LPN 7 stated it was possible R33 could have gone into another resident's room during that time. In interview on 10/19/2024 at 2:05 PM, the Regional VPO stated R33's target behaviors were the ones stated in the mood/behavior care plan which included socially inappropriate/disruptive behavior, noncompliance with medications and care, history of wandering into other residents' rooms uninvited, and a history of sexually inappropriate behaviors towards other residents. 3. Review of the facility's investigation documentation dated 04/27/2024, revealed Certified Medication Technician (CMT) 1 had seen R33 in R58's room. Continued review revealed R33 had been sitting in his wheelchair leaning over R58, who was lying on her bed. Per review, R33's hand was inside R58's unfastened brief. Further review revealed R33 was removed from R58's room and placed on 1:1 monitoring, and R58 was referred for psychiatric (psych) services. Review of R58's progress note dated 04/27/2024 at 11:55 PM, revealed staff found R33 in R58's room with his hand down her brief and her shirt pulled up exposing her breast. Further review of the note revealed R58 was asked if she wanted R33 in her room touching her and the resident stated, No. In interview on 10/16/2024 at 10:30 AM, CMT 1 stated she had been walking down the hallway on 04/27/2024 and had seen R33 in R58's room with his hand inside R58's opened brief. She stated she had to physically remove R33's hand from inside R58's brief. CMT 1 stated R33 was placed on 24 hours of 1:1 supervision for 24 hour monitoring after that incident. The resident continued on the 1:1 monitoring since his return from the hospital's behavioral health unit. Additionally, CMT 1 stated she notified the supervising nurse immediately of the incident. CMT 1 further stated she was unaware if either residents' care plan was updated following the incident. Review of R58's social services (SS) progress note dated 04/29/2024 at 8:29 AM, revealed staff reported R58 had (displayed) tearful behaviors last night. Continued review of the note revealed a stop sign was to be hung on R58's door and the resident to be referred to psych services. Review of R33's CCP revealed the facility's interventions, initiated on 04/28/2024, included monitoring the resident for behaviors when out of his room. Continued review revealed the interventions also included redirecting R33 when he went into another resident's room, and providing 1:1 monitoring for behaviors. In interview on 10/17/2024 at 3:35 PM, the Administrator stated R33 was originally care planned for 1:1 monitoring after the 04/27/2024 incident; however, the wording had been changed (she was not sure when) as the facility was trying to place R33 in another facility. The Administrator further stated no one would take him with 1:1 monitoring charted (in his medical record). The Administrator additionally stated she felt the resident's care plans were updated correctly with interventions that were effective at the time of the incidents. In interview on 10/19/2024 at 5:25 PM, the Social Services Director (SSD) stated she updated R33's CCP with new interventions for behaviors. However, she did not include the intervention of 1:1 monitoring.

Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure each resident received adequate supervision to prevent sexual abuse for 3 of 27 sampled residents (Residents (R)14, R33, and R58). On 08/10/2023, staff found R33 in R14's room with his hands under R14's shirt. The facility failed to assess R33's risk for inappropriate sexual behaviors to prevent further incidents placing other residents at risk for sexual abuse. The facility created a Mood/Behaviors Care Plan on 08/11/2023 for R33; however, they failed to develop and implement interventions for the resident in order to protect other residents from potential risk of sexual abuse by him. On 09/01/2023, staff found R33 in another resident's room (R58's) with his hand under her shirt touching her breast. The facility again failed to implement care plan interventions to protect other residents from further sexual abuse by R33. On 04/27/2024, staff found R33 in R58's room with his hands inside R58's opened brief, and her night clothing pulled up exposing her breast. In addition, the facility failed to provide documented evidence R33, R14, and R58 were assessed for their capacity to consent to sexual activity. The facility's failure to have an effective system to ensure residents received adequate supervision to prevent sexual abuse was likely to cause serious injury, impairment, or death of a resident. Immediate Jeopardy (IJ) was identified on 10/16/2024 at 42 CFR 483.25 Accidents and Supervision (F689) with a Scope and Severity (S/S) of a J. Substandard Quality of Care (SQC) was identified at 42 CFR 483.25 Accidents and Supervision (F689). The IJ was determined to exist on 08/10/2023. The facility was notified of the IJ on 10/18/2024. An acceptable Immediate Jeopardy Removal Plan was received on 10/19/2024, which alleged removal of the Immediate Jeopardy on 04/30/2024. The State Survey Agency (SSA) validated the Immediate Jeopardy was removed on 04/30/2024 and determined to be past IJ. Refer to F656 The findings include: Review of the facility's policy titled, Abuse, Neglect, Protection, Prevention, and Reporting Policy, effective 08/04/2024, revealed the facility was to establish a safe environment that supported, to the extent possible, a resident's safety. Continued review revealed the facility was to identify, correct, and intervene in situations in which abuse was more likely to occur. Further review revealed the facility's Administrator was to identify, intervene, and correct situations in which reported abuse might recur. Review of the facility's policy titled, Resident Rights Policy, effective 08/13/2024, revealed all residents had the right to be treated with respect, dignity, and in a manner and environment that promoted maintenance or enhancement of quality of life. Further review revealed the facility was to make every effort to support each resident in exercising his/her right to assure the resident was always treated with respect, kindness, and dignity. Review of the facility's policy titled, Behavioral Assessment, Intervention and Monitoring, revised 06/20/2024, revealed the interdisciplinary team (IDT) was to thoroughly evaluate new or changing behavioral symptoms in residents. Per review, the IDT was to thoroughly evaluate such residents' behaviors in order to identify underlying causes and address any modifiable factors that might have contributed to the resident's changing condition. Continued review revealed safety strategies were to be implemented immediately if necessary to protect the resident and others from harm. Further review revealed the Director of Nursing (DON) or designee was to evaluate whether the staffing needs changed based on acuity of the residents and their plans of care. Additional review revealed staff and/or staff training was to be provided if it was determined the needs of the residents could not be met with the current level of staff or staff training. 1(a). Review of R33's Admission Record revealed the facility admitted the resident on 09/11/2015, with diagnoses which included aphasia, cerebral infarction, osteoarthritis, and hemiplegia and hemiparesis. Review of R33'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 99, which indicated the resident was unable to complete the interview. Further review revealed the facility assessed R33's mental status as modified independence with decision making. Review of R33's Comprehensive Care Plan (CCP) dated 08/11/2023, revealed the facility identified a problem with mood/behaviors with a history of socially inappropriate/disruptive behavior and noncompliance with medications and care for the resident. Continued review revealed R33, at times, attempted to pocket medications, had a history of wandering into residents' rooms uninvited and had a history of sexually inappropriate behaviors towards others. Further review revealed the interventions included: administering medications as ordered; monitoring the resident for pocketing medications; and removing from public areas when his behavior was disruptive/inappropriate. Additional review revealed no documented evidence the facility implemented interventions for R33's increased monitoring or for R33 wandering into other residents' rooms uninvited. Review of the facility's investigation dated 08/10/2023, revealed at 3:20 PM, the Administrator was notified by the Activity Director (AD) that when the AD walked into R14's room the AD observed R33 with his hand up R14's shirt. Further review of the investigation revealed the facility placed R33 on increased monitoring for eight hours with no issues identified. Review of R33's progress note, dated 08/10/2023 at 5:50 PM, written by Registered Nurse (RN) 3, revealed the resident's responsible party was notified the resident was on increased monitoring. Per review, R33's responsible party was also notified the resident was not to visit other female residents in their rooms. Review of R33's progress note dated 08/11/2023 at 11:48 AM, written by the Social Services Director (SSD) revealed the resident was in his room with no signs or symptoms of psychosocial distress. Review of the facility's 15-Minute Watch Log, for R33 dated 08/10/2023, revealed the facility placed the resident on one to one (1:1) monitoring for (2) hours; then on every 15-minute checks for 2 hours. Continued review of the Log revealed the facility then placed R33 on every 30-minute checks for 2 hours; and then hourly checks for 2 hours. Further review revealed the Watch Log was only initialed by staff with no documented evidence of the resident's behaviors. During interview with R33's family member on 10/16/2024 at 12:27 PM, the family member stated the facility did not notify her of the incident on 08/10/2023. During interview on 10/19/2024 at 5:25 PM, the SSD stated she updated R33's CCP for wandering and 1:1 monitoring. The SSD stated she considered public areas to be hallways including leading into the residents' rooms. She stated she did not consider residents' rooms to be public areas. 1(b). Review of R14's Admission Record revealed the facility admitted the resident on 12/13/2017, with diagnoses that included dementia, anxiety disorder, heart disease, and Parkinsons. Review of R14's Annual MDS Assessment, dated 06/22/2023, revealed the facility assessed the resident to have a BIMS' score of seven out of 15, which indicated she was severely cognitively impaired. Review of R14's CCP, dated 08/04/2023, revealed the facility identified a problem for the resident as at risk for feelings of isolation. Continued review revealed an intervention, dated 08/15/2023, to place a privacy sign across R14's room doorway. Review of R14's progress note, dated 08/11/2023 at 11:44 AM, written by the SSD revealed R14 showed no signs or symptoms of psychosocial distress. Continued review of R14's progress notes revealed no further documentation regarding R14's psychosocial well-being until 08/14/2023 at 9:36 AM, when nursing staff noted the resident had no signs of psychosocial distress. In interview with R14's family member on 10/16/2024 at 4:51 PM, the family member stated a facility staff member called her and advised her a male resident had wandered into R14's room. Per the family member, the staff member asked if it was okay for the male resident to visit R14. The family member stated she answered, yes because she was never informed the male resident might have or might not have touched R14 inappropriately. R14's family member stated the facility placed a velcro stop sign over the resident's door entrance, but facility staff said it (the stop sign) was over the door entrance because she had an infection and required it. During interview on 10/17/2024 at 3:35 PM, the Administrator stated she investigated the allegation regarding R33 and felt the eight hours of increased monitoring had been sufficient as the resident had no further behaviors during those eight hours. During interview on 10/19/2024 at 2:05 PM, the Regional [NAME] President of Operations (VPO) stated the intent of the care plan intervention for removing R33 from public areas when his behavior was disruptive/inappropriate was to watch for residents in the hallway to keep him from going into other residents' rooms. She stated she considered residents' rooms to be public areas. During interview on 10/19/2024 at 5:25 PM, the SSD stated she updated R14's CCP to include a stop sign. 2(a). Review of R33's CCP revealed no documented evidence of further revisions to the resident's mood/behavior care plan after the incident on 08/10/2023. Review of R33's progress note, dated 09/01/2023 at 11:56 AM, documented by LPN 4, revealed staff found R33 in R58's room with R58's shirt up and R33 touching her breast. Further review revealed R33 was placed on 1:1 monitoring. Review of the facility's investigation documentation dated 09/01/2023, revealed at 10:35 AM, a Certified Nursing Assistant (CNA) notified the SSD that R33 was in R58's room. The SSD notified the Administrator of the incident Per review, R33 was placed on 1:1 monitoring and was referred to the hospital's behavioral health unit. Further review revealed R33 and R58 were placed on acute 72-hour charting to identify any signs or symptoms of psychosocial decline. Review of the facility's Social Service (SS) progress note dated 09/01/2023 at 2:56 PM, revealed R33 had been accepted to the hospital's behavioral health unit. Review of the facility's Health Status Progress Note for R33, documented by Unit 2 Manager, dated 09/07/2023 at 11:37 AM, revealed R33 had refused all medication while at the behavioral health unit and was returning with no changes. Further review revealed staff from the behavioral health unit stated there was nothing more they could do for R33. Review of the facility's progress note dated 09/07/2023 at 1:45 PM, documented by LPN 4, revealed R33 returned to the facility. Review of the facility's Health Status Progress Note, dated 09/07/2023 at 3:02 PM, documented by Unit 2 Manager, revealed R33 was oriented to the new room as an intervention for recent behavior. Further review revealed R33's ordered Paxil (an antidepressant) to be administered for the resident related to other specified depressive episodes. During interview on 10/16/2024 at 12:27 PM, R33's family member stated the facility only disclosed one incident to her and she was unaware of the incident on 09/01/2023. During interview, on 10/16/2024 at 2:31 PM, LPN 4 stated she did not remember the incident (on 09/01/2023), but would have charted everything accurately. LPN 4 stated for any abuse allegations she would notify her supervisors, including the DON and Administrator as well as the Physician and resident's responsible party. During interview on 10/17/2024 at 3:35 PM, the Administrator stated she felt the 1:1 monitoring of R33 following the incident on 09/01/2023, and the order for Paxil upon the resident's return from the behavioral health unit were effective. She stated she felt the 1:1 monitoring and Paxil had been effective because R33 had no further episodes of sexual behavior until April 2024. 2(b). Review of R58's Admission Record revealed the facility admitted the resident on 08/17/2023, with diagnoses of femur fracture, anxiety, and Alzheimer's Disease. Review of R58's Admission MDS Assessment, dated 08/19/2023, revealed the facility assessed the resident to have a BIMS' score of 99, which indicated the resident was unable to complete the interview. Further MDS review revealed the facility assessed R58's cognitive skills for decision making as severely impaired. Review of R58's Psychosocial CCP, dated 08/29/2023, revealed R58 was at risk for feelings of isolation from family and friends with interventions which included to encourage the resident to talk about her feelings. However, there was no documented evidence the facility addressed the resident's psychosocial well-being or safety from abuse. Review of R58's CCP revealed no evidence the facility updated the CCP following the incident. Review of the facility's progress note dated 09/01/2023 at 12:20 PM, documented by LPN 4, revealed R58 was in a pleasant mood, and the family was aware of the incident. However, further review of R58's progress notes revealed no documented evidence indicating the specific details of the incident. During interview on 10/16/2024 at 1:36 PM, LPN 7 stated R33 had been placed on 1:1 monitoring (after the incident on 09/01/2023). The LPN stated after the 1:1 monitoring was completed all staff knew they were to keep an eye on R33, but the task was not specifically assigned to anyone. LPN 7 stated it might been possible for R33 to have gone to a different room during that time. 3(a). Review of R33's Annual MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS' score of 99, indicating the resident was unable to complete the interview. Further review revealed the facility assessed R33 to have modified independence with decision making. Review of R33's CCP, initiated on 08/11/2023, for the resident's risk for mood/behaviors revealed the facility initiated interventions on 04/28/2024, to include monitoring R33 for behaviors when he was out of his room and redirecting him when he went into another resident's room. Review of the facility's investigation documentation dated 04/27/2024, revealed Certified Medication Technician (CMT) 1 saw R33 in R58's room. Per review, R33 was sitting in his wheelchair leaning over R58, who was lying on her bed. Continued review revealed R33 had his hand inside R58's brief which was unfastened. Further review revealed R33 was removed from the room and placed on 1:1 monitoring. Additional review revealed the facility referred R33 for weekly psychiatric (psych) services for evaluation and monitoring (after the incident). Review of the Police Call Response Run Report, dated 04/27/2024 at 11:30 PM, revealed an officer interviewed R33 and noted the resident showed no regrets for his actions. Review of R33's progress note, dated 04/29/2024 at 1:19 PM, documented by the SSM, revealed R33 had been accepted to the hospital's behavioral health unit. Review of the hospital psychiatric discharge summary for R33, dated 05/27/2024 at 8:23 AM, revealed the resident was noted as sexually aggressive with staff and other residents. Per review, R33 was also noted to often wait until an opportunity presented itself to touch other residents. Further review revealed R33 had to have constant monitoring and redirection. Review of the facility's progress record documentation for R33, dated 07/18/2024, revealed the resident's Physician stated due to the safety of individuals in the facility including residents and staff, we are unable to meet his needs due to his multiple sexual inappropriate gestures to residents. All measures have been exhausted. 3(b). Review of the facility's Quarterly MDS assessment dated [DATE], revealed the facility assessed R58 to have a BIMS' score of 99, which indicated she was unable to complete the interview. Further MDS review revealed the facility assessed R58's cognitive skills for decision making as severely impaired. Review of R58's CCP revealed no evidence the facility further developed the CCP with new interventions for the resident's safety and well-being following their investigation. Review of R58's progress note dated 04/27/2024 at 11:55 PM, revealed facility staff found R33 in R58's room with his hand down inside her brief and her shirt pulled up with her breast exposed. Continued review revealed R58 was asked if she wanted R33 in her room touching her and she stated No. Further review revealed R58 was scared, and there was redness noted to her labia upon skin assessment. Review of the facility's progress note for R58 dated 04/28/2024 at 12:44 PM, revealed the resident was noted to have had no psychosocial changes (as a result of the incident on 04/24/2024). Review of the facility's SS progress note for R58, dated 04/29/2024 at 8:29 AM, documented by the SSD, revealed staff reported R58 had tearful behaviors last night. Further review revealed a stop sign was to be hung on R58's door and the resident referred to psych services. Review of the psychiatry diagnostic interview documentation for R58 dated 05/07/2024, revealed it was the initial evaluation for the resident for follow-up on an incident involving R33. Per review, staff reported since the incident R58 had experienced one episode of tearfulness. Continued review revealed R58 had limited verbal ability and smiled and nodded during the assessment. Further review revealed R58 had been unable to answer questions appropriately due to her severely impaired cognition related to Alzheimer's Disease. In addition, review of the documentation revealed recommendations for staff to monitor and document any changes in R58's mood. During interview on 10/16/2024 at 10:30 AM, CMT 1 stated she was walking down the hallway on 04/27/2024 and saw R33 in R58's room with his hand inside R58's opened brief. CMT 1 stated she had to physically remove R33's hand from inside R58's brief. CMT 1 stated R33 was placed on 24 hour 1:1 monitoring after that second incident with R58, and had continued on 1:1 monitoring since he returned from the hospital's behavioral health unit. CMT 1 further stated R33 was known, by the facility staff, to have had behavioral issues since 2020. During an interview on 10/21/2024 at 10:36 AM, the Medical Director stated he was aware of R33's behaviors and the resident was the facility's problem child. He stated he and another Physician were co-Medical Directors of the facility. The Medical Director stated he and the other Physician had conferred and believed the only way to keep other residents safe at the facility was to keep R33 on 1:1 monitoring until he could be placed in another facility. In an interview, on 10/17/2024 at 3:35 PM, the Administrator stated the facility had provided interventions for each incident which she felt were effective.

Based on observation, interview, review of the facility's job descriptions, personnel records, and the health department's website, the facility failed to employ staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service and meet state requirements for food service personnel. According to the local health department all individuals who handled food were to obtain a valid food handler safety card to ensure the food safety standards were maintained. However, the facility failed to provide documented evidence of Dietary Aide 1's (DA1), DA 2's, and DA 3's certification. The findings include: Review of the facility's job description for Dietary Aides (DA's), undated, revealed an essential function of the DA's role was to attend in-service classes to maintain current licensure/certification, if applicable. Review of the local health department's website, www.lcdhd.org, revealed the health department required all food handlers to become certified food employees. Observation on 10/14/2024 at 5:07 PM, revealed DA 1, DA 2, and DA 3 were assisting with the dinner meal preparation and placing food and drinks on trays to be served to residents. Continued observation revealed DA 3 carried a piece of chicken from the steam table to the preparation (prep) table and placed the chicken in the blender and pureed it. During an interview on 10/14/2024 at 5:20 PM, DA 3 stated the cook had not prepared the pureed meat. She stated she was told to puree the chicken to serve to a resident. During an interview on 10/14/2024 at 5:50 PM, the Assistant Food and Nutritional Services Manager stated the Food and Nutritional Services Manager was on leave, so he was the acting manager. He stated the DAs were not required to maintain food handler certifications. He stated only the cooks were to maintain the food handler certification. During an interview on 10/14/2024 at 6:15 PM, the Regional Food and Nutritional Services Manager stated only cooks were required to have food handler certifications. During an interview on 10/15/2024 at 9:59 AM, Health Department Employee 1, stated everyone who handled food was to be food handler certified. Health Department Employee 1 stated there should be a copy of the food handler certification on file. The SSA (State Survey Agency) Surveyor requested the food handler certification for DA 1, DA 2, and DA 3 on 10/14/2024 at 6:15 PM. However, the facility provided no documented evidence of the required food handler certification for the three DAs as requested.

Based on observation, interview, and review of the facility's policy, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Observation of the kitchen revealed food items undated, labeled, or stored properly to prevent potential contamination. In addition, [NAME] 1 was observed to have no net covering his beard. The findings include: Review of the facility's policy titled, Food Safety and Sanitation, undated, revealed the food and nutrition services department was to follow regulations as outlined by other official health agencies and organizations with jurisdiction over the facility. Per review, employees were to wear hair restraints where required to cover all hair on the head, and beard nets were required when hair was visible. Continued review revealed employees were to wash their hands after handling dirty dishes, and food was to be protected from contamination (dust, flies, rodents, and other vermin). Further review revealed the facility allowed seven (7) days from the date of preparation for food safety with the day of preparation counted as day one (1). 1. Observation of the kitchen, on 10/14/2024 at 3:59 PM, revealed no vent was over the duct work in the dish room and the plates were not covered in the plate warmer with debris noted on the top plate. Continued observation revealed baking powder, stored on a shelf by the stove area, labeled as received 11/10/2022, opened 04/10/2023, with a use by date of 10/10/2023, and best if used by 08/04/2024. Further observation revealed Fruit Loops cereal stored in a pour container, on a lower shelf at the end of the steam table, with a missing snap on the top section. Additional observation revealed Cheerios stored on a lower shelf at the end of the steam table, with a preparation (prep) date of 10/04/2024, and no use by date; and a Corn Flakes container stored on a lower shelf at the end of the steam table that was undated. Observation revealed [NAME] 1 took the top plate from the warmer and placed food on it to send to a resident. However, after the interviewing related to the plate that had debris on it, [NAME] 1 placed the plate to the side on the steamer table and did not place it on the cart to go to the residents. During interview, on 10/14/2024 at 5:20 PM, the Assistant Food and Nutritional Services Manager (AFNSM) stated the dirty plate from the plate warmer should not have been used to serve food. The AFNSM stated the outdated/undated food should not be on the shelf or served to residents. The AFNSM stated dietary staff checked dates on foods weekly and he was unsure how the outdated/undated food items had been missed. During interview, on 10/14/2024 at 6:15 PM, the Regional Food and Nutritional Services Manager (RFNSM) stated the plates (in the plate warmer) should have been covered to keep them clean. 2. Observation of the kitchen, on 10/14/2024 at 3:59 PM, revealed [NAME] 1 wore a beard net without covering his mustache, and wore a bandana without a hair restraint with hair exposed below the back of the bandana. Continued observation on 10/14/2024 at 5:00 PM, revealed [NAME] 1 had no beard net on covering his facial hair. During interview, on 10/14/2024 at 3:59 PM, the AFNSM stated the facility's policy was to wear a hair net or hat, to cover all hair including over facial hair and mustaches. The AFNSM stated that was so nothing gets in the food. During interview, on 10/14/124 at 6:30 PM, [NAME] 1 stated his bandana was approved, but he needed a haircut, and his mustache should have been covered. During interview, on 10/14/2024 at 6:15 PM, the RFNSM stated all hair including facial hair, was to be covered. The RFNSM stated any hair covering, including bandanas, needed to cover all hair or a hair net should be used under it. 3. Continued observation, on 10/14/2024 at 5:07 PM, revealed [NAME] 1 took a thermometer out of a sheath in the breast pocket of his uniform and checked the cornbread temperature without using gloves. During interview, on 10/14/2024 at 5:20 PM, the AFNSM stated the thermometer used to check the temperature of the cornbread should have been cleaned with an alcohol wipe prior to using. The AFNSM stated the cornbread should not have been handled without gloves. 4. Continued observation on 10/14/2024 at 5:20 PM, revealed [NAME] 1 took a piece of chicken off the steam table, laid it on a glove on the steam table, then handed it to Dietary Aide (DA) 3. Further observation revealed DA 3 carried the piece of chicken to the preparation counter, laid it on top of the glove, washed the blender, and then picked the chicken up to place in the blender to puree. During interview, on 10/14/2024 at 5:07 PM, DA 3 stated the pureed chicken should have been prepared before the tray line started. DA 3 also stated it was not sanitary to carry the chicken without gloves. 5. Additionally, observation on 10/14/2024 at 5:55 PM, revealed [NAME] 1 picked up the tray covers and carried them against his shirt to the tray line. During further interview, on 10/14/124 at 6:30 PM, [NAME] 1 stated the tray covers should not have touched his shirt.

Based on observation, interview, record review, and policy review, it was determined that the facility failed to ensure an allegation of misappropriation of resident property (Resident #1) was reported to the State Survey Agency and Adult Protective Services no later than 24 hours after the allegation was made. Interview with staff revealed on 05/29/19, the facility discovered that Resident #1 had narcotic pain medication missing; however, the facility failed to report the allegation to the state agencies until 06/13/19, fifteen days after the resident's medication was discovered missing. The findings include: Review of the facility policy entitled Abuse policy, revealed the Misappropriation of Resident Property was the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. Further review of the policy revealed all alleged violations and all substantiated incidents would be reported to state/local agencies as required. Review of the facility policy entitled Missing Medications, dated 06/27/19, revealed that if a medication could not be found in the facility, staff were required to notify the Administrator with notification of state and local authorities as indicated. Review of Resident #1's physician orders dated 05/01/19 revealed the resident had [DIAGNOSES REDACTED]. Further review of the physician orders revealed an order for [REDACTED]. Review of the Medication Administration Record [REDACTED]. Observation of Resident #1 on 07/01/19 at 10:15 AM revealed the resident was lying in bed, awake, and receiving oxygen via nasal cannula. Interview with Resident #1 on 07/01/19 at 10:15 AM revealed the resident was admitted to the facility following a hospital stay. According to the resident, he/she had a lung removed and in (MONTH) developed a leak from the lung area into the abdominal area that required another hospital stay. According to Resident #1, the resident received pain medication every 4 to 5 hours. Interview with the Director of Nursing (DON) on 07/01/19 at 3:15 PM revealed on 5/29/19, Certified Medication Aide (CMA) #1 requested Resident #1's [MEDICATION NAME] medication from the locked medication storage cabinet in the DON's office. According to the interview, on 5/11/19 (eighteen days earlier), Pharmacy delivered the resident's medication divided into four packets. Further interview revealed Packet #1 was locked up on the medication cart and Packets #2, #3, and #4 were locked up in the medication storage cabinet. The DON stated when Packet #4 was taken from the medication storage cabinet on 05/29/19, CMA #1 found that the number of [MEDICATION NAME] tablets in the zip lock bag was not correct. The DON stated there were 16 tablets in the package; however, the package was supposed to have 30 tablets. Interview with CMA #1 on 07/03/19 at 11:38 AM revealed on 05/29/19 CMA #1 went to the DON's office to get the 4th packet of [MEDICATION NAME] for Resident #1. The CMA stated when she and the DON counted the medication, they discovered that almost half of the tablets were missing. Interview with the Administrator on 07/01/19 at 10:45 PM revealed during the facility's investigation, they discovered gaps in their procedures regarding narcotic counts at the time of delivery and narcotic counts in the medication storage cabinet. According to the Administrator, the incident was not initially reported to state agencies because the facility was covering the cost for replacing Resident #1's medication. However, the administrator stated when the Chief Executive Officer (CEO) was notified of the resident's missing medication on 06/13/19, the CEO instructed the Administrator to report the incident to state agencies and local law enforcement.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to 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. Observation on 09/20/18 at 11:32 AM revealed Licensed Practical Nurse (LPN) #1 failed to perform proper hand hygiene during a dressing change for one (1) of thirty-five (35) sampled residents (Resident #2). The findings include: Review of the facility's Dressing Change policy revealed the policy did not address handwashing after removing a soiled dressing and prior to donning clean gloves. Record review for Resident #2 revealed a physician's orders [REDACTED]. Observation on 09/20/18 at 11:32 AM revealed LPN #1 performed a dressing change for Resident #2. LPN #1 washed her hands, donned clean gloves, and removed the soiled dressing. LPN #1 then donned clean gloves to complete the wound care; however, the LPN failed to perform hand hygiene prior to applying the clean gloves. Interview with LPN #1 on 09/20/18 at 11:37 AM revealed the LPN confirmed that she had not performed hand hygiene after removing soiled gloves and prior to donning clean gloves. Interview with the Infection Control Nurse on 09/20/18 at 6:55 PM, revealed staff were expected to perform hand hygiene after removing a soiled dressing and prior to donning clean gloves. Interview with the DON on 09/20/18 at 12:10 PM revealed staff should have performed hand hygiene after removing the soiled gloves and before continuing the wound care.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to ensure nurse staffing information and the resident census was posted on a daily basis. Observations on 09/17/18, 09/18/18, 09/19/18, and 09/20/18 revealed the facility failed to ensure the number of Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and the resident census was posted as required. The findings include: Review of the facility's Staffing Policy, undated, revealed the facility would post the actual number of nursing staff on duty on each shift on a daily basis. The policy stated the numbers posted would include Registered Nurses, Licensed Practical Nurses, Medication Aides, and Nursing Assistants directly responsible for patient care. Observation on 09/17/18, 09/18/18, 09/19/18, and 09/20/18 at 5:45 PM of the facility's posted Nursing Staff Report revealed the facility listed the number of nurses working on the three units of the facility. However, the posting failed to list the specific numbers related to Registered Nurses and Licensed Practical Nurses. Further observation revealed the resident census was not included in the posting. Interview on 09/20/18 at 6:18 PM with the Director of Nursing (DON) revealed the Nursing Staff Report utilized by the facility had never differentiated between the Registered Nurses and Licensed Practical Nurses, and had never contained the resident census for as long as she could remember. The DON also stated she was not aware that the posting did not meet regulatory requirements.

Based on interview, record review, and review of the facility's policy/protocol, it was determined the facility failed to notify the physician for two (2) of fourteen (14) sampled residents (Residents #1 and #3) when the residents experienced a change in condition and there was a need to alter treatment. Resident #1's blood sugar was above 200 mg/dL (milligrams/deciliter - normal blood sugar level is ,[DATE]) on [DATE] and [DATE], and consistently over 200 from [DATE] through [DATE]. On [DATE], Resident #1's blood sugar was 307 mg/dL; however, there was no evidence the facility notified Resident #1's physician of the resident's abnormal blood sugars per the facility's protocol. On [DATE], staff found the resident unresponsive and transferred the resident to the hospital. When the resident arrived at the hospital, the resident's blood sugar was 1,028 mg/dL. The resident was admitted to the hospital with [REDACTED]. Resident #3's family and staff reported the resident had a change in condition on the morning of [DATE]. The resident was coughing, short of breath, did not get out of bed, was not his/her normal self, had decreased food intake, and was pale. However, there was no documented evidence the facility notified the resident's physician of the change in the resident's condition and need to alter treatment. When Resident #3's family visited at approximately 4:00 PM, the family member requested the resident be assessed because the resident's skin was gray/colorless and the resident was having difficulty breathing. The facility transferred the resident to the hospital and the resident was admitted [MEDICAL CONDITION] (condition caused from infection in which toxins are released in the bloodstream), health care acquired pneumonia, [MEDICAL CONDITION] (condition in which the body is deprived of adequate oxygen supply), and renal (kidney) failure. Resident #3 expired on [DATE] due to pneumonia. The facility's failure to notify physicians when residents experienced a change in condition has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE] at 42 CFR 483.10 Resident Rights (F580), 42 CFR 483.25 Quality of Care (F684), 42 CFR 483.35 Nursing Services (F726), and 42 CFR 483.70 Administration (842). The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance was received on [DATE], which alleged removal of the Immediate Jeopardy on [DATE]. The State Survey Agency determined the Immediate Jeopardy was removed on [DATE] as alleged, prior to exit, which lowered the scope and severity to D level at 42 CFR 483.10 Resident Rights (F580), 42 CFR 483.25 Quality of Care (F684), 42 CFR 483.35 Nursing Services (F726), and 42 CFR 483.70 Administration (842) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's Physician Notification Policy, dated (MONTH) 2006, revealed the resident's physician should be notified when a resident experienced a significant change in condition or if there was a need to significantly alter treatment. 1. Review of the facility's Diabetes Management policy for [MEDICAL CONDITION], dated [DATE], revealed the physician must be notified if a resident's assessment findings or glucose results indicated a need for potential dosage changes. An interview with the Assistant Director of Nursing (ADON) on [DATE] at 9:01 AM revealed each physician had established parameters that detailed when they should be notified of blood sugar results. The ADON stated the parameters were listed on the medication cart and in the play book. Review of the Blood Sugar Parameters Per Physician protocol revealed Resident #1's physician was required to be notified if the resident's blood sugar was greater than 200 mg/dL. Review of Resident #1's closed medical record revealed the facility admitted the resident on [DATE], with a readmission date of [DATE]. Resident #1 had [DIAGNOSES REDACTED]. Review of Resident #1's Physician Orders dated [DATE] revealed the facility was required to obtain the resident's blood sugar every week on Tuesday at 6:00 AM and as needed. Review of Resident #1's Comprehensive Care Plan, revised on [DATE], revealed the facility's goal was to maintain the resident's blood sugar between 60 and 105. Review of Resident #1's Medication Administration Records (MAR) revealed the resident's average monthly blood sugar increased from 128 in (MONTH) (YEAR) to 254 in (MONTH) (YEAR). The resident's blood sugar was above 200 on [DATE] and [DATE], and consistently over 200 from [DATE] through [DATE]. On [DATE], Resident #1's blood sugar was 307 mg/dL. However, review of Resident #1's medical record revealed Resident #1's physician was not notified when the resident's blood sugars were consistently above 200. Review of the Nurse's Notes for Resident #1 revealed on [DATE] at 7:35 AM, staff documented that Resident #1 was unresponsive and tremoring. The facility transferred the resident to the Emergency Department (ED) for evaluation. Review of Resident #1's ED record revealed the resident was unresponsive and had tremors when the resident arrived on [DATE] at 7:32 AM. According to the Physicians Emergency assessment dated [DATE] at 7:35 AM, Resident #1's blood sugar level upon arrival was critically elevated at 1,028 mg/dL. Resident #1 was admitted to the hospital on [DATE] at 12:36 PM with [DIAGNOSES REDACTED]. Further review of Resident #1's MAR indicated [REDACTED]. An interview with LPN #3 on [DATE] at 11:01 AM confirmed she routinely checked Resident #1's blood sugar at 6:00 AM every Tuesday. LPN #3 stated she did not consider the resident's blood sugars to be that high and she had not notified the resident's physician of the resident's sugar results. LPN #3 stated she was not aware of the facility's blood sugar parameters policy and assumed the physician should not be notified unless the resident's blood sugar was above 400. Interview with Resident #1's physician (Physician #1) on [DATE] at 2:18 PM, and on [DATE] at 10:57 AM, revealed Resident #1 expired on [DATE] from complications related to prolonged [MEDICAL CONDITION]. The physician stated that when the resident's blood sugar began increasing above 200 the facility should have notified him so he could determine whether a change in the resident's medication was needed to control the resident's blood sugar levels. However, Physician #1 was not notified of the resident's weekly blood sugar results. 2. Review of the medical record for Resident #3 revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Interviews were conducted with State Registered Nurse Aide (SRNA) #6 on [DATE] at 11:15 AM, and SRNA #10 on [DATE] at 11:49 AM. SRNA #6 stated Resident #3 was coughing and short of air on [DATE]. SRNA #10 stated the resident was normally active but stayed in bed more than usual and was falling asleep in his/her wheelchair on [DATE]. Interview with SRNA #7 on [DATE] at 11:40 AM revealed on [DATE], Resident #3 was not acting like himself/herself. She stated the resident went to bed after having a shower and eating breakfast and stayed in bed all day, which was not the resident's usual behavior. SRNA #7 further stated Resident #3 normally went to the dining room for lunch, but did not go to the dining room on [DATE], and did not eat or drink much at lunch, and was too unresponsive to eat the evening meal. SRNA #7 stated she reported to LPN #1 on numerous occasions that Resident #3 had experienced a change in condition. At approximately 3:00 PM on [DATE], SRNA #7 stated she reported to LPN #1 that Resident #3 was not feeling well and that the resident looked pale. She stated LPN #1 assessed the resident at that time and the LPN stated the resident was okay. Interview with Kentucky Medication Aide (KMA) #4 on [DATE] at 11:23 AM revealed on [DATE], Resident #3 was coughing, was short of breath, and did not act like he/she felt well. She further stated that Resident #3 told her that he/she was dying and stated, Help me. KMA #4 stated she also administered medications to Resident #3 on [DATE]. She stated Resident #3 could normally swallow medications without difficulty; however, when she administered the resident's 5:00 PM medications on [DATE], the KMA had to crush the medications so the resident could swallow them. KMA #4 stated when Resident #3's family arrived, the family member requested that a nurse assess the resident. KMA #4 stated she reported the resident's condition to LPN #4 who checked the resident's oxygen saturation. Resident #3's oxygen saturation was in the seventies (normal is ,[DATE]). She stated LPN #4 administered supplemental oxygen to the resident. Interview with Family Member #1 on [DATE] at 3:34 PM revealed when he visited the resident on [DATE] at approximately 10:00 AM, the resident was in bed and was not his/her normal self. The family member stated he visited the resident every day and the resident was normally up in a chair and alert. However, on [DATE], Resident #3's family member stated he was concerned about the resident and asked the resident's nurse (LPN #1) to watch Resident #3 closely because the resident was not doing well. According to Family Member #1, LPN #1 acknowledged that the resident was not feeling well. Continued interview with Family Member #1 revealed he returned to the facility at approximately 4:00 PM on [DATE] and found Resident #3 in bed in what appeared to be the same position that he last observed the resident at 10:00 AM that morning. The family member stated that the resident's skin was gray and colorless and the resident was not very responsive. He further stated there was not any staff present in the resident's room when he arrived at the facility, and he asked to speak to LPN #1; however, the LPN was not available. Family member #1 stated he then asked for LPN #4 to assess Resident #3. He stated when LPN #4 assessed the resident, the resident's oxygen saturation was in the seventies (normal ,[DATE]), and LPN #4 applied oxygen. Family Member #1 stated LPN #4 told him the resident's right lower lung was congested. Family Member #1 stated the resident's right lower lung sounded like the resident had pneumonia. Review of Resident #3's medical record revealed no documented evidence the facility notified the resident's physician of the change in the resident's condition. Review of the Departmental Nurse's Notes dated [DATE] at 5:33 PM revealed LPN #1 documented a late entry for 5:15 PM. LPN #1 documented that staff called him to Resident #3's room and the resident's oxygen saturation level was 82 percent, while receiving oxygen at 2 liters via nasal cannula. Further review of the note revealed the resident was transported to the Emergency Department for evaluation. A review of Resident #3's Emergency Department (ED) record revealed the resident arrived at the ED on [DATE] at 6:00 PM, with decreased oxygen (84% on 5 liters of oxygen), shortness of breath, and poorly responsive. The resident was admitted to the hospital in poor condition with [DIAGNOSES REDACTED]. Review of Resident #3's Discharge Summary revealed the resident continued to decline and expired on [DATE] due to pneumonia. Interview with LPN #4 on [DATE] at 4:52 PM revealed she was not assigned to provide care for Resident #3 on [DATE]; however, an SRNA asked the LPN to assess the resident at approximately 3:40 PM and during the evening meal. LPN #4 stated the resident's lungs were clear and his/her oxygen saturation was 91 percent at 3:40 PM. However, at approximately 4:45 PM, the resident's skin was pale, the right lower lung was congested, and the resident's oxygen was low. LPN #4 stated she did not notify the physician of the resident's change in condition. Interview with LPN #1 on [DATE] at 11:25 AM, revealed the LPN denied that Resident #3's family member spoke to him related to a change in Resident #3's condition on the morning of [DATE]. LPN #1 stated that at approximately 3:40 PM, SRNA #7 reported that Resident #3 had a large bowel movement and the dressing to the resident's buttocks needed to be changed. He stated he and LPN #4 assessed the resident, and determined the resident did not show any signs of distress. Further interview with LPN #1 revealed that during the evening meal SRNA #7 reported that Resident #3's family wanted to speak with him. LPN #1 stated when he entered Resident #3's room, the resident's oxygen saturation was in the low eighties, and he transferred the resident to the ED for evaluation. An interview with Resident #3's Physician on [DATE] at 3:08 PM, revealed he could not recall whether he was notified of Resident #3's change in condition. **The facility implemented the following corrective actions to remove the Immediate Jeopardy: 1. Resident #1 and Resident #3 no longer reside in the facility. Both residents expired at the hospital. The DON completed an audit of blood sugar results for Resident #1 and all residents with a [DIAGNOSES REDACTED]. 2. An audit was completed as of [DATE] by the DON, ADON, and other Administrative Nursing staff to identify any residents who had a significant change in condition in the last 30 days, any issues noted were addressed, interventions implemented, and the physician notified. 3. Orders were obtained for new parameters for all diabetic residents noting when to notify the resident's physician. All attending physicians agreed to parameters of less than 60 mg/dL or greater than 400 mg/dL. All non-insulin dependent Diabetes Mellitus (NIDDM) residents have orders to check their blood sugar at least every day. 4. A new blood sugar tracking sheet was implemented to accompany the shift change report for review of blood sugar results. 5. A sticker was applied to the charts of all residents with the [DIAGNOSES REDACTED]. 6. All licensed nurses have received in-service education on the following: -Physician Notification -Diabetes Management -The new blood sugar parameters for when to notify the Physician -Obtaining labs -Alert Charting (which includes the immediate follow-up on any reported change of condition) -Documentation Guidelines - all documentation should be completed as close as possible to the time of the event; however, in the event of a resident transfer, a legal late entry may be completed up to 24 hours from the time of the transfer. All SRNAs have been in-serviced on resident change of condition criteria and the need to report any observed changes to the charge nurse immediately. This education was provided by: the Director of Nursing, Assistant Director of Nursing, Restorative Coordinator, Minimum Data Set (MDS) Nurses, Infection Control Nurse, and Central Supply Nurse, completed on [DATE]. 7. A Quality Assurance and Performance Improvement (QAPI) meeting was held on [DATE], [DATE], and [DATE] to review the investigation findings and the action plan with the QAPI team and Medical Director. 8. Daily monitoring of Blood Glucometer Checks, Daily Census, 24-hour Report sheet, and Two-Hour rounds checklist (rounds are completed by the charge nurse every two hours and documented) by the DON or ADON or designated Administrative Nurse (Restorative Coordinator, MDS Nurse, Infection Control Nurse, or Central Supply Nurse) to identify a change of condition, MD notification, and implemented interventions. Concerns identified will be reported to the Administrator and QAPI Committee. 9. The QAPI indicator for the monitoring of diabetes management will be utilized by the DON or ADON or designated Administrative Nurse (Restorative Coordinator, MDS Nurse, Infection Control Nurse, or Central Supply Nurse) weekly for four weeks, monthly for two months, quarterly for one year, and then every six months thereafter. This tool directs the audit of five (5) residents' records with the [DIAGNOSES REDACTED]. The completed indicator and any indicated action plans will be reviewed in the monthly QAPI Committee meetings. 10. The QAPI indicator for the monitoring of management of changes in resident condition will be utilized by the DON, ADON or designated Administrative Nurse (Restorative Coordinator, MDS Nurse, Infection Control Nurse, or Central Supply Nurse) weekly for four weeks, monthly for two months, and then quarterly thereafter. This tool directs the audit of the records of residents who have demonstrated a significant change in condition to determine that the documentation includes but is not limited to timely notification of the MD and notification of the MDS team for review/revision of the care plan as indicated. 11. The QAPI indicator for the monitoring of Nursing Documentation of Electronic Medical Records will be utilized by the DON, ADON, or designated Administrative Nurse (Restorative Coordinator, MDS Nurse, Infection Control Nurse, or Central Supply Nurse) weekly for four weeks, monthly for two months, and then quarterly thereafter to verify complete and timely documentation of residents with a significant change in condition. **The State Survey Agency validated the corrective actions taken by the facility as follows: 1. Review of the audit completed on [DATE] revealed the DON, ADON, and/or administrative nurses revealed the staff reviewed blood sugar flowsheets for the past 30 days on all residents with a [DIAGNOSES REDACTED]. No problems were identified. Resident #1 was transferred to the hospital on [DATE] and did not return to the facility. Resident #3 was transferred to the hospital on [DATE] and did not return to the facility. 2. Review of the audit completed on [DATE], revealed the DON, ADON, and/or administrative nurses had reviewed all resident records to identify residents who had a change in condition in the past 30 days. The audit indicated that any issues identified were addressed. Interview with the ADON on [DATE] at 4:30 PM and the DON at 1:30 PM revealed no problems were identified with the physician not being notified when a resident experienced a change in condition. 3. Review of the facility policy, Diabetes Management, undated, revealed that physician notification was required for blood sugars less than 60 mg/dL and for blood sugars greater than 400 mg/dL. Review of facility documentation revealed copies of Physician's Orders dated [DATE], for all residents with a [DIAGNOSES REDACTED]. Interview with the DON on [DATE] at 1:30 PM and the ADON on [DATE] at 11:45 AM, revealed residents' blood sugars were monitored daily to ensure the resident's physician was notified of any blood sugars outside the set parameters in the facility policy. 4. Review of the Accucheck Tracking Sheets dated [DATE] through [DATE] revealed the sheets were completed daily. Interviews with the DON on [DATE] at 1:30 PM, the ADON on [DATE] at 11:45 AM, and the Administrator on [DATE] at 5:50 PM revealed administrative staff reviewed resident blood sugar levels daily to ensure that the tracking sheets were completed. The ADON stated that any blood sugar result outside the parameters were tracked to ensure the physician was notified. Continued review of the Accucheck Tracking Sheets revealed unsampled Resident A had an elevated blood sugar of 471 mg/dL on [DATE] at approximately 4:00 PM. Review of the Nurse's Notes revealed the resident's physician was notified on [DATE] at 4:34 PM of the elevated blood sugar, per facility policy. 5. Review of Resident #10 and Resident #11's medical records revealed the exterior of the binder had a sticker that read DIABETIC. Interview with the ADON on [DATE] at 1:30 PM, revealed stickers noting the resident's [DIAGNOSES REDACTED]. 6. Review of the in-service training records revealed that licensed nursing staff had received training on the following: Physician Notification, Diabetes Management, Blood Sugar Parameters, Obtaining Labs, Alert Charting, and Documentation Guidelines. The trainings started on [DATE] and were completed by [DATE]. Continued review of training records revealed SRNAs and Certified Medical Technicians (CMT) had received training on vital sign parameters and on reporting any change in resident status to the nurse. The training records indicated these trainings were completed on [DATE]. Interview with the ADON on [DATE] at 1:30 PM revealed that she had verified that all facility employed nursing staff had received the above trainings. Further interview with the ADON on [DATE] at 11:45 AM revealed the facility had no new hires since [DATE]. The ADON stated she completed the new licensed nurse orientation and that it would include the previously mentioned areas of education. The DON also stated a Playbook was located at each nurses' station and contained the recent staff training for staff to refer to if needed. Further interview revealed administrative staff met daily and reviewed audits to ensure staff competency with the previously mentioned policies and trainings. Interviews on [DATE] with LPN #5 at 3:50 PM, LPN #8 at 3:59 PM, LPN #9 at 2:38 PM, and Registered Nurse (RN) #2 at 4:10 PM revealed all had received in-service training on Change in Resident Condition, Physician Notification, Diabetes Management, Blood Sugar and Vital Sign Parameters, Labs, and Timely Physician Documentation, and Documentation Guidelines. The nurses stated that anytime a resident had a change in condition, or it was reported, a resident assessment must be completed and the resident's physician notified depending on the results of the resident assessment. Interviews on [DATE] with CMT #1 at 3:45 PM, CMT #2 at 3:40 PM, CMT #5 at 1:20 PM, CMT #6 at 3:30 PM, SRNA #3 at 1:58 PM, and SRNA #12 at 3:30 PM, revealed all had received in-service training on vital sign parameters and to report to the nurse any change in resident status/condition. SRNA #12 stated she had noted a change in a resident's condition on [DATE] and she immediately notified the nurse who assessed the resident and called the resident's physician. The CMTs and SRNAs stated they were given a laminated card with vital sign parameters printed on the card. Staff stated they were trained to report any vital sign reading outside the parameters printed on the card. 7. Review of Quality Assurance Performance Improvement (QAPI) Agenda/Meeting notes revealed QAPI meetings were held on [DATE], [DATE], and [DATE]. Interviews on [DATE] with the DON at 1:30 PM, the ADON at 11:45 AM, and the Administrator at 5:50 PM confirmed the QAPI meetings had been held per the plan. 8. The daily monitoring of Blood Glucometer Checks, Daily Census, 24-hour Report sheet, and Two-Hour rounds checklist (rounds are completed by the charge nurse every two hours and documented) were reviewed and had been completed since [DATE] per the facility's plan. Interviews on [DATE] with the ADON at 4:30 PM, the DON at 1:30 PM, and the Administrator at 5:50 PM revealed they were reviewing the audits included in the plan and no problems had been identified. The staff stated morning meetings were also conducted to review 24-hour reports, blood sugar checks, and two-hour rounds reports, etc. 9. Review of the QAPI audits for the monitoring of diabetes management revealed the audits were completed by administrative nurses on [DATE] and [DATE]. This tool audited five (5) resident records with the [DIAGNOSES REDACTED]. None of these audits identified any problems and all thresholds were at 100%. Interview on [DATE] with the ADON at 4:30 PM, the DON at 1:30 PM, and the Administrator at 5:50 PM revealed they reviewed the audits included in the plan and no problems had been identified. All stated that morning meetings were also conducted to review 24-hour reports, blood sugar checks, two-hour rounds reports, etc. Record review revealed Resident #10, Resident #11, and Resident #13 had [DIAGNOSES REDACTED]. Record review revealed the blood sugars were being obtained as ordered and sliding scale insulin was being administered as ordered. Blood sugar results outside the facility's policy parameters (less than 60 or greater than 400) were called to the physician. 10. The QAPI audits for the monitoring of management of changes in resident condition were completed by administrative nurses on [DATE] and [DATE] with no problems identified. This tool audited records of residents who had demonstrated a significant change in condition to determine that the documentation included but was not limited to: timely notification of the MD and notification of the MDS team for review/revision of the care plan as indicated. Interview on [DATE] with the ADON at 4:30 PM, the DON at 1:30 PM, and the Administrator at 5:50 PM revealed they were reviewing the audits included in the plan and no problems had been identified. The staff stated morning meetings were also conducted to review 24-hour reports, blood sugar checks, two-hour rounds reports, etc. The facility identified that Resident #9 and Resident 14 had a change in condition since [DATE]. Both residents' medical records were reviewed and no concerns were identified related to timely physician notification. 11. The QAPI audit for the monitoring of Nursing Documentation was completed by administrative nurses on [DATE], [DATE], [DATE], and [DATE]. This audit was being completed to verify complete and timely documentation of residents with a significant change in condition. Interview with the ADON on [DATE] at 4:30 PM revealed this audit was currently being completed daily. The facility identified that Resident #9 and Resident #14 had a change in condition since [DATE]. Both residents' medical records were reviewed and no concerns were identified related to timely physician notification. Both records contained timely documentation related to the change in condition and notification of the resident's physician.

Based on interview, record review, and review of the facility's policy/protocol, it was determined the facility failed to provide care and services for two (2) of fourteen sampled (14) residents (Residents #1 and #3). Resident #1 had a physician's order for weekly and as needed blood sugar levels. The resident's average monthly blood sugars increased from 128 milligrams/deciliter (mg/dL) in (MONTH) (YEAR) to 254 mg/dL in (MONTH) (YEAR) (normal blood sugar level is ,[DATE]) and was consistently over 200 mg/dL from [DATE] through [DATE]. On [DATE], Resident #1 developed a urinary tract infection and antibiotics were initiated to treat the infection, and on [DATE], Resident #1's blood sugar was 307 mg/dL. However, there was no documented evidence the facility assessed the resident's blood sugar as needed when the resident's blood sugar was elevated or when the resident developed an infection and was being treated with antibiotics (infection and some medications increase blood sugar levels). On [DATE], staff found Resident #1 with tremors and unresponsive. Resident #1 was subsequently transported to the Emergency Department where the resident's blood sugar was greater than 1,000 mg/dL. The resident was diagnosed with [REDACTED]. Resident #1 expired on [DATE] from complications related to [MEDICAL CONDITION] (high blood sugar). Resident #3's family and staff reported the resident had a change in condition on [DATE], at approximately 10:00 AM; however, the facility failed to assess the resident. At approximately 5:15 PM on [DATE], the resident's family visited the resident again and requested that staff assess the resident. Resident #3 was assessed to have a low oxygen level and was transferred to the hospital where the resident was diagnosed with [REDACTED]. The resident expired on [DATE] due to complications of pneumonia. The facility's failure to provide necessary care and services to residents has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE] at 42 CFR 483.10 Resident Rights (F580), 42 CFR 483.25 Quality of Care (F684), 42 CFR 483.35 Nursing Services (F726), and 42 CFR 483.70 Administration (842). The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance was received on [DATE], which alleged removal of the Immediate Jeopardy on [DATE]. The State Survey Agency determined the Immediate Jeopardy was removed on [DATE] as alleged, prior to exit, which lowered the scope and severity to D level at 42 CFR 483.10 Resident Rights (F580), 42 CFR 483.25 Quality of Care (F684), 42 CFR 483.35 Nursing Services (F726), and 42 CFR 483.70 Administration (842) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: 1. Review of the facility's Diabetes Management policy for [MEDICAL CONDITION] (high blood sugar), dated [DATE], revealed when receiving orders for diabetic glucose monitoring, the physician's order should include how often to perform blood sugar testing and low and high blood sugar parameters for physician notification. The physician must be notified if a resident's assessment findings or glucose results indicate a need for potential dosage changes. Residents demonstrating [MEDICAL CONDITION] would be assessed by the nurse for signs and symptoms of any change in status which would be reported to the resident's physician, including increased thirst, increased urination, dry mouth, shortness of breath, or fruity smelling breath. Review of the facility's Blood Sugar Parameters Per Physician protocol revealed Resident #1's Physician was required to be notified if the resident's blood sugar was greater than 200 mg/dL. Review of Resident #1's closed medical record revealed the facility admitted the resident on [DATE], and readmitted the resident on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #1'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 99, indicating the resident was unable to complete the interview. The facility also assessed the resident to be dependent upon staff for activities of daily living, including eating. Review of Resident #1's Comprehensive Care Plan developed on [DATE], and last revised on [DATE], revealed the facility identified that the resident had an alteration in blood sugars related to Type II Diabetes Mellitus. Further review revealed the facility's goal was to maintain the resident's blood sugars between 60 and 105 for three months. Review of Resident #1's Physician Orders revealed an order dated [DATE], to obtain the resident's blood sugar every week on Tuesday at 6:00 AM and as needed. Resident #1 also had a physician's order for a daily oral medication to treat his/her diabetes ([MEDICATION NAME]). Review of Resident #1's Medication Administration Record [REDACTED]. A review of the resident's hemoglobin A1c (HgbA1c indicates the average blood sugar level over the past two to three months), dated [DATE], revealed the resident's level was increased at 8 (Target level for individuals with diabetes is less than 7. When the level goes above 7, the individual has increased risk for complications). Further review of the resident's MAR indicated [REDACTED]. On [DATE], Resident #1's blood sugar was 279, on [DATE] it was 305, on [DATE] it was 256, on [DATE] it was 292, and on [DATE] it was 307. However, review of the Departmental Nurse's Notes revealed that even though the resident had a physician's order to obtain Resident #1's blood sugar as needed, there was no documented evidence the facility monitored Resident #1's blood sugars more frequently when the resident's blood sugar was elevated. There was no documented evidence that Resident #1's Physician was notified when the resident's blood sugars were consistently above the facility's care planned goal for the resident (105) or above 200 as required by the facility's protocol. Review of Resident #1's Nurses' Notes dated [DATE], revealed the resident had a new physician's order for [MEDICATION NAME], an antibiotic (injected into the muscle) every day for ten days for treatment of [REDACTED]. An interview with LPN #3 on [DATE] at 11:01 AM revealed she routinely checked Resident #1's blood sugar at 6:00 AM every Tuesday. LPN #3 stated she was not aware that the facility had a protocol regarding physician notification of blood sugar results. The LPN further stated she did not consider the resident's blood sugars to be that high and had not monitored the resident for signs and symptoms of [MEDICAL CONDITION] or conducted any further blood sugar monitoring, even when the resident had an infection. Interview with the Assistant Director of Nursing (ADON) on [DATE] at 9:01 AM and with the Director of Nursing (DON) on [DATE] at 1:01 PM revealed no one monitored blood sugar results for residents with non-insulin dependent diabetes. The DON and ADON stated staff should have monitored Resident #1's blood sugar more often (as needed) when the resident's blood sugar results were high and should have reported the resident's blood sugar results to the resident's physician. Further interview revealed staff should have especially monitored Resident #1's blood sugar more closely when the resident was being treated for [REDACTED]. Review of the Nurse's Notes for Resident #1 revealed on [DATE] at 7:35 AM, Licensed Practical Nurse (LPN) #5 documented that Resident #1 was unresponsive to stimuli and had tremors. The documentation further revealed the resident's physician was notified and the facility transferred the resident to the Emergency Department (ED) for evaluation. Interview with LPN #5 on [DATE] at 4:34 PM revealed on the morning of [DATE], Resident #1 was in a wheelchair in the hallway. LPN #5 stated a nurse aide yelled for a nurse to assess Resident #1. LPN #5 stated Resident #1 was unresponsive and was shaking. LPN #5 stated he did not have time to check the resident's blood sugar before transferring the resident to the hospital. Review of Resident #1's ED record revealed the resident presented to the hospital on [DATE] at 7:32 AM, with unresponsiveness and tremors. Review of the Physician's Emergency Assessment on [DATE] at 7:35 AM, revealed the resident was unresponsive upon arrival and his/her blood sugar level was 1,028. Resident #1 was admitted to the hospital on [DATE] at 12:36 PM with [DIAGNOSES REDACTED]. Interview with Resident #1's Physician on [DATE] at 2:18 PM and on [DATE] at 10:57 AM revealed Resident #1 expired on [DATE] from complications related to [MEDICAL CONDITION]. The physician stated the resident's kidneys were fried as a result of prolonged [MEDICAL CONDITION]. The physician stated the facility faxed Resident #1's laboratory results to him, but did not notify him of the resident's weekly blood sugar results. The physician stated that in (MONTH) (YEAR), the resident's HgbA1c was elevated, and he asked staff to fax the resident's medication list; however, he could not find that the facility provided the list. The physician stated a prescription was sent for [MEDICATION NAME] to treat the resident's blood sugars because he believed that up until that time, the resident's blood sugars were being controlled through the resident's diet. Resident #1's Physician stated that when the resident's blood sugar was elevated, staff should have monitored the resident's blood sugar more and should have monitored the resident more closely when he/she developed an infection, because an infection could elevate the blood sugar level. 2. An interview with the Director of Nursing on [DATE] at 11:30 AM, revealed the facility did not have a policy related to conducting routine resident assessments or conducting resident assessments when a change in the resident's condition occurred. Review of the medical record for Resident #3 revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of the resident'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 four (4), indicating the resident was severely cognitively impaired. The assessment further revealed the resident required assistance with walking and eating, utilized a wheelchair, and was participating in physical therapy. Further review of the resident's MDS revealed the resident did not have a condition or chronic disease that could result in a life expectancy of less than six months. Review of Resident #3's care plan dated [DATE] revealed the resident had periods of confusion, but was alert and oriented to his/her name and was able to voice his/her concerns. Interview with Family Member #1 on [DATE] at 3:34 PM revealed he visited Resident #3 at the facility daily. He stated when he visited the resident on [DATE] at approximately 10:00 AM, the resident was in bed and was not his/her normal self. Resident #3's family member stated he was concerned about the resident and asked to speak with the resident's nurse (LPN #1). He stated he asked the nurse to watch Resident #3 closely because the resident was not doing well. According to Family Member #1, LPN #1 stated he was aware that the resident was not feeling well. Interview with State Registered Nurse Aide (SRNA) #7 on [DATE] at 11:40 AM revealed she reported to LPN #1 on numerous occasions on [DATE] that Resident #3 was not acting like himself/herself. She stated the resident went to bed after having a shower and eating breakfast and stayed in bed all day, which was not the resident's usual behavior. SRNA #7 further stated Resident #3 normally went to the dining room for lunch, but did not get up on [DATE], and did not eat or drink much at lunch. However, review of Resident #3's medical record revealed no documented evidence that LPN #1 or any other licensed (nurse) staff member assessed Resident #3 after the resident's family and SRNA #7 reported the resident's condition had changed on the morning of [DATE]. Further interview with CNA #7 on [DATE] at 11:40 AM revealed at approximately 3:00 PM on [DATE], she reported to LPN #1 that Resident #3 was not feeling well and that the resident looked pale. She stated that LPN #1 assessed the resident and stated the resident was okay. However, there was no documented evidence the LPN assessed the resident and documented the assessment on [DATE]. Interview with Kentucky Medication Aide (KMA) #4 on [DATE] at 11:23 AM revealed she administered medications to Resident #3 on [DATE]. She stated Resident #3 could normally swallow medications without difficulty; however, when she administered Resident #3's 5:00 PM medications on [DATE], the KMA had to crush them and administer them with applesauce so the resident could swallow the medications. KMA #4 stated on [DATE], Resident #3 was coughing, was short of breath, and did not act like he/she was feeling well all day. She further stated that Resident #3 told her that he/she was dying and stated, Help me. However, there was no evidence the KMA reported the change in the resident's condition until the family arrived and requested that a nurse assess the resident. Continued interview with Family Member #1 on [DATE] at 3:34 PM revealed he returned to the facility at approximately 4:00 PM on [DATE] and found Resident #3 in bed in what appeared to the same position that he last observed the resident at 10:00 AM that morning. The family member stated that the resident's skin was gray and colorless and the resident was not very responsive. He further stated there was not any staff present in the resident's room when he arrived at the facility, and he asked to speak to Resident #3's nurse again (LPN #1). However, staff (KMA #4) told him the nurse was in another resident's room and was not available. Family Member #3 stated he then asked for LPN #4 to assess Resident #3. He stated when LPN #4 assessed the resident, the resident's oxygen saturation was in the seventies (normal ,[DATE]), and LPN #4 applied oxygen. Family Member #1 stated LPN #4 told him the resident's right lower lung was congested. He stated the resident's right lower lung sounded like the resident had pneumonia. Continued interview with KMA #4 on [DATE] at 11:23 AM, revealed when Resident #3's family member arrived, he requested that LPN #4 assess the resident. KMA #4 stated she reported the resident's condition to LPN #4 who checked the resident's oxygen saturation. Resident #3's oxygen saturation was in the seventies and LPN #4 administered supplemental oxygen to the resident. Further review of Resident #3's medical record revealed there was no documented evidence dated [DATE], that LPN #4 assessed Resident #3. Review of Departmental Nurse's Notes dated [DATE] at 5:33 PM, revealed LPN #1 documented a late entry for 5:15 PM. LPN #1 documented that staff called him to Resident #3's room and the resident's oxygen saturation level was 82 percent, while receiving oxygen at 2 liters via nasal cannula. The LPN documented that the resident's vital signs were within normal limits. However, there was no evidence the resident's lungs, skin color, or cognition was assessed/documented. Further review of the Note revealed the resident was transported to the emergency room for evaluation. Interview with LPN #4 on [DATE] at 4:52 PM revealed she was called to Resident #3's room on [DATE] at approximately 3:40 PM, and assisted LPN #1 with assessing Resident #3. LPN #4 stated the resident's lungs were clear and his/her oxygen saturation was 91 percent. She stated she was called back to the resident's room at approximately 4:45 PM. LPN #4 stated that upon entering the resident's room, the resident was lying on his/her back and his/her skin was pale. She stated she assessed the resident's lungs and the right lower lobe was congested. She stated the resident's oxygen saturation was low and that she administered supplemental oxygen via nasal cannula. Further interview with LPN #4 revealed she told SRNA #7 to notify LPN #1 that the resident needed to be sent to the Emergency Department (ED) for evaluation. Interview with LPN #1 on [DATE] at 11:25 AM, revealed the LPN denied that Resident #3's family member spoke to him related to Resident #3's condition during the morning of [DATE]. LPN #1 stated that at approximately 3:40 PM, SRNA #7 reported that Resident #3 had a large bowel movement and that the dressing to the resident's buttocks needed to be changed. He stated he and LPN #4 assessed the resident, and the resident's vital signs were within normal limits, respirations were even and unlabored, and the resident did not show any distress. Further interview with LPN #1 revealed during the evening meal, SRNA #7 reported that Resident #3's family wanted to speak with him. LPN #1 stated when he entered Resident #3's room, the resident's oxygen saturation was in the low eighties, and he increased the resident's oxygen from two percent to five percent. The LPN stated he notified the resident's physician, called Emergency Medical Services (EMS), and notified the ED of the transfer. Review of Departmental Nurse's Notes dated [DATE] at 5:33 PM, revealed a late entry was documented for 5:15 PM, in which Licensed Practical Nurse (LPN) #1 documented that he was called to Resident #3's room by staff. The resident's oxygen saturation level was 82 percent while on oxygen at 2 liters via nasal cannula. Vitals signs were obtained and were documented within normal limits. There was no documentation of the resident's lung sounds or skin color, and no documented evidence of the resident's cognitive state. Further review of the note revealed the resident was transported to the ED for evaluation. Continued interview with Family Member #1 on [DATE] at 3:34 PM, revealed the attending physician told the family member that Resident #3 had severe, advanced pneumonia upon admission to the ED, and he did not know if the resident could be successfully treated. Review of Resident #3's Emergency Department record revealed the resident arrived at the ED on [DATE] at 6:00 PM, with decreased oxygen (84% on 5 liters of oxygen), shortness of breath, and poorly responsive. The resident was admitted to the hospital in poor condition with [DIAGNOSES REDACTED]. Review of Resident #3's Discharge Summary revealed the resident continued to decline and expired on [DATE], due to pneumonia. **The facility implemented the following corrective actions to remove the Immediate Jeopardy: 1. Resident #1 and Resident #3 no longer reside in the facility. Both residents expired at the hospital. The DON completed an audit of blood sugar results for Resident #1 and all residents with a [DIAGNOSES REDACTED]. 2. An audit was completed as of [DATE] by the DON, ADON, and other Administrative Nursing staff to identify any residents who had a significant change in condition in the last 30 days, any issues noted were addressed, interventions implemented, and the physician notified. 3. Orders were obtained for new parameters for all diabetic residents noting when to notify the resident's physician. All attending physicians agreed to parameters of less than 60 mg/dL or greater than 400 mg/dL. All non-insulin dependent Diabetes Mellitus (NIDDM) residents have orders to check their blood sugar at least every day. 4. A new blood sugar tracking sheet was implemented to accompany the shift change report for review of blood sugar results. 5. A sticker was applied to the charts of all residents with the [DIAGNOSES REDACTED]. 6. All licensed nurses have received in-service education on the following: -Physician Notification -Diabetes Management -The new blood sugar parameters for when to notify the Physician -Obtaining labs -Alert Charting (which includes the immediate follow-up on any reported change of condition) -Documentation Guidelines - all documentation should be completed as close as possible to the time of the event; however, in the event of a resident transfer, a legal late entry may be completed up to 24 hours from the time of the transfer. All SRNAs have been in-serviced on resident change of condition criteria and the need to report any observed changes to the charge nurse immediately. This education was provided by: the Director of Nursing, Assistant Director of Nursing, Restorative Coordinator, Minimum Data Set (MDS) Nurses, Infection Control Nurse, and Central Supply Nurse, completed on [DATE]. 7. A Quality Assurance and Performance Improvement (QAPI) meeting was held on [DATE], [DATE], and [DATE] to review the investigation findings and the action plan with the QAPI team and Medical Director. 8. Daily monitoring of Blood Glucometer Checks, Daily Census, 24-hour Report sheet, and Two-Hour rounds checklist (rounds are completed by the charge nurse every two hours and documented) by the DON or ADON or designated Administrative Nurse (Restorative Coordinator, MDS Nurse, Infection Control Nurse, or Central Supply Nurse) to identify a change of condition, MD notification, and implemented interventions. Concerns identified will be reported to the Administrator and QAPI Committee. 9. The QAPI indicator for the monitoring of diabetes management will be utilized by the DON or ADON or designated Administrative Nurse (Restorative Coordinator, MDS Nurse, Infection Control Nurse, or Central Supply Nurse) weekly for four weeks, monthly for two months, quarterly for one year, and then every six months thereafter. This tool directs the audit of five (5) residents' records with the [DIAGNOSES REDACTED]. The completed indicator and any indicated action plans will be reviewed in the monthly QAPI Committee meetings. 10. The QAPI indicator for the monitoring of management of changes in resident condition will be utilized by the DON, ADON or designated Administrative Nurse (Restorative Coordinator, MDS Nurse, Infection Control Nurse, or Central Supply Nurse) weekly for four weeks, monthly for two months, and then quarterly thereafter. This tool directs the audit of the records of residents who have demonstrated a significant change in condition to determine that the documentation includes but is not limited to timely notification of the MD and notification of the MDS team for review/revision of the care plan as indicated. 11. The QAPI indicator for the monitoring of Nursing Documentation of Electronic Medical Records will be utilized by the DON, ADON, or designated Administrative Nurse (Restorative Coordinator, MDS Nurse, Infection Control Nurse, or Central Supply Nurse) weekly for four weeks, monthly for two months, and then quarterly thereafter to verify complete and timely documentation of residents with a significant change in condition. **The State Survey Agency validated the corrective actions taken by the facility as follows: 1. Review of the audit completed on [DATE] revealed the DON, ADON, and/or administrative nurses revealed the staff reviewed blood sugar flowsheets for the past 30 days on all residents with a [DIAGNOSES REDACTED]. No problems were identified. Resident #1 was transferred to the hospital on [DATE] and did not return to the facility. Resident #3 was transferred to the hospital on [DATE] and did not return to the facility. 2. Review of the audit completed on [DATE], revealed the DON, ADON, and/or administrative nurses had reviewed all resident records to identify residents who had a change in condition in the past 30 days. The audit indicated that any issues identified were addressed. Interview with the ADON on [DATE] at 4:30 PM and the DON at 1:30 PM revealed no problems were identified with the physician not being notified when a resident experienced a change in condition. 3. Review of the facility policy, Diabetes Management, undated, revealed that physician notification was required for blood sugars less than 60 mg/dL and for blood sugars greater than 400 mg/dL. Review of facility documentation revealed copies of Physician's Orders dated [DATE], for all residents with a [DIAGNOSES REDACTED]. Interview with the DON on [DATE] at 1:30 PM and the ADON on [DATE] at 11:45 AM, revealed residents' blood sugars were monitored daily to ensure the resident's physician was notified of any blood sugars outside the set parameters in the facility policy. 4. Review of the Accucheck Tracking Sheets dated [DATE] through [DATE] revealed the sheets were completed daily. Interviews with the DON on [DATE] at 1:30 PM, the ADON on [DATE] at 11:45 AM, and the Administrator on [DATE] at 5:50 PM revealed administrative staff reviewed resident blood sugar levels daily to ensure that the tracking sheets were completed. The ADON stated that any blood sugar result outside the parameters were tracked to ensure the physician was notified. Continued review of the Accucheck Tracking Sheets revealed unsampled Resident A had an elevated blood sugar of 471 mg/dL on [DATE] at approximately 4:00 PM. Review of the Nurse's Notes revealed the resident's physician was notified on [DATE] at 4:34 PM of the elevated blood sugar, per facility policy. 5. Review of Resident #10 and Resident #11's medical records revealed the exterior of the binder had a sticker that read DIABETIC. Interview with the ADON on [DATE] at 1:30 PM, revealed stickers noting the resident's [DIAGNOSES REDACTED]. 6. Review of the in-service training records revealed that licensed nursing staff had received training on the following: Physician Notification, Diabetes Management, Blood Sugar Parameters, Obtaining Labs, Alert Charting, and Documentation Guidelines. The trainings started on [DATE] and were completed by [DATE]. Continued review of training records revealed SRNAs and Certified Medical Technicians (CMT) had received training on vital sign parameters and on reporting any change in resident status to the nurse. The training records indicated these trainings were completed on [DATE]. Interview with the ADON on [DATE] at 1:30 PM revealed that she had verified that all facility employed nursing staff had received the above trainings. Further interview with the ADON on [DATE] at 11:45 AM revealed the facility had no new hires since [DATE]. The ADON stated she completed the new licensed nurse orientation and that it would include the previously mentioned areas of education. The DON also stated a Playbook was located at each nurses' station and contained the recent staff training for staff to refer to if needed. Further interview revealed administrative staff met daily and reviewed audits to ensure staff competency with the previously mentioned policies and trainings. Interviews on [DATE] with LPN #5 at 3:50 PM, LPN #8 at 3:59 PM, LPN #9 at 2:38 PM, and Registered Nurse (RN) #2 at 4:10 PM revealed all had received in-service training on Change in Resident Condition, Physician Notification, Diabetes Management, Blood Sugar and Vital Sign Parameters, Labs, and Timely Physician Documentation, and Documentation Guidelines. The nurses stated that anytime a resident had a change in condition, or it was reported, a resident assessment must be completed and the resident's physician notified depending on the results of the resident assessment. Interviews on [DATE] with CMT #1 at 3:45 PM, CMT #2 at 3:40 PM, CMT #5 at 1:20 PM, CMT #6 at 3:30 PM, SRNA #3 at 1:58 PM, and SRNA #12 at 3:30 PM, revealed all had received in-service training on vital sign parameters and to report to the nurse any change in resident status/condition. SRNA #12 stated she had noted a change in a resident's condition on [DATE] and she immediately notified the nurse who assessed the resident and called the resident's physician. The CMTs and SRNAs stated they were given a laminated card with vital sign parameters printed on the card. Staff stated they were trained to report any vital sign reading outside the parameters printed on the card. 7. Review of Quality Assurance Performance Improvement (QAPI) Agenda/Meeting notes revealed QAPI meetings were held on [DATE], [DATE], and [DATE]. Interviews on [DATE] with the DON at 1:30 PM, the ADON at 11:45 AM, and the Administrator at 5:50 PM confirmed the QAPI meetings had been held per the plan. 8. The daily monitoring of Blood Glucometer Checks, Daily Census, 24-hour Report sheet, and Two-Hour rounds checklist (rounds are completed by the charge nurse every two hours and documented) were reviewed and had been completed since [DATE] per the facility's plan. Interviews on [DATE] with the ADON at 4:30 PM, the DON at 1:30 PM, and the Administrator at 5:50 PM revealed they were reviewing the audits included in the plan and no problems had been identified. The staff stated morning meetings were also conducted to review 24-hour reports, blood sugar checks, and two-hour rounds reports, etc. 9. Review of the QAPI audits for the monitoring of diabetes management revealed the audits were completed by administrative nurses on [DATE] and [DATE]. This tool audited five (5) resident records with the [DIAGNOSES REDACTED]. None of these audits identified any problems and all thresholds were at 100%. Interview on [DATE] with the ADON at 4:30 PM, the DON at 1:30 PM, and the Administrator at 5:50 PM revealed they reviewed the audits included in the plan and no problems had been identified. All stated that morning meetings were also conducted to review 24-hour reports, blood sugar checks, two-hour rounds reports, etc. Record review revealed Resident #10, Resident #11, and Resident #13 had [DIAGNOSES REDACTED]. Record review revealed the blood sugars were being obtained as ordered and sliding scale insulin was being administered as ordered. Blood sugar results outside the facility's policy parameters (less than 60 or greater than 400) were called to the physician. 10. The QAPI audits for the monitoring of management of changes in resident condition were completed by administrative nurses on [DATE] and [DATE] with no problems identified. This tool audited records of residents who had demonstrated

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure licensed nursing staff had the knowledge and skill sets to provide nursing services and respond to individualized needs which were identified through the resident's assessments and described in the resident's plan of care for one (1) of fourteen (14) sampled residents (Resident #1). Resident #1's average monthly blood sugars increased from 128 mg/dL (milligrams/deciliter) in (MONTH) (YEAR) to 254 mg/dL in (MONTH) (YEAR) (normal blood sugar level is ,[DATE]) and was consistently over 200 mg/dL from [DATE] through [DATE]. In addition, the resident also developed an infection on [DATE]. Although the facility educated staff regarding the facility's blood sugar monitoring policy/protocol and staff interviews revealed they checked the resident's blood sugar weekly as ordered, there was no evidence the facility notified the resident's physician or took any action to address the resident's increased blood sugar level. Subsequently, on [DATE], staff found Resident #1 unresponsive and transferred the resident to the Emergency Department where the resident's blood sugar was greater than 1,000 mg/dL. The resident was diagnosed with [REDACTED]. The facility's failure to ensure licensed nurses were knowledgeable and competent has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE] at 42 CFR 483.10 Resident Rights (F580), 42 CFR 483.25 Quality of Care (F684), 42 CFR 483.35 Nursing Services (F726), and 42 CFR 483.70 Administration (842). The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance was received on [DATE], which alleged removal of the Immediate Jeopardy on [DATE]. The State Survey Agency determined the Immediate Jeopardy was removed on [DATE] as alleged, prior to exit, which lowered the scope and severity to D level at 42 CFR 483.10 Resident Rights (F580), 42 CFR 483.25 Quality of Care (F684), 42 CFR 483.35 Nursing Services (F726), and 42 CFR 483.70 Administration (842) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of facility staff education records revealed the facility conducted Spring Reviews in April, May, and (MONTH) (YEAR). Further review revealed staff completed a Medication Administration Skills Checklist and a Nurse Competency Skills Checklist that included competency with glucose monitoring protocols. Review of the facility's Diabetes Management protocol/policy for [MEDICAL CONDITION] (high blood sugar) dated [DATE], revealed the physician must be notified if resident assessment findings or glucose results indicated a need for potential dosage changes. The policy further stated follow-up blood sugar testing would be completed as ordered by the physician and could be performed by the nurse if the diabetic resident continued to exhibit signs and symptoms of [MEDICAL CONDITION]. Review of the Blood Sugar Parameters Per Physician protocol revealed Resident #1's physician was required to be notified if the resident's blood sugar was greater than 200 mg/dL. Review of Resident #1's closed medical record revealed the facility admitted the resident on [DATE], and readmitted the resident on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed the resident to have moderately impaired cognition but no mood disturbances, and the resident denied having little interest or pleasure in doing things or feeling tired or having little energy. Review of Resident #1's Comprehensive Care Plan revised on [DATE], revealed the facility identified that the resident had a [DIAGNOSES REDACTED]. The facility-developed goal was for the resident to maintain a blood sugar between 60 and 105, with interventions to continue labs and blood sugars as ordered, continue oral medications, and continue current interventions. Review of Resident #1's Physician Orders dated [DATE] revealed the resident had an order for [REDACTED]. Review of Resident #1's Medication Administration records revealed the resident's blood sugar was above 200 mg/dL on [DATE] and [DATE], and consistently over 200 from [DATE] through [DATE]. However, review of Resident #1's medical record revealed no documented evidence that staff assessed the resident for [MEDICAL CONDITION] or conducted blood sugars as needed, as ordered by the resident's physician when the resident's blood sugars were consistently above 200 mg/dL. In addition, there was no documented evidence the facility revised the resident's care plan with interventions to meet the resident's goal of maintaining blood sugars between 60 and 105. Review of Resident #1's Nurse's Notes dated [DATE] revealed the resident had a new physician's order for [MEDICATION NAME], an antibiotic administered intramuscularly every day for ten (10) days for treatment of [REDACTED]. On [DATE], Resident #1's blood sugar increased to 307. Again, there was no documented evidence the facility monitored the resident's blood sugar, even though the resident's blood sugar was elevated and the resident had an infection. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment, dated [DATE], revealed the facility assessed the resident to have a moderately impaired cognition and the resident now presented with little interest or pleasure in doing things, feeling tired, and having little energy. However, there was no evidence the facility considered that the decline in mood status could be related to the resident's increase in blood sugars. Nor was there evidence that the facility revised the resident's care plan with interventions to address the resident's increased blood sugar levels. Interview with Resident #1's Physician on [DATE] at 2:18 PM and on [DATE] at 10:57 AM, revealed staff should have monitored the resident's blood sugar more often when the resident's blood sugar was elevated, and should have monitored the resident more closely when the resident developed an infection because infection and antibiotic use could elevate the blood sugar level. Interview with LPN #3 on [DATE] at 11:01 AM revealed she routinely checked Resident #1's blood sugar at 6:00 AM every Tuesday. Even though facility documentation revealed LPN #3 attended an in-service in (MONTH) (YEAR) related to the facility's blood sugar monitoring policies/procedures, LPN #3 stated she was not aware that the facility had a protocol that required Resident #1's Physician to be notified if the resident's blood sugar was over 200. LPN #3 stated she had not notified the resident's physician because she assumed the physician should not be notified unless the resident's blood sugar was above 400. She stated Resident #1 had been weak and had not been feeling well; however, the resident had a Urinary Tract Infection [MEDICAL CONDITION] and she contributed the resident's condition to the UTI. Continued interview revealed she did not consider conducting more frequent blood sugar checks even though the resident had an infection and was receiving an antibiotic that could cause elevated blood sugar levels. Interview with LPN #2 on [DATE] at 3:04 PM revealed she was aware that Resident #1 was more tired and not acting like his/her normal self; however, she stated she contributed the resident's change in condition to the resident's UTI diagnosis. LPN #2 stated that she should have monitored the resident's blood sugar more during that time because he/she could have [MEDICAL CONDITION] due to the infection and antibiotic therapy the resident was receiving. She further stated she did not consider conducting blood sugar checks for Resident #1. Interview with LPN #5 on [DATE] at 4:34 PM, revealed he had never checked Resident #1's blood sugar level and was not aware the resident's blood sugars had been elevated. Interview with the Assistant Director of Nursing (ADON) on [DATE] at 9:01 AM, revealed she was aware having an infection increased blood sugar levels; however, the facility did not monitor blood sugar levels for residents who had non-Insulin Dependent Diabetes to ensure out-of-range blood sugars were being monitored, acted upon appropriately, and reported to the physician. Therefore, the facility failed to recognize staff were not monitoring residents' blood sugars appropriately and taking necessary action when a resident's blood sugar was elevated. Interview with the Director of Nursing (DON) on [DATE] at 1:01 PM revealed nursing staff should have checked Resident #1's blood sugar more frequently while the resident was receiving antibiotic therapy for a UTI. She stated audits were performed quarterly when it came up in their QAPI meetings. However, they did not realize non-insulin dependent diabetics were not monitored to ensure the resident's care plan goals were met and the physician was notified for out-of-range blood sugar levels until Resident #1 was admitted to the hospital and diagnosed with [REDACTED]. Review of the nurse's notes for Resident #1 revealed on [DATE] at 7:35 AM, Licensed Practical Nurse (LPN) #5 documented that Resident #1 was unresponsive and had tremors, and was transferred to the Emergency Department (ED) for evaluation. Review of Resident #1's ED record dated [DATE] revealed the resident was unresponsive upon arrival and his/her blood sugar level was 1,028. Resident #1 was admitted to the hospital with [REDACTED]. Resident #1 expired on [DATE] from complications related to [MEDICAL CONDITION]. **The facility implemented the following corrective actions to remove the Immediate Jeopardy: 1. Resident #1 and Resident #3 no longer reside in the facility. Both residents expired at the hospital. The DON completed an audit of blood sugar results for Resident #1 and all residents with a [DIAGNOSES REDACTED]. 2. An audit was completed as of [DATE] by the DON, ADON, and other Administrative Nursing staff to identify any residents who had a significant change in condition in the last 30 days, any issues noted were addressed, interventions implemented, and the physician notified. 3. Orders were obtained for new parameters for all diabetic residents noting when to notify the resident's physician. All attending physicians agreed to parameters of less than 60 mg/dL or greater than 400 mg/dL. All non-insulin dependent Diabetes Mellitus (NIDDM) residents have orders to check their blood sugar at least every day. 4. A new blood sugar tracking sheet was implemented to accompany the shift change report for review of blood sugar results. 5. A sticker was applied to the charts of all residents with the [DIAGNOSES REDACTED]. 6. All licensed nurses have received in-service education on the following: -Physician Notification -Diabetes Management -The new blood sugar parameters for when to notify the Physician -Obtaining labs -Alert Charting (which includes the immediate follow-up on any reported change of condition) -Documentation Guidelines - all documentation should be completed as close as possible to the time of the event; however, in the event of a resident transfer, a legal late entry may be completed up to 24 hours from the time of the transfer. All SRNAs have been in-serviced on resident change of condition criteria and the need to report any observed changes to the charge nurse immediately. This education was provided by: the Director of Nursing, Assistant Director of Nursing, Restorative Coordinator, Minimum Data Set (MDS) Nurses, Infection Control Nurse, and Central Supply Nurse, completed on [DATE]. 7. A Quality Assurance and Performance Improvement (QAPI) meeting was held on [DATE], [DATE], and [DATE] to review the investigation findings and the action plan with the QAPI team and Medical Director. 8. Daily monitoring of Blood Glucometer Checks, Daily Census, 24-hour Report sheet, and Two-Hour rounds checklist (rounds are completed by the charge nurse every two hours and documented) by the DON or ADON or designated Administrative Nurse (Restorative Coordinator, MDS Nurse, Infection Control Nurse, or Central Supply Nurse) to identify a change of condition, MD notification, and implemented interventions. Concerns identified will be reported to the Administrator and QAPI Committee. 9. The QAPI indicator for the monitoring of diabetes management will be utilized by the DON or ADON or designated Administrative Nurse (Restorative Coordinator, MDS Nurse, Infection Control Nurse, or Central Supply Nurse) weekly for four weeks, monthly for two months, quarterly for one year, and then every six months thereafter. This tool directs the audit of five (5) residents' records with the [DIAGNOSES REDACTED]. The completed indicator and any indicated action plans will be reviewed in the monthly QAPI Committee meetings. 10. The QAPI indicator for the monitoring of management of changes in resident condition will be utilized by the DON, ADON or designated Administrative Nurse (Restorative Coordinator, MDS Nurse, Infection Control Nurse, or Central Supply Nurse) weekly for four weeks, monthly for two months, and then quarterly thereafter. This tool directs the audit of the records of residents who have demonstrated a significant change in condition to determine that the documentation includes but is not limited to timely notification of the MD and notification of the MDS team for review/revision of the care plan as indicated. 11. The QAPI indicator for the monitoring of Nursing Documentation of Electronic Medical Records will be utilized by the DON, ADON, or designated Administrative Nurse (Restorative Coordinator, MDS Nurse, Infection Control Nurse, or Central Supply Nurse) weekly for four weeks, monthly for two months, and then quarterly thereafter to verify complete and timely documentation of residents with a significant change in condition. **The State Survey Agency validated the corrective actions taken by the facility as follows: 1. Review of the audit completed on [DATE] revealed the DON, ADON, and/or administrative nurses revealed the staff reviewed blood sugar flowsheets for the past 30 days on all residents with a [DIAGNOSES REDACTED]. No problems were identified. Resident #1 was transferred to the hospital on [DATE] and did not return to the facility. Resident #3 was transferred to the hospital on [DATE] and did not return to the facility. 2. Review of the audit completed on [DATE], revealed the DON, ADON, and/or administrative nurses had reviewed all resident records to identify residents who had a change in condition in the past 30 days. The audit indicated that any issues identified were addressed. Interview with the ADON on [DATE] at 4:30 PM and the DON at 1:30 PM revealed no problems were identified with the physician not being notified when a resident experienced a change in condition. 3. Review of the facility policy, Diabetes Management, undated, revealed that physician notification was required for blood sugars less than 60 mg/dL and for blood sugars greater than 400 mg/dL. Review of facility documentation revealed copies of Physician's Orders dated [DATE], for all residents with a [DIAGNOSES REDACTED]. Interview with the DON on [DATE] at 1:30 PM and the ADON on [DATE] at 11:45 AM, revealed residents' blood sugars were monitored daily to ensure the resident's physician was notified of any blood sugars outside the set parameters in the facility policy. 4. Review of the Accucheck Tracking Sheets dated [DATE] through [DATE] revealed the sheets were completed daily. Interviews with the DON on [DATE] at 1:30 PM, the ADON on [DATE] at 11:45 AM, and the Administrator on [DATE] at 5:50 PM revealed administrative staff reviewed resident blood sugar levels daily to ensure that the tracking sheets were completed. The ADON stated that any blood sugar result outside the parameters were tracked to ensure the physician was notified. Continued review of the Accucheck Tracking Sheets revealed unsampled Resident A had an elevated blood sugar of 471 mg/dL on [DATE] at approximately 4:00 PM. Review of the Nurse's Notes revealed the resident's physician was notified on [DATE] at 4:34 PM of the elevated blood sugar, per facility policy. 5. Review of Resident #10 and Resident #11's medical records revealed the exterior of the binder had a sticker that read DIABETIC. Interview with the ADON on [DATE] at 1:30 PM, revealed stickers noting the resident's [DIAGNOSES REDACTED]. 6. Review of the in-service training records revealed that licensed nursing staff had received training on the following: Physician Notification, Diabetes Management, Blood Sugar Parameters, Obtaining Labs, Alert Charting, and Documentation Guidelines. The trainings started on [DATE] and were completed by [DATE]. Continued review of training records revealed SRNAs and Certified Medical Technicians (CMT) had received training on vital sign parameters and on reporting any change in resident status to the nurse. The training records indicated these trainings were completed on [DATE]. Interview with the ADON on [DATE] at 1:30 PM revealed that she had verified that all facility employed nursing staff had received the above trainings. Further interview with the ADON on [DATE] at 11:45 AM revealed the facility had no new hires since [DATE]. The ADON stated she completed the new licensed nurse orientation and that it would include the previously mentioned areas of education. The DON also stated a Playbook was located at each nurses' station and contained the recent staff training for staff to refer to if needed. Further interview revealed administrative staff met daily and reviewed audits to ensure staff competency with the previously mentioned policies and trainings. Interviews on [DATE] with LPN #5 at 3:50 PM, LPN #8 at 3:59 PM, LPN #9 at 2:38 PM, and Registered Nurse (RN) #2 at 4:10 PM revealed all had received in-service training on Change in Resident Condition, Physician Notification, Diabetes Management, Blood Sugar and Vital Sign Parameters, Labs, and Timely Physician Documentation, and Documentation Guidelines. The nurses stated that anytime a resident had a change in condition, or it was reported, a resident assessment must be completed and the resident's physician notified depending on the results of the resident assessment. Interviews on [DATE] with CMT #1 at 3:45 PM, CMT #2 at 3:40 PM, CMT #5 at 1:20 PM, CMT #6 at 3:30 PM, SRNA #3 at 1:58 PM, and SRNA #12 at 3:30 PM, revealed all had received in-service training on vital sign parameters and to report to the nurse any change in resident status/condition. SRNA #12 stated she had noted a change in a resident's condition on [DATE] and she immediately notified the nurse who assessed the resident and called the resident's physician. The CMTs and SRNAs stated they were given a laminated card with vital sign parameters printed on the card. Staff stated they were trained to report any vital sign reading outside the parameters printed on the card. 7. Review of Quality Assurance Performance Improvement (QAPI) Agenda/Meeting notes revealed QAPI meetings were held on [DATE], [DATE], and [DATE]. Interviews on [DATE] with the DON at 1:30 PM, the ADON at 11:45 AM, and the Administrator at 5:50 PM confirmed the QAPI meetings had been held per the plan. 8. The daily monitoring of Blood Glucometer Checks, Daily Census, 24-hour Report sheet, and Two-Hour rounds checklist (rounds are completed by the charge nurse every two hours and documented) were reviewed and had been completed since [DATE] per the facility's plan. Interviews on [DATE] with the ADON at 4:30 PM, the DON at 1:30 PM, and the Administrator at 5:50 PM revealed they were reviewing the audits included in the plan and no problems had been identified. The staff stated morning meetings were also conducted to review 24-hour reports, blood sugar checks, and two-hour rounds reports, etc. 9. Review of the QAPI audits for the monitoring of diabetes management revealed the audits were completed by administrative nurses on [DATE] and [DATE]. This tool audited five (5) resident records with the [DIAGNOSES REDACTED]. None of these audits identified any problems and all thresholds were at 100%. Interview on [DATE] with the ADON at 4:30 PM, the DON at 1:30 PM, and the Administrator at 5:50 PM revealed they reviewed the audits included in the plan and no problems had been identified. All stated that morning meetings were also conducted to review 24-hour reports, blood sugar checks, two-hour rounds reports, etc. Record review revealed Resident #10, Resident #11, and Resident #13 had [DIAGNOSES REDACTED]. Record review revealed the blood sugars were being obtained as ordered and sliding scale insulin was being administered as ordered. Blood sugar results outside the facility's policy parameters (less than 60 or greater than 400) were called to the physician. 10. The QAPI audits for the monitoring of management of changes in resident condition were completed by administrative nurses on [DATE] and [DATE] with no problems identified. This tool audited records of residents who had demonstrated a significant change in condition to determine that the documentation included but was not limited to: timely notification of the MD and notification of the MDS team for review/revision of the care plan as indicated. Interview on [DATE] with the ADON at 4:30 PM, the DON at 1:30 PM, and the Administrator at 5:50 PM revealed they were reviewing the audits included in the plan and no problems had been identified. The staff stated morning meetings were also conducted to review 24-hour reports, blood sugar checks, two-hour rounds reports, etc. The facility identified that Resident #9 and Resident 14 had a change in condition since [DATE]. Both residents' medical records were reviewed and no concerns were identified related to timely physician notification. 11. The QAPI audit for the monitoring of Nursing Documentation was completed by administrative nurses on [DATE], [DATE], [DATE], and [DATE]. This audit was being completed to verify complete and timely documentation of residents with a significant change in condition. Interview with the ADON on [DATE] at 4:30 PM revealed this audit was currently being completed daily. The facility identified that Resident #9 and Resident #14 had a change in condition since [DATE]. Both residents' medical records were reviewed and no concerns were identified related to timely physician notification. Both records contained timely documentation related to the change in condition and notification of the resident's physician.

Based on interview, record review, and review of the facility's policy/protocol, it was determined the facility failed to maintain accurate, complete medical records for one (1) of fourteen (14) residents (Resident #3) when the resident experienced a change in condition and there was a need to alter treatment. Resident #3's family and staff reported the resident had a change in condition on the morning of [DATE]; however, there was no documented assessment of the resident until 5:15 PM on [DATE]. Resident #3's family returned to the facility at approximately 4:00 PM and the resident's skin was gray/colorless, the resident's oxygen was in the seventies (normal is ,[DATE]), and the resident was having difficulty breathing. The facility transferred the resident to the hospital and the resident was admitted [MEDICAL CONDITION] (condition caused from infection in which toxins are released in the bloodstream), health care acquired pneumonia, [MEDICAL CONDITION] (condition in which the body is deprived of adequate oxygen supply), and renal (kidney) failure, and Resident #3 expired on [DATE], due to pneumonia. Resident #3's family member delivered a letter to the facility on [DATE], concerned that the resident was neglected because the facility did not assess and treat the resident timely prior to being transferred to the hospital. Subsequent review of Resident #3's medical record revealed after receiving the family member's letter, the facility entered late entries for [DATE] on [DATE], four days later, which detailed other assessments that had not previously been entered into the resident's record which appeared to address each concern voiced by the family member. The facility's failure to maintain accurate, complete medical records has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE] at 42 CFR 483.10 Resident Rights (F580), 42 CFR 483.25 Quality of Care (F684), 42 CFR 483.35 Nursing Services (F726), and 42 CFR 483.70 Administration (842). The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance was received on [DATE], which alleged removal of the Immediate Jeopardy on [DATE]. The State Survey Agency determined the Immediate Jeopardy was removed on [DATE] as alleged, prior to exit, which lowered the scope and severity to D level at 42 CFR 483.10 Resident Rights (F580), 42 CFR 483.25 Quality of Care (F684), 42 CFR 483.35 Nursing Services (F726), and 42 CFR 483.70 Administration (842) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: A review of the facility's Alert Charting Policy and Procedures, revised [DATE], revealed it was the policy of the facility to institute Alert Charting for any change in condition or unusual occurrence that may or may not result in injury to a resident. The policy stated that examples of a change in condition included behavior changes, signs or symptoms of infection (congestion, mental status changes, diarrhea, etc.), abnormal vital signs, or shortness of breath. The policy further stated that depending on the type of condition change, nurses would assess and evaluate the resident's condition and determine what was needed, notify the physician, and notify the responsible party. Review of the medical record for Resident #3 revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of the 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 four (4), indicating the resident was severely cognitively impaired. Interview with Family Member #1 on [DATE] at 3:34 PM revealed he visited Resident #3 at the facility daily. He stated the resident had not been feeling well for a few days, but when he visited Resident #3 on [DATE] at approximately 10:00 AM, the resident was in bed and did not present with his/her normal behavior. Family Member #1 stated he told Licensed Practical Nurse (LPN) #1 that the resident was not feeling well and asked the LPN to watch the resident more closely. However, when the family member returned to the facility at approximately 4:00 PM on [DATE], the resident's skin looked gray and colorless and the resident was not very responsive to him when he tried to speak to the resident. The family member stated he summoned staff to the resident's room. The resident's oxygen level was in the seventies (normal is ,[DATE]) and the facility transferred the resident to the hospital where the resident was diagnosed with [REDACTED]. was severe and advanced and did not know if it could be controlled. A review of the resident's medical record revealed [REDACTED].#3 on [DATE] was at 5:15 PM. The assessment stated the resident's oxygen saturation level was at 82 percent while on oxygen at 2 liters via nasal cannula. There was no documentation that staff assessed the resident's lung sounds, skin color, or cognition. The note stated the resident was transported to the emergency room for evaluation. Continued interview with Family Member #1 on [DATE] at 3:34 PM, revealed he delivered a letter to the facility on [DATE], after the resident was hospitalized , that stated he felt like the facility neglected the resident. The family member stated staff did not assess the resident and seek treatment for [REDACTED]. A review of a facility Grievance form dated [DATE], revealed Family Member #1 filed a verbal and written grievance that stated on [DATE], State Registered Nurse Aides (SRNAs) stated they reported to LPN #1 that Resident #3's oxygen was low and LPN #1 told the SRNAs to reposition the resident. When Family Member #1 arrived at the facility prior to the resident being transferred to the hospital, no staff were in the resident's room and when a staff member came in, the resident's oxygen was at 82 percent. However, further review of Resident #3's medical record revealed that on [DATE] at 1:31 PM, the day the facility received a complaint/grievance from the resident's family and four days after the resident was discharged from the facility, LPN #1 made an addendum to the [DATE], 5:15 PM entry into the resident's record. The LPN documented that when Resident #3 finished breakfast and staff was transferring the resident back to his/her room, the resident was yelling, Oh, Lord, help me! LPN #1 documented that the resident complained of knee pain and Tylenol was administered for pain; however, there was no documentation on the resident's Medication Administration Record [REDACTED]. At 3:40 PM on [DATE], LPN #1 documented that staff called the LPN to Resident #3's room and the resident was assessed by two (2) nurses (LPN #1 and LPN #4) to have clear lung sounds, no cough, and vital signs within normal range. The documentation revealed the resident's oxygen saturation was at 77 percent when the reading was taken in the right hand; however, it increased to 91 percent in the left hand. Further review revealed during evening meal service, an SRNA reported to him that Resident #3's oxygen saturation was at 79 percent and the LPN #1 instructed the SRNA to check the resident's oxygen saturation in another finger (the oxygen saturation monitor is checked by placing a finger into a small clip placed over the end of the finger). The LPN documented that he continued to admit a new patient to the facility until the SRNA returned and informed LPN #1 that the resident was going to be transferred. LPN #1 documented that he then went into Resident #3's room and observed two SRNAs, the social worker, and Family Member #1 at the resident's bedside. The LPN then called Emergency Medical Services (EMS) and prepared paperwork for the resident's transfer. Further review revealed LPN #4 also entered a late entry into Resident #3's medical record on [DATE] at 4:03 PM, after the resident's family member sent a letter to the facility concerned about the resident's care. LPN #4 documented that on [DATE] at approximately 3:40 PM, Resident #3's oxygen saturation read in the 70's on the right hand, but was at 91 percent when the monitor was moved to the left hand. The nurse documented that the resident's lungs were clear and the resident's skin and lips were pink. LPN #4 documented that she was called to the resident's room again at supper and the resident's response to verbal stimuli was more sluggish than the prior assessment and the resident's oxygen saturation fluctuated from the low to high seventies. Oxygen was administered to the resident and the resident's oxygen saturation increased to the eighties. LPN #4 documented the resident was showing more signs and symptoms of shortness of air. The resident's condition was reported to LPN #1 and the resident was awaiting EMS to transport the resident to the Emergency Department. Interview with LPN #1 on [DATE] at 11:03 AM revealed the LPN documented late entries into Resident #3's medical record on [DATE] to give a better description of what happened on [DATE]. Interview with LPN #4 on [DATE] at 4:52 PM revealed she was aware that documentation should be completed when incidents occurred or as soon as possible if there was an emergency. LPN #4 stated she assessed Resident #3 and gave the assessment information to LPN #1, who was the resident's assigned nurse, and assumed LPN #1 had documented the assessments. LPN #4 stated she should have documented Resident #3's assessment on [DATE], and when she discovered on [DATE] that the assessment was not documented, she felt the need to document in depth the resident's assessment on [DATE]. According to the facility's Grievance form, LPN #1 would be educated on assessment of residents and proper documentation. Interview with the facility Administrator on [DATE] at 1:28 PM revealed he instructed LPN #1 and LPN #4 to add additional documentation to Resident #3's medical record because there was not enough documentation about what happened with Resident #3. A review of Resident #3's hospital medical record revealed the resident was admitted to the hospital on [DATE], with [DIAGNOSES REDACTED]. Resident #3 expired on [DATE], due to pneumonia. **The facility implemented the following corrective actions to remove the Immediate Jeopardy: 1. Resident #1 and Resident #3 no longer reside in the facility. Both residents expired at the hospital. The DON completed an audit of blood sugar results for Resident #1 and all residents with a [DIAGNOSES REDACTED]. 2. An audit was completed as of [DATE] by the DON, ADON, and other Administrative Nursing staff to identify any residents who had a significant change in condition in the last 30 days, any issues noted were addressed, interventions implemented, and the physician notified. 3. Orders were obtained for new parameters for all diabetic residents noting when to notify the resident's physician. All attending physicians agreed to parameters of less than 60 mg/dL or greater than 400 mg/dL. All non-insulin dependent Diabetes Mellitus (NIDDM) residents have orders to check their blood sugar at least every day. 4. A new blood sugar tracking sheet was implemented to accompany the shift change report for review of blood sugar results. 5. A sticker was applied to the charts of all residents with the [DIAGNOSES REDACTED]. 6. All licensed nurses have received in-service education on the following: -Physician Notification -Diabetes Management -The new blood sugar parameters for when to notify the Physician -Obtaining labs -Alert Charting (which includes the immediate follow-up on any reported change of condition) -Documentation Guidelines - all documentation should be completed as close as possible to the time of the event; however, in the event of a resident transfer, a legal late entry may be completed up to 24 hours from the time of the transfer. All SRNAs have been in-serviced on resident change of condition criteria and the need to report any observed changes to the charge nurse immediately. This education was provided by: the Director of Nursing, Assistant Director of Nursing, Restorative Coordinator, Minimum Data Set (MDS) Nurses, Infection Control Nurse, and Central Supply Nurse, completed on [DATE]. 7. A Quality Assurance and Performance Improvement (QAPI) meeting was held on [DATE], [DATE], and [DATE] to review the investigation findings and the action plan with the QAPI team and Medical Director. 8. Daily monitoring of Blood Glucometer Checks, Daily Census, 24-hour Report sheet, and Two-Hour rounds checklist (rounds are completed by the charge nurse every two hours and documented) by the DON or ADON or designated Administrative Nurse (Restorative Coordinator, MDS Nurse, Infection Control Nurse, or Central Supply Nurse) to identify a change of condition, MD notification, and implemented interventions. Concerns identified will be reported to the Administrator and QAPI Committee. 9. The QAPI indicator for the monitoring of diabetes management will be utilized by the DON or ADON or designated Administrative Nurse (Restorative Coordinator, MDS Nurse, Infection Control Nurse, or Central Supply Nurse) weekly for four weeks, monthly for two months, quarterly for one year, and then every six months thereafter. This tool directs the audit of five (5) residents' records with the [DIAGNOSES REDACTED]. The completed indicator and any indicated action plans will be reviewed in the monthly QAPI Committee meetings. 10. The QAPI indicator for the monitoring of management of changes in resident condition will be utilized by the DON, ADON or designated Administrative Nurse (Restorative Coordinator, MDS Nurse, Infection Control Nurse, or Central Supply Nurse) weekly for four weeks, monthly for two months, and then quarterly thereafter. This tool directs the audit of the records of residents who have demonstrated a significant change in condition to determine that the documentation includes but is not limited to timely notification of the MD and notification of the MDS team for review/revision of the care plan as indicated. 11. The QAPI indicator for the monitoring of Nursing Documentation of Electronic Medical Records will be utilized by the DON, ADON, or designated Administrative Nurse (Restorative Coordinator, MDS Nurse, Infection Control Nurse, or Central Supply Nurse) weekly for four weeks, monthly for two months, and then quarterly thereafter to verify complete and timely documentation of residents with a significant change in condition. **The State Survey Agency validated the corrective actions taken by the facility as follows: 1. Review of the audit completed on [DATE] revealed the DON, ADON, and/or administrative nurses revealed the staff reviewed blood sugar flowsheets for the past 30 days on all residents with a [DIAGNOSES REDACTED]. No problems were identified. Resident #1 was transferred to the hospital on [DATE] and did not return to the facility. Resident #3 was transferred to the hospital on [DATE] and did not return to the facility. 2. Review of the audit completed on [DATE], revealed the DON, ADON, and/or administrative nurses had reviewed all resident records to identify residents who had a change in condition in the past 30 days. The audit indicated that any issues identified were addressed. Interview with the ADON on [DATE] at 4:30 PM and the DON at 1:30 PM revealed no problems were identified with the physician not being notified when a resident experienced a change in condition. 3. Review of the facility policy, Diabetes Management, undated, revealed that physician notification was required for blood sugars less than 60 mg/dL and for blood sugars greater than 400 mg/dL. Review of facility documentation revealed copies of Physician's Orders dated [DATE], for all residents with a [DIAGNOSES REDACTED]. Interview with the DON on [DATE] at 1:30 PM and the ADON on [DATE] at 11:45 AM, revealed residents' blood sugars were monitored daily to ensure the resident's physician was notified of any blood sugars outside the set parameters in the facility policy. 4. Review of the Accucheck Tracking Sheets dated [DATE] through [DATE] revealed the sheets were completed daily. Interviews with the DON on [DATE] at 1:30 PM, the ADON on [DATE] at 11:45 AM, and the Administrator on [DATE] at 5:50 PM revealed administrative staff reviewed resident blood sugar levels daily to ensure that the tracking sheets were completed. The ADON stated that any blood sugar result outside the parameters were tracked to ensure the physician was notified. Continued review of the Accucheck Tracking Sheets revealed unsampled Resident A had an elevated blood sugar of 471 mg/dL on [DATE] at approximately 4:00 PM. Review of the Nurse's Notes revealed the resident's physician was notified on [DATE] at 4:34 PM of the elevated blood sugar, per facility policy. 5. Review of Resident #10 and Resident #11's medical records revealed the exterior of the binder had a sticker that read DIABETIC. Interview with the ADON on [DATE] at 1:30 PM, revealed stickers noting the resident's [DIAGNOSES REDACTED]. 6. Review of the in-service training records revealed that licensed nursing staff had received training on the following: Physician Notification, Diabetes Management, Blood Sugar Parameters, Obtaining Labs, Alert Charting, and Documentation Guidelines. The trainings started on [DATE] and were completed by [DATE]. Continued review of training records revealed SRNAs and Certified Medical Technicians (CMT) had received training on vital sign parameters and on reporting any change in resident status to the nurse. The training records indicated these trainings were completed on [DATE]. Interview with the ADON on [DATE] at 1:30 PM revealed that she had verified that all facility employed nursing staff had received the above trainings. Further interview with the ADON on [DATE] at 11:45 AM revealed the facility had no new hires since [DATE]. The ADON stated she completed the new licensed nurse orientation and that it would include the previously mentioned areas of education. The DON also stated a Playbook was located at each nurses' station and contained the recent staff training for staff to refer to if needed. Further interview revealed administrative staff met daily and reviewed audits to ensure staff competency with the previously mentioned policies and trainings. Interviews on [DATE] with LPN #5 at 3:50 PM, LPN #8 at 3:59 PM, LPN #9 at 2:38 PM, and Registered Nurse (RN) #2 at 4:10 PM revealed all had received in-service training on Change in Resident Condition, Physician Notification, Diabetes Management, Blood Sugar and Vital Sign Parameters, Labs, and Timely Physician Documentation, and Documentation Guidelines. The nurses stated that anytime a resident had a change in condition, or it was reported, a resident assessment must be completed and the resident's physician notified depending on the results of the resident assessment. Interviews on [DATE] with CMT #1 at 3:45 PM, CMT #2 at 3:40 PM, CMT #5 at 1:20 PM, CMT #6 at 3:30 PM, SRNA #3 at 1:58 PM, and SRNA #12 at 3:30 PM, revealed all had received in-service training on vital sign parameters and to report to the nurse any change in resident status/condition. SRNA #12 stated she had noted a change in a resident's condition on [DATE] and she immediately notified the nurse who assessed the resident and called the resident's physician. The CMTs and SRNAs stated they were given a laminated card with vital sign parameters printed on the card. Staff stated they were trained to report any vital sign reading outside the parameters printed on the card. 7. Review of Quality Assurance Performance Improvement (QAPI) Agenda/Meeting notes revealed QAPI meetings were held on [DATE], [DATE], and [DATE]. Interviews on [DATE] with the DON at 1:30 PM, the ADON at 11:45 AM, and the Administrator at 5:50 PM confirmed the QAPI meetings had been held per the plan. 8. The daily monitoring of Blood Glucometer Checks, Daily Census, 24-hour Report sheet, and Two-Hour rounds checklist (rounds are completed by the charge nurse every two hours and documented) were reviewed and had been completed since [DATE] per the facility's plan. Interviews on [DATE] with the ADON at 4:30 PM, the DON at 1:30 PM, and the Administrator at 5:50 PM revealed they were reviewing the audits included in the plan and no problems had been identified. The staff stated morning meetings were also conducted to review 24-hour reports, blood sugar checks, and two-hour rounds reports, etc. 9. Review of the QAPI audits for the monitoring of diabetes management revealed the audits were completed by administrative nurses on [DATE] and [DATE]. This tool audited five (5) resident records with the [DIAGNOSES REDACTED]. None of these audits identified any problems and all thresholds were at 100%. Interview on [DATE] with the ADON at 4:30 PM, the DON at 1:30 PM, and the Administrator at 5:50 PM revealed they reviewed the audits included in the plan and no problems had been identified. All stated that morning meetings were also conducted to review 24-hour reports, blood sugar checks, two-hour rounds reports, etc. Record review revealed Resident #10, Resident #11, and Resident #13 had [DIAGNOSES REDACTED]. Record review revealed the blood sugars were being obtained as ordered and sliding scale insulin was being administered as ordered. Blood sugar results outside the facility's policy parameters (less than 60 or greater than 400) were called to the physician. 10. The QAPI audits for the monitoring of management of changes in resident condition were completed by administrative nurses on [DATE] and [DATE] with no problems identified. This tool audited records of residents who had demonstrated a significant change in condition to determine that the documentation included but was not limited to: timely notification of the MD and notification of the MDS team for review/revision of the care plan as indicated. Interview on [DATE] with the ADON at 4:30 PM, the DON at 1:30 PM, and the Administrator at 5:50 PM revealed they were reviewing the audits included in the plan and no problems had been identified. The staff stated morning meetings were also conducted to review 24-hour reports, blood sugar checks, two-hour rounds reports, etc. The facility identified that Resident #9 and Resident 14 had a change in condition since [DATE]. Both residents' medical records were reviewed and no concerns were identified related to timely physician notification. 11. The QAPI audit for the monitoring of Nursing Documentation was completed by administrative nurses on [DATE], [DATE], [DATE], and [DATE]. This audit was being completed to verify complete and timely documentation of residents with a significant change in condition. Interview with the ADON on [DATE] at 4:30 PM revealed this audit was currently being completed daily. The facility identified that Resident #9 and Resident #14 had a change in condition since [DATE]. Both residents' medical records were reviewed and no concerns were identified related to timely physician notification. Both records contained timely documentation related to the change in condition and notification of the resident's physician.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to follow the menu spreadsheet to ensure the meal served met the nutritional needs of eighteen (18) residents who received puree consistency food. The noon meal spreadsheet on 08/08/17 revealed staff were required to serve 5 ounces of the pureed entrée (turkey goulash) and 2.5 to 3 ounces of pureed vegetables (Capri vegetable blend). However, observation revealed the eighteen (18) residents on a puree consistency diet only received a 2 ounce portion of the pureed entrée and the pureed vegetables. The findings include: Review of the facility's policy, Standardized Portions/Pre-Portioning, (no date) revealed portion sizes were written on the menu to ensure equal portions were served in order to provide adequate nutritional care. Review of the menu spreadsheet for the noon meal on 08/08/17 revealed the menu serving size for the pureed entrée (turkey goulash) was 5 ounces, and the serving size for the pureed vegetables (Capri vegetable blend) was 2.5 - 3 ounces. Observation of the steam table during the noon meal at 11:25 AM on 08/08/17 revealed a pan of pureed entrée (turkey goulash), and a pan of pureed vegetables was being served. Observation of the scoops used for serving the pureed food appeared to be a smaller scoop than what was specified on the menu spreadsheet. Interview with the cook at 11:35 AM on 08/08/17 revealed all the scoops used to serve the pureed food were a size #16 (2 ounces). Further interview with the cook at 12:05 PM on 08/08/17 revealed she was supposed to use the scoop sizes that were specified on the menu spreadsheet to serve the pureed food. The cook stated she had gotten mixed up and used the wrong scoop sizes for the pureed entrée and the pureed vegetables. Interview with the Registered Dietitian (RD) and the Dietary Manager (DM) at 10:00 AM on 08/09/17 revealed staff were supposed to use the scoop sizes specified on the menu spreadsheet.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to store and prepare food in accordance with professional standards for food service safety. Review of the facility's policy revealed foods not completely thawed by production time may be thawed under cold, running water; however, observation revealed three (3) rolls of frozen ground turkey were being thawed in a preparation sink with a small stream of water running on one (1) roll of frozen turkey. The findings include: Review of the facility's policy (no date) revealed foods not completely thawed by production time may be thawed under cold, running water. Observation at 7:25 AM on 08/08/17 revealed three (3) rolls of frozen ground turkey were being thawed in a preparation sink with a very small stream of water running on one (1) roll of frozen turkey, and water splashes landing on the other two (2) rolls of frozen ground turkey. Interview with the cook at 7:35 AM on 08/08/17 revealed staff rotated the rolls of frozen ground turkey. However, the cook did not indicate how often the meat was rotated. Interview with the Registered Dietitian (RD) and Dietary Manager (DM) at 11:00 AM on 08/09/17 revealed frozen meat should only be thawed under running water that covered all of the frozen meat.

Based on observation, interview, and record review, it was determined the facility failed to provide services in accordance with the written plan of care for one (1) of sixteen (16) sampled residents (Resident #5). A review of the comprehensive plan of care for Resident #5 revealed the resident's indwelling urinary catheter tubing was required to be secured with a device. However, observation of indwelling urinary catheter care for Resident #5 revealed the catheter was not secured (to prevent trauma). The findings include: Interview with Licensed Practical Nurse (LPN) #2 on 08/09/17 at 2:00 PM Central Standard Time, revealed the facility did not have a policy related to ensuring the comprehensive plan of care was implemented; however, staff were instructed to follow the Resident Assessment Instrument (RAI) guidelines. Review of the RAI User Manual revealed A well developed and executed assessment and care plan .provides information regarding how the causes and risks associated with issues and/or conditions can be addressed to provide for a resident's highest practicable level of well-being (care planning). A review of the medical record revealed the facility admitted Resident #5 on 07/17/17 with an indwelling urinary catheter and [DIAGNOSES REDACTED]. A review of Resident #5's initial Minimum Data Set (MDS) assessment revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of four (4), which indicated the resident was severely cognitively impaired and was not interviewable. The MDS further revealed the resident had an indwelling urinary catheter. Review of Resident #5's comprehensive plan of care dated 07/28/17, revealed the resident's indwelling urinary catheter tubing was required to be secured to the resident's upper, inner thigh with an anchor device. Review of the State Registered Nurse Aide (SRNA) care plan record for Resident #5, dated August 2017, revealed the resident was required to have a Catheter Anchor Device. Observation on 08/08/17 at 3:43 PM Central Standard Time (CST), revealed SRNA #1 was providing indwelling urinary catheter care for Resident #5. At the conclusion of the catheter care, the SRNA draped the catheter tubing over the resident's left leg and applied a brief and the resident's pants without securing the catheter tubing to the resident's upper, inner thigh prior to leaving the resident's bedside. Interview with SRNA #1 on 08/09/17 at 12:55 PM CST, revealed she was aware securing the catheter tubing with an anchor device to the resident's upper, inner thigh was required according to Resident #5's comprehensive plan of care and SRNA care plan record. SRNA #1 revealed the comprehensive plan of care and SRNA care plan record was kept at the nurse's station and she was required to look at the SRNA care plan record daily. SRNA #1 stated she usually secured Resident #5's catheter, but was nervous and forgot. Interview conducted with Registered Nurse (RN) #1 on 08/09/17 at 2:30 PM CST, revealed SRNA's should look at the daily care plan record every shift to ensure they know the care residents required. RN #1 further revealed the SRNA's had been educated regarding ensuring indwelling urinary catheter were secured/anchored. Interview with the Director of Nursing (DON) on 08/09/17 at 2:40 PM CST, revealed SRNAs should review the SRNA care plan record every shift. The DON stated staff should have secured/anchored Resident #5's indwelling urinary catheter tubing to the resident's upper, inner thigh with an anchor device. The DON revealed she made rounds throughout the facility several times a day to ensure residents were receiving the care and treatments as directed by the residents' comprehensive plan of care and the SRNA care plan record. The DON further stated she had not identified any concerns with staff not following residents' comprehensive plans of care or SRNA care plan records and had not identified any concerns with staff not properly securing/anchoring indwelling urinary catheter tubing.

Based on observation, interview, and record review it was determined the facility failed to ensure a resident received the appropriate care and services related to securing indwelling urinary catheters to prevent trauma or injury for one (1) of sixteen (16) sampled residents (Resident #5). Observations during indwelling urinary catheter care for Resident #5 revealed staff failed to secure/anchor the indwelling urinary catheter tubing after performing catheter care. The findings include: Review of the facility policy titled Care of Indwelling Catheter, undated, revealed the policy did not address securing/anchoring catheter tubing to prevent trauma or injury. Review of the medical record for Resident #5 revealed the resident was admitted by the facility on 07/17/17, with an indwelling urinary catheter and with [DIAGNOSES REDACTED]. Review of the initial Minimum Data Set (MDS) assessment dated [DATE] for Resident #5 revealed the resident had a Brief Interview for Mental Status (BIMS) score of four (4), which indicated the resident was severely cognitively impaired and was not interviewable. The MDS also revealed the resident had an indwelling urinary catheter. Review of the Comprehensive Plan of Care dated 07/28/17 revealed Resident #5's indwelling catheter tubing was required to be secured to the resident's upper, inner thigh with an anchor device. Review of the State Registered Nurse Aide Care Plan Record for August 2017 also revealed the catheter was to be secured with a catheter anchoring device. Observation of indwelling urinary catheter care for Resident #5 conducted on 08/08/17 at 3:43 PM revealed State Registered Nurse Aide (SRNA) #1 failed to secure/anchor the resident's indwelling urinary catheter after completing catheter care. SRNA #1 draped the catheter tubing over the resident's left upper leg, applied a brief, and pulled up the resident's pants, but did not secure/anchor the catheter tubing. Interview with SRNA #1 on 08/09/17 at 12:55 PM revealed she was aware that Resident #5's indwelling urinary catheter was required to be secured/anchored to the resident's upper thigh. However, SRNA #1 stated she forgot to secure the resident's catheter during the observation. Interview with Registered Nurse (RN) #1 on 08/09/17 at 2:30 PM revealed Resident #5's indwelling urinary catheter tubing should have been secured/anchored. RN #1 further stated staff had been trained to ensure catheters were secured/anchored and had not identified a concern with residents' urinary catheter tubing not being secured/anchored. Interview with the Director of Nursing (DON) on 08/09/17 at 2:40 PM revealed Resident #5's indwelling urinary catheter tubing should have been secured/anchored. The DON stated staff were trained to ensure catheters were secured/anchored and completed annual skill check-offs. The DON also revealed she monitored resident care by making frequent rounds and watching staff as they provided care. The DON stated she had not identified any concerns with indwelling urinary catheter tubing not being secured/anchored.

Based on interview, record review, and review of the facility's policy and procedure, it was determined the facility failed to ensure an allegation of abuse and neglect was immediately reported for one (1) resident (Resident #1). State Registered Nurse Aide (SRNA) #1 witnessed SRNA #2 verbally abuse Resident #1 (exact date unknown, but approximately 04/17/17). However, SRNA #1 failed to report the allegation until 04/24/17, after SRNA #1 thought about what SRNA #2 said to the resident. The findings include: Review of the facility's policy and procedure titled Prohibiting Abuse, Neglect, Misappropriation and Exploitation, revised 11/24/16, revealed staff would report immediately any alleged incidents of abuse to their supervisor and/or the Administrator of the facility. Record review revealed the facility admitted Resident #1 on 11/24/03, with [DIAGNOSES REDACTED]. Review of an annual Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed Resident #1's cognition as intact with a Brief Interview for Mental Status (BIMS) score of thirteen (13), indicating the resident was interviewable. Further review of the MDS revealed Resident #1 was incontinent of bowel and bladder and required extensive assistance from staff for care. Review of a facility Investigation Summary, not dated, revealed on 04/24/17, SRNA #1 reported to the Social Services Director that SRNA #2 verbally abused a resident. Additional review revealed SRNA #1 reported that while providing incontinence care for Resident #1, in a stand-up lift, SRNA #2 stated to Resident #1, If you didn't sh-t on yourself, you wouldn't have to be in this. Further review of the Investigation Summary revealed no documented evidence of when the allegation occurred. Interview with Resident #1 on 05/17/17 at 2:10 PM revealed he/she did not recall any incidents where he/she was verbally abused by the staff. Interview with SRNA #1 on 05/17/17 at 12:40 PM and 1:11 PM revealed Resident #1 had a bowel movement and he and SRNA #2 took the resident to the tub room to use a stand-up lift to perform incontinence care. SRNA #1 stated as they began to stand the resident in the stand-up lift, the resident moaned. SRNA #1 further reported that SRNA #2 said to Resident #1 that the resident would not have to be in a lift if the resident had not sh-t on yourself. SRNA #1 stated he could not remember the exact date that the incident occurred, but believed it occurred approximately 04/17/17. Additional interview revealed SRNA #1 did not report the incident immediately as required by the facility's policy and procedure. SRNA #1 stated as he thought about what SRNA #2 had said to Resident #1, it bothered him, and he decided to tell the Social Services Director about the incident on 04/24/17. Interview with SRNA #2 on 05/17/17 at 2:02 PM revealed she was accused of verbally abusing Resident #1; however, SRNA #2 stated she did not recall the incident and stated, I would never talk to anyone like that. Additional interview with SRNA #2 revealed she was fired after the investigation. SRNA #2 stated the facility called and thanked her for her services, but stated they were going to have to let her go. Interview with the Social Services Director on 05/17/17 at 12:58 PM and 3:32 PM, revealed SRNA #1 reported that SRNA #2 verbally abused Resident #1 several days ago. The Social Services Director stated she immediately removed SRNA #2 from patient care, suspended the SRNA, and notified the Administrator. Interview with the Administrator on 05/17/17 at 2:20 PM revealed he expected all staff to follow the facility's policy and procedure regarding reporting abuse and neglect. The Administrator revealed that since Resident #1 did not recall the incident, the facility did not substantiate the allegation. However, the Administrator stated he felt like it was in the facility's best interest to terminate the employment of SRNA #2. In addition, the Administrator stated SRNA #1 was disciplined with a written reprimand because he did not report the allegation immediately.

Based on interview, record review, and review of the facility's investigation and abuse policy, it was determined the facility failed to ensure an allegation of abuse for one (1) of four (4) sampled residents (Resident #2) was reported immediately to the Administrator and to the appropriate state agencies and failed to ensure the allegation was investigated. On an unknown date in the fall of 2016, staff observed Resident #1, who had a history of [REDACTED].#2 at the resident's bedside. Resident #2's blanket was down around the resident's knees and the resident's brief was unfastened. Staff stated they reported to the Assistant Administrator and the Assistant Director of Nursing (ADON) immediately; however, there was no evidence the allegation of abuse was investigated. The findings include: Review of the facility's policy titled Prohibiting Abuse, Neglect, Misappropriation and Exploitation, revised 11/24/16, revealed any alleged incident of abuse must be reported immediately to the supervisor and/or the Administrator of the facility. The policy further revealed if the incident of abuse involved a resident-to-resident altercation, the resident's safety and protection would first be assured. Continued review of the policy revealed an investigation would be performed to determine that abuse had occurred, and an evaluation of the resident would be completed to determine if there was a problem that required medical intervention. The policy stated the incident would be viewed as a reportable incident with proper protocol followed, which included conducting an investigation and reporting the allegation to the state agencies as required. Review of the medical record for Resident #1 revealed the facility admitted the resident on 03/30/16 with [DIAGNOSES REDACTED]. Review of Resident #1's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had verbal behaviors that occurred one (1) to three (3) days during the assessment period and the behaviors impacted the resident's participation in activities or social interactions. Further review of the MDS assessment revealed the resident's Brief Interview for Mental Status (BIMS) score was eight (8) which revealed the resident was assessed to be moderately cognitively impaired but interviewable. Review of Resident #1's Comprehensive Care Plan related to behavior problems, dated 04/12/16, revealed the resident exhibited verbally abusive behaviors and sexually inappropriate behaviors that included grabbing female staff members and making inappropriate sexual comments to female staff members. Review of the medical record for Resident #2 revealed the facility admitted the resident on 01/16/14 with [DIAGNOSES REDACTED]. Review of Resident #2's quarterly MDS assessment dated [DATE] revealed the resident was assessed to need extensive assistance of two (2) staff members for transfers and bed mobility. Further review of the MDS assessment revealed the resident's BIMS score was 99, which revealed the resident was severely cognitively impaired. Interview on 03/08/17 at 4:20 PM with State Registered Nurse Aide (SRNA) #9 revealed on an unknown date the SRNA was making rounds with SRNA #10 and the SRNAs observed Resident #1 in his/her wheelchair in Resident #2's room at the resident's bedside. The interview further revealed Resident #2's blanket was down around Resident #2's knees and the SRNAs yelled for the nurse, to notify her that Resident #1 was in Resident #2's room. The staff member stated she was concerned because of the resident's history of inappropriate sexual behaviors toward staff. When they yelled, Resident #1 was startled and the resident attempted to back away from Resident #2. Continued interview revealed Registered Nurse (RN) #3 entered the room and the SRNAs removed Resident #1 from Resident #2's room. SRNA #9 revealed she also reported to Administrative staff that Resident #1 was observed to be in Resident #2's room at the resident's bedside and that Resident #2's blanket was down around Resident #2's knees. Interview on 03/08/17 at 5:13 PM with SRNA #10 revealed the SRNA was making rounds with SRNA #9 and observed Resident #1 in Resident #2's room at the resident's bedside. SRNA #10 stated she observed Resident #2 in bed on his/her back with the blanket down around the resident's knees, the brief unfastened on one side, and the resident appeared to be angry with a scowl on his/her face and fist clinched. SRNA #10 stated the SRNAs yelled for the nurse because of Resident #1's history of inappropriate sexual behaviors toward staff members; she was afraid something inappropriate might have happened. Continued interview revealed Resident #1 appeared to be startled when the SRNAs yelled for the nurse and the resident attempted to back away from Resident #2's bed. SRNA #10 revealed the SRNAs removed Resident #1 from the room and assisted the resident to the hallway. SRNA #10 revealed Administrative staff asked her about the incident and she stated she reported the details of the incident including Resident #2's blanket being pulled down and Resident #2's brief being unfastened. Interview on 03/08/17 at 4:28 PM and 4:51 PM with RN #3 revealed on an unknown date in the fall of 2016, SRNA #9 and SRNA #10 informed the nurse that Resident #1 was in Resident #2's room at the bedside. The interview further revealed RN #3 and the SRNAs entered Resident #2's room and Resident #1 was at the resident's bedside. Resident #2's blanket was down around Resident #2's knees and Resident #2's brief was unfastened on one side. Continued interview revealed the SRNAs removed Resident #1 from the room into the hallway and RN #3 checked on Resident #2. RN #3 revealed Resident #2 appeared to be agitated, the resident's face appeared to have an angry expression, and the resident's hands were in a tight fist. The interview further revealed RN #3 adjusted Resident #2's brief, covered the resident with the blanket, and immediately called and reported the incident to the Assistant Administrator. Continued interview with RN #3 revealed she reported the incident to the Assistant Administrator due to Resident #1's history of inappropriate sexual behaviors toward staff and she was unsure if something inappropriate had occurred. Interview on 03/08/17 at 3:36 PM, 5:01 PM, and 5:45 PM with the ADON and the Assistant Administrator revealed on an unknown date the Assistant Administrator was notified by RN #3 that Resident #1 was found in Resident #2's room. The Assistant Administrator and ADON denied that RN #3, SRNA #9, or SNRA #10 reported that Resident #2's brief was unfastened or that the resident's blanket was pulled down. However, the Administrative staff stated they immediately went to the unit. The Administrative staff revealed when they arrived at Resident #2's room, Resident #2 was in his/her bed against the wall, and Resident #1 was in his/her wheelchair facing the door. The Administrative staff revealed Resident #1 was removed from Resident #2's room and was questioned regarding why the resident was in Resident #2's room. Resident #1 stated he/she was just visiting. Further interview revealed the Administrative staff did not report the incident to the Administrator or conduct an investigation of the incident because they did not feel anything inappropriate had occurred. However, the Administrative staff revealed they reported to Resident #2's Responsible Party (RP) that Resident #1 had been found in Resident #2's room visiting and the RP did not have a problem with the residents visiting. Interviews with the Assistant Administrator and the ADON revealed about a month earlier they had heard a new employee was telling other employees that the incident occurred as reported by SRNA #9, SRNA #10, and RN #3; however, the Administrative staff stated they did not conduct an investigation because they felt a disgruntled employee had embellished the incident and the information was hearsay. Interview on 03/08/17 at 5:45 PM with the Administrator revealed he was not in the facility the day the incident occurred; however, the Administrative staff told the Administrator that direct care staff was concerned because they found Resident #1 in Resident #2's room. The Administrator stated they did not tell him that Resident #2's brief was unfastened or that the blanket was pulled down. The interview revealed after the incident Administrative staff had a conversation with Resident #2's family member and informed the family member that Resident #1 had been found in Resident #2's room, and Resident #2's family did not have a problem with the residents visiting. Further interview with the Administrator revealed he was not aware staff had concerns of alleged abuse until the state agency questioned him about the incident the previous week. However, the Administrator stated the facility did not conduct an investigation after discussing the incident with the state agency surveyor.

Based on observation, interview, record review, and review of the facility's Care Plan Policy Statement, the Certified Nurse Aide (CNA) Care Plan Record policy, and the facility's investigation, it was determined the facility failed to ensure services were provided in accordance with the written plan of care for one (1) of seventeen (17) sampled residents (Resident #6). The facility assessed Resident #6 to require staff support with transfers and had care plan interventions for a mechanical lift to be used during all transfers. However, facility staff failed to utilize a mechanical lift during a transfer on 02/11/4 at approximately 7:00 PM. On 02/11/14 at approximately 9:00 PM, staff assessed the resident to have bruising and swelling of the right arm/shoulder. The facility transferred the resident to the Emergency Department (ED) for evaluation and treatment. Review of the Emergency Department's Physician's Progress Notes revealed the resident was diagnosed with [REDACTED]. The findings include: Review of the facility's Care Plan Policy Statement (not dated) revealed a Comprehensive Plan of Care would be developed by the interdisciplinary team based on the completion of the comprehensive Minimum Data Set (MDS) assessment. The policy statement did not address implementation of the residents' care plans. Review of the Certified Nurse Aide (CNA) Care Plan Record policy (no date) revealed the care plan would be utilized to identify/document each resident's daily care needs. The policy further noted the CNA care plan would provide information regarding the amount of assistance the resident required for transfers and any assistive devices to be used for mobility. Review of the Quarterly MDS assessment dated [DATE], revealed the facility assessed Resident #6 to require total assistance of two staff persons for transfers. The MDS further revealed the resident was assessed to have a Brief Interview for Mental Status (BIMS) score of 1, which indicated the resident was not interviewable. Review of the Comprehensive Care Plan with a review date of 12/20/13, revealed the facility had addressed the resident's alteration in mobility. Interventions included using a mechanical lift for all transfers. Review of the CNA care plan dated February 2014 revealed Resident #6 was non-weight bearing and staff was directed to use a "Viking" lift (a mobile device used for lifting) for transfers. Review of the February 2014 physician's orders [REDACTED].#6 with the use of a mechanical lift. Review of the facility's investigation, dated 02/12/14 at 9:00 AM, revealed facility staff failed to utilize a mechanical lift during transfer of Resident #6 from the chair to the bed on 02/11/14 at approximately 7:00 PM. Continued review of the investigation revealed on 02/11/14 at approximately 9:00 PM, after staff transferred the resident to bed, Registered Nurse (RN) #3 assessed Resident #6 and noted the resident had a newly identified discolored area and [MEDICAL CONDITION] of the right shoulder area. Further review revealed the facility transferred the resident to the Emergency Department (ED) for further evaluation and treatment. According to the Emergency Department's Physician's Report, the resident had a large amount of "ecchymosis" (escape of blood into the tissues from ruptured blood vessels, marked by a purple discoloration of the skin) and a firm/swollen area on the right shoulder. Further review of the ED Report revealed no fractures were identified and the resident was diagnosed with [REDACTED]." Observation of a skin assessment conducted by facility staff on 02/18/14, at 11:10 AM, revealed Resident #6 had a raised area measuring 13 centimeters (cm) by 10 cm on the anterior area of the right shoulder; fading dark purple bruising measuring 3.5 cm by 9 cm near the right axilla; a 22 cm by 10.5 cm yellowish fading discoloration across the resident's upper chest area; a 16 cm yellow fading area extending down the resident's right upper arm; and a 16 cm by 10 cm yellow/purplish area on the right side under the resident's rib cage. Observation at 12:10 PM on 02/18/14, revealed CNAs #7 and #10 transferred Resident #6 from the bed into a Broda chair (chair that reduces pressure and provides long-term sitting support) using the mechanical lift device. Interview conducted with CNA #1 on 02/18/14, at 3:55 PM, revealed he had been trained to review the CNA care plan at the beginning of each shift. However, the CNA stated he had not looked at the care plan "in a while" and did not know Resident #6 was to be transferred using a mechanical lift. CNA #1 stated he and CNA #2 transferred Resident #6 from the Broda chair to the bed at approximately 7:00 PM on 02/11/14. CNA #1 stated he and CNA #2 each placed an arm underneath the resident's arms and their hand on the resident's waist and assisted the resident onto the bed. CNA #1 stated during the transfer on 02/11/14, he observed a fading bruise on the resident's right upper arm that had been caused by the application of a blood pressure cuff from "about" a week earlier. The CNA stated he did not observe any new bruises at the time of the transfer. CNA #1 also stated the resident did not exhibit or verbalize pain during or after the transfer. Interview conducted with CNA #2 on 02/18/14, at 4:15 PM, revealed she also had been trained to follow the CNA care plan when she transferred a resident. CNA #2 stated she knew Resident #6 was to be transferred at all times with a mechanical lift. She stated that she assisted CNA #1 to transfer Resident #6 from the Broda chair to the bed on 02/11/14, at approximately 7:00 PM. CNA #2 stated Resident #6 was transferred using a two-person transfer and the mechanical lift had not been used. She further stated she did not tell CNA #1 the resident was supposed to be transferred with the mechanical lift and she did not know why the lift had not been used. Interview conducted with the Director of Nursing (DON) on 02/19/14 at 11:50 AM, revealed the Charge Nurse was responsible to monitor care being provided by the CNAs and to ensure the care was in accordance with the resident's plan of care. The DON stated RN #3 called her at home after discovering the bruises on the resident's right shoulder area when the nurse was preparing to administer an injection to the resident on 02/11/14. The DON stated the nurse reported the resident did not complain of pain, but the bruising was discovered after the resident pulled his/her gown down below his/her right shoulder and breast area. Interview conducted on 02/19/14, at 1:50 PM with RN #2 revealed she was the Charge Nurse for Station I, the unit where Resident #6 resided. She stated her responsibilities included monitoring resident care. RN #2 stated she periodically reminded the CNAs to read the residents' CNA care plans to ensure they knew what care needs the resident required. RN #2 stated she also observed staff providing resident care when she often walked by resident rooms. The RN stated she had observed staff transferring residents, but had not had the opportunity to observe the CNAs transfer Resident #6. Interview conducted with Licensed Practical Nurse (LPN) #2 on 02/20/14, at 9:05 AM, revealed she was responsible for orientation with new employees and competency skills checks annually to evaluate staff's ability to provide resident care. LPN #2 stated transfer procedures, following the care plan, and mechanical lift procedures were included in the training and annual competency skills checks. LPN #2 also stated she conducted "spot checks" daily to verify residents were being transferred according to their individual plan of care and she had not identified any problems. Interview with the facility's Compliance Officer on 02/20/14, at 4:00 PM, revealed the facility did not have a specific policy/procedure related to implementation of the resident's written plan of care. The Compliance Officer stated random audits were conducted by the administrative nurses to monitor direct care staff to ensure care needs were provided according to the resident's individual care plan. The Compliance Officer stated no problems had been reported concerning resident transfers prior to the incident involving Resident #6.

Based on observation, interviews, record reviews, and review of the facility's policies, Investigation Report, and the Emergency Department (ED) Record and the Physician's Progress Notes, it was determined the facility failed to ensure adequate supervision and assistive devices to prevent accidents was provided for one (1) of seventeen (17) sampled residents (Resident #6). Review of the Comprehensive Care Plan and the Certified Nurse Aide (CNA) Care Plan revealed the facility assessed Resident #6 to require the total assistance of two staff persons and the use of a mechanical lift for all transfers. However, facility staff failed to transfer Resident #6 from the chair to the bed with the assistance of a mechanical lift on 02/11/14 at approximately 7:00 PM. On 02/11/14, at approximately 9:00 PM, after staff had transferred the resident from the chair to the bed, a nurse entered the resident's room to monitor the resident's blood glucose level. At that time, the resident reached over with his/her left hand and pulled the gown down from his/her right shoulder. The nurse observed the resident's right shoulder was swollen and bruised. The facility transferred Resident #6 to the Emergency Department (ED) for further evaluation and treatment, and according to the ED Physician's Progress Note dated 02/11/14, Resident #6 had sustained a torn pectoral muscle of the right shoulder area. In addition, observations on 02/18/14 at 1:00 PM revealed the hot water temperatures in the women's shower room on Station II was 132 degrees Fahrenheit (F) (22 degrees above the acceptable temperature range); the hot water temperature in the men's shower room on Station II was 120 degrees Fahrenheit (10 degrees above acceptable temperature range); and the hot water temperature in resident room 221 was observed to be 122 degrees F (12 degrees above the acceptable temperature range). Additional observations of the women's and men's shower rooms and resident room 221, conducted with the Maintenance Director on 02/18/14 at 1:15 PM, revealed the hot water temperature in the areas fluctuated from 90 degrees to 117 degrees F. Further observation on 02/18/14 at 1:30 PM, revealed the hot water temperature at the mixing valve for the Station II hallway was 120 degrees (10 degrees above the acceptable temperature range). The findings include: Review of the Mechanical Lift policy (no date) revealed a safe working environment would be provided by utilizing a lift transfer system as deemed appropriate based on the resident's comprehensive assessment and the resident care planning process. The policy noted facility staff was required to use the mechanical lift equipment when specified by the resident assessment and care plan. An interview with the Administrator on 02/20/14 at 3:47 PM revealed the facility did not have a written policy that directed staff how and/or when to monitor water temperatures. However, according to the Administrator, it was the facility's procedure for the Maintenance Department to check the water temperatures on a daily basis in resident care areas and to document the temperature on the preventive maintenance checklist for each month. The Administrator stated the facility's Maintenance Department attempted to maintain the water temperatures between 100 and 110 degrees Fahrenheit (F). 1. Review of the medical record revealed the facility admitted Resident #6 on 10/05/10 with [DIAGNOSES REDACTED]. Review of the Quarterly Comprehensive assessment dated [DATE], revealed the facility assessed Resident #6 to require total assistance of two staff members for transfers and a wheelchair was used for mobility/locomotion. The MDS further revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 1, which indicated the resident was not interviewable. Review of the Comprehensive Care Plan reviewed/updated on 12/20/13, revealed the facility addressed the resident's alteration in mobility related to a history of falls and [DIAGNOSES REDACTED]. Interventions included instructing the resident on appropriate use of assistive/supportive devices; to verbally remind the resident not to ambulate or transfer without assistance; and to use a mechanical lift for all transfers. Further record review revealed the February 2014 CNA care plan indicated the resident was non-weight bearing and required the use of a "Viking" lift (a mobile device used for lifting) for transfers. Review of the facility's Investigation Report dated 02/12/14, at 9:00 AM, revealed after the ED physician contacted the resident's attending physician regarding the resident's injury, the resident's attending physician contacted the facility to inform the Administrator of the injury to Resident #6's shoulder. The facility initiated an investigation on 02/12/14 and interviewed all staff who had provided care for Resident #6 from 02/06-11/14. Based on the findings of the facility's investigation, the facility determined Certified Nurse Aide (CNA) #1 and CNA #2 had transferred Resident #6 from a Broda chair (chair that reduces pressure and provides long-term sitting support) to the bed on 02/11/14 at approximately 7:00 PM. However, according to the facility's investigation, CNAs #1 and #2 failed to follow the Plan of Care that had been developed for Resident #6 as they failed to use a mechanical lift when they transferred the resident to bed. The investigation further revealed when Registered Nurse (RN) #3 entered Resident #6's room on 02/11/14 at approximately 9:00 PM to monitor the resident's blood glucose levels, the resident pulled his/her gown down from the right shoulder area with his/her left hand. The nurse observed "new" bruising and swelling to the resident's right shoulder area. Observation of a skin assessment conducted by facility staff on 02/18/14, at 11:10 AM, revealed Resident #6 had a raised area measuring 13 centimeters (cm) by 10 cm on the anterior area of the right shoulder; fading dark purple bruising measuring 3.5 cm by 9 cm near the right axilla; a 22 cm by 10.5 cm yellowish fading discoloration across the resident's upper chest area; a 16 cm yellow fading discolored area extending down the resident's right upper arm; and a 16 cm by 10 cm yellow/purplish area on the right side under the resident's rib cage. Review of documentation by nursing staff in Resident #6's medical record dated 02/11/14, at 9:04 PM, revealed RN #3 entered the resident's room to assess the resident's blood glucose level and noted the resident had discoloration and edema of the right shoulder. Further review revealed RN #3 notified the physician and arranged for the resident to be transferred to the hospital's ED for further evaluation and treatment. Review of the ED record dated 02/11/14, revealed Resident #6 was assessed to have a large amount of ecchymosis (bruising) and a "firm/swollen" area of the right shoulder. X-rays obtained at the ED revealed no evidence of a fracture or dislocation of the right shoulder. Further review of the ED report revealed the resident was admitted to the hospital on [DATE] for observation. Review of Resident #6's Attending Physician's Progress Note, dated 02/11/14, revealed the physician assessed Resident #6 to have a hematoma (bruising) to the right anterior chest with bruising to the right upper arm. Further review of the Physician's Progress Note revealed the cause of the bruising "appeared to be a torn muscle/tendon." The physician further noted the tear was probably associated with moving or pulling the resident up in bed or a wheelchair. Interview conducted with CNA #1 on 02/18/14, at 3:55 PM, revealed staff should review the CNA care plan each shift to determine the care needs of each resident. According to CNA #1, the CNA care plan included the requirements staff was to follow for each resident's transfer. CNA #1 stated he had not looked at Resident #6's care plan "in a while" and did not know a mechanical lift was to be used for transfers for Resident #6. CNA #1 stated he and CNA #2 transferred Resident #6 from the Broda chair to the bed at approximately 7:00 PM on 02/11/14. CNA #1 stated he and CNA #2 had placed one arm underneath the resident's arms and placed a hand on the resident's waistband, and assisted the resident to transfer from the chair to the bed. CNA #1 confirmed he did not see any bruises or swelling on the resident's right shoulder area. CNA #1 further stated the resident did not indicate any injury or pain had occurred during the transfer. Interview conducted with CNA #2 on 02/18/14, at 4:15 PM, revealed she was aware Resident #6 was to be transferred at all times with a mechanical lift. CNA #2 stated she assisted CNA #1 to transfer Resident #6 from the Broda chair to the bed on 02/11/14, at approximately 7:00 PM and a mechanical lift had not been used during the transfer. CNA #2 stated she did not tell CNA #1 staff was to use a mechanical lift when they transferred Resident #6 and offered no explanation as to why they had not used the mechanical lift. Interview conducted with RN #3 on 02/19/14, at 3:30 PM, revealed she had worked the 7:00 PM to 7:00 AM shift on 02/11/14. RN #3 stated Resident #6 was in bed when she went to the resident's room to check his/her blood glucose level at approximately 8:45 PM on 02/11/14. RN #3 stated after she obtained the results of the resident's blood glucose, she proceeded to administer insulin to the resident. The resident placed his/her left hand on the neck of his/her gown and pulled the gown down below the right breast area. The RN stated she observed edema and "a hard knot" on the resident's right shoulder and right breast area with dark purplish/red discoloration noted primarily to the resident's right armpit. RN #3 stated although the resident was able to verbalize pain at times, the resident "mumbled" and did not verbalize he/she was in pain when asked if his/her right arm hurt. The RN stated she did not know what had caused the discoloration of the resident's right shoulder and breast and had not attempted to raise the resident's arm to assess further due to not knowing the extent of the injury. RN #3 stated she notified the resident's attending physician and arranged for the resident to be transferred to the ED. RN #3 further stated she received a call from the ED physician on 02/11/14 at approximately 11:00 PM, and the ED physician wanted to know what had caused the swelling and bruising to the resident's right shoulder. According to RN #3, she told the ED physician she did not know and the ED physician stated he was admitting the resident to the hospital for observation. Interview conducted with Licensed Practical Nurse (LPN) #2 on 02/20/14, at 9:05 AM, revealed she provided orientation to new employees and also observed employees on an annual basis perform competency skills to evaluate their ability to provide resident care. LPN #2 stated transfer procedures, following the care plan, and mechanical lift procedures were included in the training and annual competency skills checks. LPN #2 also stated she conducted "spot checks" daily to verify staff transferred residents according to their individual plan of care and she had not identified any problems. Review of the Annual Competency Check List completed on 01/15/14 for CNA #1, and for CNA #2 on 10/22/13, revealed the facility had assessed the CNAs to be competent in the use of the mechanical lift. Interview conducted with Physician #1 on 02/19/14, at 1:40 PM, revealed he was Resident #6's attending physician and had been contacted by the ED physician on 02/11/14 regarding Resident #6's injury. Physician #1 stated the ED physician said he did not know what had caused the resident's injury. Physician #1 stated he assessed Resident #6 on 02/12/14 and determined the injury was due to a torn pectoral muscle, and called the facility's Administrator to report the injury. He further stated the torn pectoral muscle most likely occurred when staff lifted Resident #6. Physician #1 stated the injury could have been prevented if the resident had been transferred with a mechanical lift. Interview conducted with the Administrator on 02/20/14, at 4:10 PM, revealed Physician #1 informed him the injury sustained by Resident #6 on 02/12/14 was due to a torn pectoral muscle. The Administrator stated a facility investigation was initiated and determined CNAs #1 and #2 failed to transfer Resident #6 using a mechanical lift on 02/11/14. The Administrator stated CNA #1 and CNA #2 had been suspended immediately and remained on suspension pending further investigation. 2. Observations conducted on 02/18/14 at 1:00 PM revealed the hot water temperature in the women's shower room located on Station II was 132 degrees Fahrenheit (F) (22 degrees higher than the acceptable temperature range of 110 degrees Fahrenheit); the hot water temperature in the men's shower room located on Station II was observed to be 120 degrees F; and the hot water temperature in resident room 221 was observed to be 122 degrees F. Additional observations of the women and men's shower rooms and resident room 221, conducted with the Maintenance Director on 02/18/14 at 1:15 PM, revealed the hot water temperature fluctuated from 90 degrees to 117 degrees F (10 degrees below and 17 degrees higher than the acceptable range). Review of the facility's census report on 02/18/14 revealed 18 residents resided on the two hallways located at Station II and had access to the shower rooms. Review of the Monthly Preventative Maintenance Checklist completed in December 2013, January 2014, and through February 18, 2014 revealed the hot water temperatures had been within normal limits. Interview conducted with the Maintenance Director on 02/18/14 at 1:30 PM (EST) revealed the hot water temperatures in the facility were maintained at 100-110 degrees F. According to the Maintenance Director, he had obtained the hot water temperatures located in resident rooms (rooms 106, 216, and 114) on Stations I and II on the morning of 02/18/14 and had not identified any concerns. Further interview with the Maintenance Director revealed the mixing valve on the hot water heater might have failed since he had obtained the temperatures, and he had shut the hot water to the Station II hallway off until the repairs could be completed. The Maintenance Director stated he had ordered the defective part for the mixing valve on 02/18/14 and expected it to be delivered to the facility on [DATE]. The Maintenance Director also stated he had directed staff to use the shower rooms on Station I for bathing residents until the repairs were made. An interview conducted with the Administrator on 02/20/14 at 3:47 PM revealed he had not received any complaints about water temperatures. The Administrator stated he had not been aware of any concerns with the hot water temperatures or the failure of the mixing valves until the Maintenance Director had informed him on 02/20/14.

Based on observation, interview, and record review it was determined the facility failed to ensure the physician was notified of a change in a resident's condition for one of five sampled residents (Resident #3). Interviews with staff revealed they had observed a split/tear in Resident #3's penis for approximately one month, and on 06/18/13, the split/tear in the resident's penis had enlarged and was bloody. However, based on documentation/interviews, the facility failed to notify the physician of the change in Resident #3's condition (refer to F282 and F315). The findings include: An interview with the facility's Compliance Officer on 06/25/13, at 11:10 AM, revealed the facility did not have a policy related to physician notification when there was a change in a resident's condition. She stated nurses should use nursing judgment on when to notify a resident's physician. Review of Resident #3's medical record revealed the facility admitted Resident #3 on 12/30/11 with [DIAGNOSES REDACTED]. Review of Resident #3's most recent Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively impaired with a BIMS (Brief Interview for Mental Status) score of 6 with 15 indicating no cognitive impairment. According to the MDS assessment, Resident #3 had a urinary catheter and was dependent on staff for assistance with transferring, walking, dressing, and hygiene/bathing. Review of Resident #3's care plan dated 02/13/12 revealed Resident #3 had a urinary catheter since that time (02/13/12). Observation of Resident #3 on 06/21/13 at 5:30 PM, with Licensed Practical Nurse (LPN) #2 revealed the resident's penis was split/torn from the urinary meatus (opening in the penis through which urine flows) approximately three-fourths of the way down the shaft of the resident's penis. The catheter tubing was observed to be protruding from the base of the split area on the left side of the penis. The resident's penis and left inner thigh were observed to be bloody. Interview with Resident #3 on 06/21/13, at 4:00 PM, revealed approximately two days prior the "girls" told him his penis was bloody but he did not know what happened. Interview with Certified Nurse Aide (CNA) #5 on 06/21/13, at 6:23 PM, revealed Resident #3's penis had been split/torn for "months." However, according to CNA #5, on Tuesday (06/18/13) she noticed Resident #3's penis was "more open and bleeding," and she notified LPN #4. An interview was conducted with LPN #4 on 06/22/13, at 9:00 PM, and on 06/24/13, at 12:20 PM. LPN #4 stated that on 06/18/13, CNA #5 reported that Resident #3's penis looked "different." LPN #4 stated she observed the resident's penis on 06/18/13 and observed the penis to be split/torn and bleeding. LPN #4 stated it was late and the resident's physician's office was closed so she documented her observation of Resident #3's penis in the Nursing Notes and asked staff that was beginning their shift to call the resident's physician the next morning. LPN #4 stated she reviewed the resident's record prior to the interview and could find no documentation that the resident's physician was notified. Interview with LPN #1 on 06/21/13, at 6:23 PM, revealed she had provided direct care to Resident #3 occasionally and stated Resident #3's penis had been split down the side for "months"; however, according to LPN #1, on 06/18/13 Resident #3's penis was "more irritated/swollen." On 06/21/13, at 6:07 PM, a review of Resident #3's medical record, including the computerized Nursing Note dated 06/18/13 at 8:50 PM, was conducted with assistance provided by LPN #3. At that time, documentation by LPN #4 revealed the CNA noticed the "F/C (Foley catheter) had split down the shaft of (Resident #3's) penis a small amount" and the resident's physician would be notified "in the AM." However, a copy of the Nursing Note dated 06/18/13 at 8:50 PM, obtained from the Director of Nursing (DON) on 06/21/13 at approximately 7:00 PM, indicated the resident's physician was notified of the change in the resident's condition on 06/18/13 (although interview with LPN #4 and a review of documentation revealed the physician was not notified of the change in the resident's condition). (See F514.) An interview with Resident #3's physician on 06/24/13, at 2:30 PM, revealed the facility had not notified him of the change in the condition of Resident #3's penis and stated he should have been notified.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure the care plans for four of five sampled residents were implemented (Residents #2, #3, #4, and #5). Review of the care plans developed by facility staff for Residents #2, #3, #4, and #5 revealed staff was to ensure the resident's urinary catheter tubing was secured to the resident's thigh to prevent pulling (the facility's policy indicated male catheters should be secured to the abdomen). There was no evidence staff implemented this intervention for Residents #2, #4, or #5. A review of Resident #3's medical record revealed the resident had the urinary catheter since at least 02/13/12. There was no evidence staff implemented the intervention for Resident #3 until 06/18/13, after the resident's penis was observed to be bloody and torn/split from the urinary meatus (the opening in the penis from which urine flows) and down the shaft of the resident's penis. The findings include: An interview with the facility's Compliance Officer on 06/25/13, at 11:10 AM, revealed the facility did not have a policy related to implementing the care plan. Review of the facility's policy/procedure entitled "Staff Instructions-Management of Long-term Indwelling Catheters" dated September 2005, revealed a resident's catheter should be stabilized. The policy/procedure stated for women the catheter should be anchored to the upper thigh, and for men should be anchored to the abdomen, to prevent catheter tension. 1. A review of Resident #3's medical record revealed the facility admitted Resident #3 on 12/30/11, with [DIAGNOSES REDACTED]. Review of Resident #3's most recent Minimum Data Set (MDS) assessment dated [DATE], revealed the resident was cognitively impaired with a BIMS (Brief Interview for Mental Status) score of 6 with 15 indicating no cognitive impairment. Review of Resident #3's (male resident) care plan initially dated 02/13/12, and updated on 05/20/13, revealed staff was required to secure the resident's indwelling urinary catheter tubing to the resident's thigh to prevent pulling (which was not in accordance with facility policy). Review of Resident #3's CNA (Certified Nursing Assistant) care plan for June 2013 revealed the resident had a catheter and staff was required to provide catheter care every shift and as needed. According to the CNA care plan, the facility failed to indicate the use of a catheter strap, or any other device, to secure the catheter tubing as required. Observation of Resident #3 on 06/21/13, at 5:30 PM, with Licensed Practical Nurse (LPN) #2 revealed the resident had a catheter and a leg strap was observed on the resident's left thigh. The resident's penis was observed to be split/torn from the meatus approximately three-fourths of the way down the shaft of the resident's penis. The catheter tubing was observed to be protruding from the base of the split area on the left side of the penis. The resident's penis and left inner thigh were observed to be bloody. An interview with LPN #2 on 06/21/13, at 5:30 PM revealed the catheter strap had been in use for approximately two weeks and was implemented after the resident's penis was observed to be "split" and bloody. The LPN stated she was not sure how long the resident's penis had been split/torn, but knew that it was splint/torn when the resident went out to the doctor approximately one month prior. Interviews with Resident #3 on 06/21/13, at 4:00 PM and 5:30 PM, revealed facility staff began utilizing a catheter strap approximately two days prior. The resident stated the "girls" told him his penis was bloody and the strap would keep the catheter from pulling. Interview with CNA #5 on 06/21/13, at 6:23 PM, revealed Resident #3's penis had been split/torn for months; however, on Tuesday (06/18/13) she noticed Resident #3's penis was "more open and bleeding." She stated she notified LPN #4 and they placed a catheter strap on the resident's thigh to secure the tubing. CNA #5 stated prior to 06/18/13, staff had not utilized a catheter strap for Resident #3. An interview was conducted with LPN #4 on 06/22/13, at 9:00 PM, and on 06/24/13, at 12:20 PM. LPN #4 stated that on 06/18/13, CNA #5 reported that Resident #3's penis looked different. LPN #4 stated the resident's penis was split/torn and was bleeding. LPN #4 stated she had not taken care of Resident #3 in a while so she got LPN #1 to look at the resident's penis and LPN #1 confirmed the resident's penis was worse. LPN #4 stated she placed a catheter strap on Resident #3 to keep the catheter tubing from getting pulled/tugged and to prevent the split/tear from getting worse. Interview with LPN #1 on 06/21/13, at 10:15 AM, and on 06/21/13, at 6:23 PM, revealed Resident #3's penis had been "split" down the side for months; however, according to LPN #1, the resident's penis was more swollen/irritated on 06/18/13. Interviews with LPN #3 on 06/21/13, at 6:07 PM, and with LPN #4 on 06/22/13, at 9:00 PM, revealed they were not aware a care plan had been developed that identified the use of a device to secure Resident #3's catheter tubing to his/her leg in an effort to prevent the tubing from being pulled. 2. A review of the medical record revealed the facility admitted Resident #2 on 03/14/11, with [DIAGNOSES REDACTED]. A review of Resident #2's MDS revealed the facility assessed the resident to be interviewable with a BIMS score of 13. A review of Resident #2's care plan initially dated 03/21/11, and updated on 05/13/13, revealed staff was required to secure the resident's catheter tubing to the resident's thigh to prevent pulling. Review of Resident #2's CNA care plan for June 2013 revealed the resident had a "Foley" (indwelling) catheter and staff was required to provide catheter care every shift and as needed. Review of the CNA Care Plan revealed the facility failed to indicate a catheter strap, or any other device, to secure the catheter tubing to prevent pulling was required. Observation of Resident #2 on 06/21/13, at 3:00 PM, revealed the resident had a urinary catheter and was not wearing any type of device to secure the catheter tubing to the resident's thigh. An interview with the resident revealed staff did not utilize anything to secure the catheter tubing. 3. Review of the medical record revealed the facility admitted Resident #4 on 06/11/12 with [DIAGNOSES REDACTED]. A review of Resident #4's MDS assessment dated [DATE] revealed the facility assessed the resident as being interviewable with a BIMS score of 12. Review of Resident #4's care plan initially dated 08/07/12, and updated on 05/30/13, revealed staff was required to secure the resident's catheter tubing to the resident's thigh to prevent pulling. A review of Resident #4's CNA care plan for June 2013 revealed the resident had a "Foley" (indwelling) catheter and staff was required to provide catheter care every shift and as needed. A review of the CNA care plan revealed the facility failed to indicate a catheter strap, or any other device, to secure the catheter tubing to prevent pulling was required. Observation of Resident #4 on 06/21/13, at 10:15 AM, revealed the resident had a urinary catheter, but was not wearing any type of device to secure the catheter tubing to the resident's thigh. Interviews conducted with CNA #1, CNA #2, and LPN #1 on 06/21/13, at 10:15 AM, during the observation, revealed Resident #4 did not utilize any type of device to secure the catheter. Interview with Resident #4 on 06/21/13, at 11:40 AM, revealed the resident was not sure why he/she had to have a catheter and stated he/she had never worn any type of device to hold the catheter tubing. 4. Review of the medical record revealed the facility admitted Resident #5 on 05/27/09 with [DIAGNOSES REDACTED]. Review of Resident #5's MDS dated [DATE] revealed the facility assessed the resident to be cognitively impaired with a BIMS score of 8. Review of Resident #5's care plan initially dated 03/01/12, and updated on 05/15/13, revealed staff was required to secure the resident's catheter tubing to the resident's thigh to prevent pulling. Review of Resident #5's CNA care plan for June 2013 revealed the resident had a "Foley" (indwelling) catheter and staff was required to provide catheter care every shift and as needed. A review of the CNA care plan revealed the facility failed to indicate a catheter strap, or any other device, to secure the catheter tubing to prevent pulling was required. Observation of Resident #5 on 06/21/13, at 9:55 AM, revealed the resident had a urinary catheter but was not wearing any type of device to secure the catheter tubing to the resident's thigh. An interview with CNA #6 on 06/23/13, at 11:15 PM, revealed prior to 06/21/13 she had not utilized a catheter strap or any other device to secure residents' catheter tubing. An interview with CNA #1 and CNA #2 on 06/21/13, at 10:15 AM, revealed the CNAs did not use any type of device on residents with catheters to secure the indwelling catheter. An interview with LPN #1 on 06/21/13, at 10:15 AM, revealed some of the male residents utilized a catheter strap when they were out of bed; otherwise, a device was not used to secure residents' catheters. An interview conducted with the MDS Coordinator on 06/24/13, at 1:00 PM, revealed the Restorative Nurse, who was on vacation, was responsible for ensuring nurse aide care plans matched residents' comprehensive care plans. Interview with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) on 06/21/13, at 7:00 PM, revealed the facility did not have a system for monitoring to ensure residents' care plans were implemented.

Based on observation, interview, record review, and review of facility policies, it was determined the facility failed to ensure four of five sampled residents (Residents #2, #3, #4, and #5) received urinary catheter care based on the resident's comprehensive assessment and care plan. A review of the care plans developed by facility staff for Residents #2, #3, #4, and #5 revealed staff was to ensure the resident's urinary catheter tubing was secured to the resident's thigh to prevent pulling (the facility's policy indicated male residents' catheters should be secured to the abdomen). There was no evidence staff implemented this intervention for Residents #2, #4, or #5. A review of Resident #3's medical record, including the care plan, revealed the resident had the urinary catheter since at least 02/13/12. There was no evidence staff implemented the intervention for Resident #3 until 06/18/13, after the resident's penis was observed to be bloody and torn/split from the urinary meatus (the opening in the penis from which urine flows) and down the shaft of the resident's penis. In addition, Resident #3's physician was not notified of the trauma to the resident's penis. The findings include: An interview with the facility's Compliance Officer on 06/25/13, at 11:10 AM, revealed the facility did not have a policy related to implementing the care plan. Review of the facility's policy/procedure entitled "Staff Instructions-Management of Long-term Indwelling Catheters" dated September 2005, revealed a resident's catheter should be stabilized. The policy/procedure stated that for women the catheter should be anchored to the upper thigh and that for men the catheter should to be anchored to the abdomen, to prevent catheter tension. 1. A review of Resident #3's medical record revealed the facility admitted Resident #3 on 12/30/11, with [DIAGNOSES REDACTED]. Review of Resident #3's most recent Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident as being cognitively impaired with a BIMS (Brief Interview for Mental Status) score of 6. According to the MDS assessment, Resident #3 had a urinary catheter and required extensive assistance from staff with transferring, walking, dressing, hygiene/bathing, and toilet use (which includes managing a catheter). Review of Resident #3's (male resident) care plan initially dated 02/13/12, and updated on 05/20/13, revealed staff was required to provide catheter care for Resident #3 every shift and secure the resident's indwelling urinary catheter tubing to the resident's thigh (facility's policy stated male residents' catheters were to be secured to the abdomen) to prevent pulling. Review of the CNA (Certified Nursing Assistant) care plan for Resident #3 for June 2013 revealed the resident had a catheter and staff was required to provide catheter care every shift and "as needed." According to the CNA care plan, the facility failed to ensure the use of a catheter strap, or any other device to secure the catheter tubing, was included on the CNA care plan. Observation of Resident #3 on 06/21/13, at 5:30 PM, with Licensed Practical Nurse (LPN) #2 revealed the resident had a catheter and a leg strap on the resident's left thigh. The resident's penis was observed to be split/torn from the meatus approximately three-fourths of the way down the shaft of the resident's penis. The catheter tubing was observed to be protruding from the base of the split area on the left side of the penis. The resident's penis and left inner thigh were observed to be bloody. An interview with Resident #3 on 06/21/13, at 4:00 PM and 5:30 PM, revealed facility staff began utilizing a catheter strap approximately two days prior. The resident stated the "girls" told him his penis was bloody but the resident was not sure what happened. The resident stated the "girls" told the resident that the strap would keep the catheter tubing from being pulled. An interview with LPN #2 on 06/21/13, at 5:30 PM, revealed she was not sure how long Resident #3's penis had been split/torn, but knew that it had been split/torn for at least one month. According to LPN #2, the catheter strap had been in use approximately two weeks and was implemented after the resident's penis was observed to be bloody and the "split" had advanced further. Interview with CNA #5 on 06/21/13, at 6:23 PM, revealed on Tuesday (06/18/13) she noticed Resident #3's penis was "more open and bleeding." She stated she notified LPN #4 and they placed a catheter strap on the resident's thigh to secure the tubing. CNA #5 stated Resident #3's penis had been split/torn for months; however, prior to 06/18/13, staff had not utilized a catheter strap for Resident #3. An interview was conducted with LPN #4 on 06/22/13, at 9:00 PM, and 06/24/13, at 12:20 PM. LPN #4 stated that on 06/18/13, CNA #5 reported that Resident #3's penis looked "different." LPN #4 stated Resident #3's penis was observed to be split/torn and was bleeding. LPN #4 stated LPN #1 confirmed the resident's penis was worse. LPN #4 stated she placed a catheter strap on Resident #3 to keep the catheter tubing from getting pulled/tugged and to prevent the split/tear from getting worse. LPN #4 stated she did not notify the resident's physician of the trauma to Resident #3's penis. She stated she reported the information to the next shift so day shift could notify the physician. LPN #4 also stated she documented in Resident #3's Nursing Notes that the resident's physician would be notified the next morning. LPN #4 stated she reviewed the resident's record prior to the interview and could find no documentation that the resident's physician was notified. On 06/21/13, at 6:07 PM, a review of the nursing note dated 06/18/13, at 8:50 PM, was conducted with LPN #3. At that time, LPN #4's Nursing Note revealed the CNA noticed the "F/C (Foley catheter) had split down the shaft of (the resident's) penis a small amount" and the resident's physician would be notified "in the AM" (morning). An interview with LPN #1 on 06/21/13, at 10:15 AM, and on 06/21/13, at 6:23 PM, revealed Resident #3's penis had been "split" down the side for months; however, according to LPN #1, the resident's penis was more swollen/irritated on 06/18/13. Interviews with LPN #3 on 06/21/13, at 6:07 PM, and with LPN #4 on 06/22/13, at 9:00 PM, revealed they were not aware a care plan had been developed that required the use of a device to secure Resident #3's catheter tubing to his/her leg in an effort to prevent the tubing from being pulled. An interview with Resident #3's physician on 06/24/13, at 2:30 PM, revealed the resident's physician was not notified that the resident's penis was torn, but should have been. According to Resident #3's physician, the facility should have used a catheter strap or some type of device to support the catheter tubing because if there was not some type of support, the tubing would put pressure on the penis. The physician stated the tearing/splitting was caused by pressure from the catheter and that not wearing some type of device to relieve the pressure/tension "had something to do with (Resident #3's) penis tearing." 2. Review of the medical record revealed the facility admitted Resident #2 on 03/14/11, with [DIAGNOSES REDACTED]. A review of Resident #2's MDS assessment dated [DATE] revealed the facility assessed the resident to be interviewable with a Brief Interview Mental Status (BIMS) score of 13. The MDS assessment revealed the resident required extensive assistance from staff for bed mobility, dressing, bathing/hygiene, and toilet use (which includes care of the catheter). According to the MDS, Resident #2 did not transfer from bed or ambulate. Review of Resident #2's care plan initially dated 03/21/11, and updated on 05/13/13, revealed staff was to secure the resident's catheter tubing to the resident's thigh to prevent pulling. However, a review of Resident #2's CNA (Certified Nursing Assistant) care plan for June 2013 revealed the facility failed to indicate a catheter strap, or any other device, was required to secure the catheter tubing to prevent the catheter from being pulled. Observation of Resident #2 on 06/21/13, at 3:00 PM, revealed the resident had a urinary catheter and was not wearing any type of device to secure the catheter tubing. An interview with the resident revealed staff did not utilize anything to secure the catheter tubing. 3. A review of the medical record revealed the facility admitted Resident #4 on 06/11/12 with [DIAGNOSES REDACTED]. Review of Resident #4's MDS assessment dated [DATE] revealed the facility assessed the resident as being interviewable with a BIMS score of 12. The facility also assessed the resident to require extensive assistance with bed mobility, transferring, dressing, hygiene/bathing, and toilet use (which includes catheter care). A review of Resident #4's care plan initially dated 08/07/12, and updated on 05/30/13, revealed staff was required to secure the resident's catheter tubing to the resident's thigh to prevent pulling. Review of the June 2013 CNA (Certified Nursing Assistant) care plan for Resident #4 revealed the resident had a "Foley" (indwelling) catheter and staff was to provide catheter care every shift and as needed. A review of the CNA care plan revealed the facility failed to indicate a catheter strap, or any other device to secure the catheter tubing to prevent pulling, was required. Observation of Resident #4 on 06/21/13, at 10:15 AM, revealed the resident had a urinary catheter but was not wearing any type of device to secure the catheter tubing to the resident's thigh. Interviews conducted with CNA #1, CNA #2, and LPN #1 on 06/21/13, at 10:15 AM, during the observation, revealed staff did not provide Resident #4 with any type of device to secure the resident's catheter. Interview with Resident #4 on 06/21/13, at 11:40 AM, revealed the resident was not sure why she had to have a catheter and stated she had never worn any type of device to hold the catheter tubing. 4. Review of the medical record revealed the facility admitted Resident #5 on 05/27/09 with [DIAGNOSES REDACTED]. A review of Resident #5's MDS dated [DATE] revealed the facility assessed the resident to be cognitively impaired with a BIMS score of 8. The facility also assessed Resident #5 to require extensive assistance with activities of daily living, including managing the resident's catheter. Review of Resident #5's care plan initially dated 03/01/12, and updated on 05/15/13, revealed staff was required to secure the resident's catheter tubing to the resident's thigh to prevent pulling. However, a review of the June 2013 CNA (Certified Nursing Assistant) care plan for Resident #5 revealed the facility failed to indicate a catheter strap, or any other device to secure the catheter tubing to prevent pulling, was required. Observation of Resident #5 on 06/21/13, at 9:55 AM, revealed the resident had a urinary catheter, but was not wearing any type of device to secure the catheter tubing to the resident's thigh. An interview with CNA #6 on 06/23/13, at 11:15 PM, revealed prior to 06/21/13, she had not utilized a catheter strap, or any other device to secure a resident's catheter tubing. An interview with CNA #1 and CNA #2 on 06/21/13, at 10:15 AM, revealed the CNAs did not use any type of device on residents with catheters to secure the indwelling catheter. An interview with LPN #1 on 06/21/13, at 10:15 AM, revealed some of the male residents utilized a catheter strap when they were out of bed; otherwise, a device was not used to secure residents' catheters. Interviews with LPN #3 on 06/21/13, at 6:07 PM, and with LPN #4 on 06/22/13, at 9:00 PM, revealed they were not aware a care plan had been developed that required the use of a device to secure catheter tubing to the resident's leg for Residents #2, #3, #4, and #5 in an effort to prevent the tubing from being pulled. On 06/24/13, at 1:00 PM, an interview was conducted with the MDS Coordinator who stated the Restorative Nurse, who was on vacation, was responsible for ensuring nurse aide care plans matched residents' comprehensive care plans. On 06/21/13, at 7:00 PM, an interview with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) revealed the facility did not have a system for monitoring to ensure residents' care plans were implemented.

Based on observation, interview, record review, policy review, and review of the facility investigation it was determined the facility failed to ensure the physician was notified when one of three sampled residents (Resident #2) experienced a change of condition and decline in function after a fall. On 03/27/12, Resident #2 was ambulating, unassisted, from the bed and sustained a fall. The facility notified the resident's physician of the fall and an x-ray was obtained of the resident's pelvis, sacrum, and coccyx which revealed no evidence of fractures. However, Resident #2 suffered pain and a decrease in function following the fall, from 03/28/12 through 04/03/12, a timeframe of seven days, and the physician was not notified of the change in the resident's condition. On 04/03/12, following a radiology examination, Resident #2 was diagnosed to have a fractured pelvis. The findings include: A review of the facility's policy "Physician/Legal Representative Notification," dated June 2003, revealed the facility was required to inform the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status, e.g., deterioration in health, mental, psychosocial status in either life threatening conditions or clinical complications. A review of Resident #2's medical record revealed the facility admitted the resident on 01/06/12, with [DIAGNOSES REDACTED]. In addition, the resident was receiving Physical Therapy and Occupational Therapy. A review of an "Event Report Investigation" for Resident #2 revealed on 03/27/12, at 5:03 AM, the resident's personal alarms sounded and, upon entering the resident's room, Licensed Practical Nurse (LPN) #1 found the resident lying on the floor on his/her back. The report revealed the resident hit his/her head and was complaining of hip pain. Based on documentation in the report, the resident experienced no obvious trauma but staff was unable to perform range of motion to assess Resident #2 due to his/her complaints of pain in the right hip/leg area. The report revealed the resident's physician was notified of the fall and the physician requested the resident be transported to the hospital for a radiology examination. A review of a hospital report dated 03/27/12, revealed Resident #2 had fallen at the facility and complained of pelvic pain. An x-ray of the resident's pelvis, sacrum, and coccyx was obtained and revealed no evidence of a fracture. Continued review of Resident #2's medical record revealed physician's orders [REDACTED]. In addition, the physician's orders [REDACTED].#2 every eight hours as needed for moderate to severe pain. A review of Resident #2's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Further review of the MAR indicated [REDACTED]. A review of Resident #2's Physical Therapy (PT) plan of care, updated 03/05/12, revealed the resident had shown progress in all areas of care, demonstrated improved transfer and gait status, and ambulated with the assistance of one staff person. A review of PT progress notes dated 03/20/12 through 03/26/12, revealed Resident #2 had met the short-term goal to perform transfers from bed to chair with assistance of one person, and to propel self in the wheelchair to meals with verbal cues and supervision. The therapist's written summary revealed the resident continued to participate well, showed progress toward treatment, and required the assistance of one for transfer from bed to chair. Continued review of documentation revealed an updated Physical Therapy plan of care dated 04/03/12, which revealed the resident experienced a fall on 03/27/12, and was transported for x-rays, with no fracture noted. According to the plan of care, the resident had been extremely sore with reported pain levels of 9 out of 10 on the pain scale, had experienced a decline in status with greater assistance required with transfers and ambulation, and noted that although the resident was improving daily he/she had not returned to the level of the resident's previous function. An interview conducted with Physical Therapist (PT) #1 on 06/21/12, at 12:14 PM, revealed Resident #2 had been admitted to the facility for rehabilitation following a fracture. According to the therapist, the resident had improved and had shown progress toward mobility and functional status until after the fall sustained on 03/27/12. The therapist stated Resident #2 had increased pain and complained of stiffness and soreness after the fall and had experienced a decline in status. Further interview revealed the PT informed the resident's nurse during the week of 03/26/12 to 04/03/12, of the increase in pain and decline in function. PT #1 acknowledged that she had not called Resident #2's physician to inform him of the increase in pain and decline in function. PT #1 also stated prior to the resident's fall, Resident #2 was transferred with the assistance of one staff person and ambulated with minimal to moderate assistance of one staff person. PT #1 stated after Resident #2 sustained the fall on 03/27/12, Resident #2 required the maximum assistance of two staff members for ambulation. Interview with Certified Nursing Assistant (CNA) #1 on 06/21/12, at 11:37 AM, revealed after Resident #2's fall on 03/27/12, the resident was "hurting really bad." CNA #1 further stated Resident #2 was no longer able to assist staff with activities of daily living and would hold her/his side when staff assisted the resident with such things as transferring from the bed. CNA #1 stated she reported the resident's condition to the nurse or medication technician and they gave Resident #2 Tylenol for pain. Interview with CNA #2 on 06/21/12, at 11:38 AM, revealed after Resident #2 experienced the fall on 03/27/12, the resident could no longer get out of bed. CNA #2 stated staff had to perform complete bed baths instead of taking the resident to the bathtub and Resident #2 required the assistance of two staff persons after the fall. CNA #2 further stated prior to the fall, Resident #2 was going to therapy, walking up and down the hall, and "doing well." On 04/03/12, Resident #2 had a follow-up appointment with a physician for evaluation of a previous right femoral neck fracture (right [MEDICAL CONDITION]). A review of the physician's evaluation dated 04/03/12, revealed the physician conducted a follow-up examination of Resident #2 related to the previous right femoral neck fracture (right [MEDICAL CONDITION]) and based on documentation the physician also noted the resident had sustained a fall, a week prior to the visit, and had experienced pain in the groin area since the fall. An x-ray was obtained on 04/03/12, and revealed Resident #2 had a right inferior pubic rami fracture (a [MEDICAL CONDITION] pelvic bone). Interview with Registered Nurse (RN) #1 on 06/21/12, at 11:17 AM, revealed Resident #2 experienced increased pain the week after the fall on 03/27/12, and would hold her/his side when assisted. RN #1 further stated she "kept questioning" the x-ray taken on 03/27/12, that revealed no fracture. Interview further revealed RN #1 could not remember if Resident #2's physician had been notified of the resident's increased pain and decrease in function. Interview with Resident #2's physician on 06/21/12, at 11:15 AM, revealed the physician could not remember if facility staff had contacted him after the resident had sustained the fall on 03/27/12, to inform him of Resident #2's increased complaints of pain and functional decline. Further interview revealed the facility staff would routinely fax him any updates or notes on residents, he would write and sign an order if needed, and fax the order back to the facility. The physician was not able to find notification from the facility related to a change in the resident's condition after the resident's fall on 03/27/12. The physician further stated he would expect facility staff to notify him of a resident's increase in pain and functional decline.

Based on interview, record review, and review of the facility's investigation, it was determined the facility failed to ensure services were provided in accordance with the written plan of care for two of three sampled residents (Residents #1 and #2). A review of Resident #1's plan of care revealed the resident had been assessed to require the use of foot pedals on the wheelchair. However, on 04/25/12, Certified Nursing Assistant (CNA) #3 failed to apply foot pedals to Resident #1's wheelchair and Resident #1 fell out of the wheelchair and hit his/her head on the floor. Resident #1 was later transported to the hospital and diagnosed with [REDACTED]. On 04/29/12, Resident #2 was seated in a wheelchair in the chapel of the facility and staff left the resident without staff supervision. Documentation revealed Resident #2 stood up out of the wheelchair and attempted to take a step before falling to the ground. It was discovered the alarm on Resident #2's wheelchair was not plugged in and therefore was not working at the time of the fall. Resident #2 did not suffer any injuries due to the fall. The findings include: Interview with the Facility Compliance Officer on 06/21/12, at 5:48 PM, revealed the facility did not have a policy on care plans and stated resident care plans were updated with each Minimum Data Set (MDS) update and as needed. 1. A review of Resident #1's medical record revealed the facility admitted the resident on 01/15/12. Resident #1's [DIAGNOSES REDACTED]. A review of Resident #1's plan of care revealed facility staff assessed Resident #1 on 01/18/12, to have an alteration in mobility related to the risk for falls and a [DIAGNOSES REDACTED]. Documentation in the plan of care revealed Resident #1 required extensive assistance with bed mobility, transfers, locomotion on/off unit, was nonambulatory, and was a high risk for falls. Continued review of the plan of care revealed a foot rest was to be used on Resident #1's wheelchair and was to be kept at the nurses' station while not in use. In addition, the plan of care revealed Resident #1 and staff were to be instructed on the appropriate use of assistive/supportive devices. A review of Resident #1's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #1's cognition to be moderately impaired. The assessment revealed the resident had upper extremity impairment, used a wheelchair, required extensive assistance of two for transfers, and extensive assistance of one for locomotion to areas off the unit, such as the dining room. In addition, documentation revealed the resident had experienced two falls since the prior assessment that resulted in no injuries. A review of an "Event Report Investigation" for Resident #1 revealed on 04/25/12, at 11:15 AM, Resident #1 sustained a fall from the wheelchair. According to the report, Resident #1 was seated in a wheelchair and CNA #3 was pushing the resident's wheelchair to the dining room when the resident put his/her feet down on the floor causing the wheelchair to tip and the resident fell forward to the floor. The resident was assessed to have a slightly swollen and darker right eye. Further review of the investigation revealed Resident #1 had a physician's orders [REDACTED]. Interview with CNA #3 on 06/20/12, at 12:55 PM, revealed Resident #1 was a high risk for falls due to previous falls. CNA #3 stated each resident's care plan stated what interventions facility staff was to put into place to prevent falls, and each resident's care plan was "back there to look at." CNA #3 stated she was pushing Resident #1 in the wheelchair to the dining room on 04/25/12, and Resident #1 put his/her feet down on the floor while the wheelchair was moving. CNA #3 stated the resident was wearing non-skid diabetic shoes and when he/she put the shoes on the floor, he/she fell out of the wheelchair. CNA #3 stated she attempted to stop the resident from falling out of the wheelchair by holding the resident's shoulders, but failed to prevent the fall. Interview further revealed Resident #1 did not have foot pedals on the wheelchair at the time of the fall. CNA #3 stated "honestly" she "didn't know (Resident #1) had them, had never seen (the pedals) on (his/her) wheelchair, didn't know (the pedals) was on the care plan till after" the fall occurred. According to CNA #3, she knew Resident #1 had foot pedals for the wheelchair previously but was not aware the resident still required the use of the foot pedals. Interview with RN #1 on 06/20/12, at 8:45 AM, revealed she was sitting at the nurses' desk on 04/25/12, when she heard someone say "oh no" and when she looked up over the desk Resident #1 was falling out of the wheelchair. RN #1 stated CNA #3 attempted to hold the resident's shoulders to prevent the fall but was unsuccessful and Resident #1 continued to fall and landed on the upper body with the head on the floor. RN #1 further stated there were no foot pedals on Resident #1's wheelchair at the time of the fall. A review of the hospital record dated 04/25/12, revealed Resident #1 was diagnosed with [REDACTED]. 2. A review of Resident #2's medical record revealed the facility admitted the resident on 01/06/12, with [DIAGNOSES REDACTED]. The resident was also to receive physical and occupational therapy. A review of Resident #2's plan of care dated 01/19/12, revealed the resident had an alteration in mobility related to a history of falls and [DIAGNOSES REDACTED]. According to the plan of care, Resident #2 required assistance from staff with bed mobility, transfers, ambulation, and locomotion. The facility had assessed the resident to require an alarm on the wheelchair at all times as an approach to prevent falls. A review of the facility's investigation, including the Event Report dated 04/29/12, revealed on 04/29/12, Resident #2 was in the chapel, left unattended by staff, and attempted to stand from the wheelchair and take a step when the resident fell to the floor. Further review of the fall investigation revealed the alarm on the wheelchair did not sound when the resident stood up from the wheelchair. Documentation on the report revealed the personal alarm had not been properly connected to the resident's wheelchair at the time of the resident's fall. Interview with CNA #5 on 06/20/12, at 11:40 AM, revealed the CNA had assisted Resident #2 into the wheelchair prior to the resident being transported to the chapel on 04/29/12. CNA #5 stated when the resident was assisted out of bed and into the wheelchair, the alarm on the bed and the floor alarm were sounding, and when she turned around to turn the alarms off, another staff member left the room with Resident #2 in the wheelchair. CNA #5 stated she did not check to ensure the wheelchair alarm was plugged in and properly working before the facility staff left the room with the resident. However, CNA #5 stated she was aware Resident #2 required the use of an alarm on the wheelchair to prevent falls. Interview with Certified Nursing Assistant (CNA) #4 on 06/20/12, at 11:21 AM, revealed interventions that were required to be put in place to assist residents and prevent falls were listed on each resident's plan of care. CNA #4 further stated she had been educated by the facility on falls. Interview with CNA #4 further revealed on 04/29/12, the CNA was assisting residents from the chapel and to their rooms. CNA #4 reported she was walking back to the chapel to assist more residents when she observed visitors that had been in the chapel standing in the hallway stating a resident had fallen. CNA #4 stated she observed Resident #2 lying on the floor of the chapel and although there was an alarm on the wheelchair the alarm was not sounding. CNA #4 stated she had not checked the alarm since other staff members had brought the resident into the chapel and the CNA assumed the staff would have ensured the alarm was working when the resident was assisted into the wheelchair. Interview with the Restorative Coordinator on 06/20/12, at 2:54 PM, revealed it was the responsibility of the CNA who transported Resident #2 into the chapel to ensure the alarm was working properly prior to leaving the resident in the chapel. The Restorative Coordinator further stated the Restorative Department was responsible for checking each resident's alarm one time a day. CNAs who worked on the floor were responsible for ensuring all alarms were in place and functioning properly prior to leaving the resident and every two hours throughout the day.

Based on interview, record review, and a review of the facility policy it was determined the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, psychosocial well-being for one of three sampled residents (Resident #2). Resident #2 experienced a fall on 03/27/12; an x-ray that same day revealed no fractures. However, from 03/27/12 to 04/03/12, the resident experienced an onset of pain and a decline in functional ability. Facility staff failed to evaluate Resident #2's pain to determine the cause and characteristics of the pain and factors that influenced the pain. On 04/03/12, seven days after the resident sustained [REDACTED]. According to the resident's physician, it was not uncommon for a fracture not to show on the first x-ray due to swelling. The findings include: A review of the facility's "Pain Management" policy and procedure, not dated, revealed all residents would be assessed for their level of pain and the effectiveness of pain management therapy would be monitored. In addition, the policy revealed staff was to conduct a Clinical Pain Assessment of all residents upon admission, quarterly, and with any significant change in their behavior or activity level. According to the policy, if staff identified a resident had issues and/or met certain criteria, such as use of "as needed" pain medications which required the assessment of the severity of pain, staff was to implement an electronic pain management record. The policy revealed staff was also to conduct observations on each shift, and as needed, of the resident's level of pain and cognition. A review of Resident #2's medical record revealed the facility admitted the resident on 01/06/12, with [DIAGNOSES REDACTED]. The resident was also receiving physical and occupational therapy. A review of the resident's admitting Minimum Data Set (MDS) dated 01/13/12, revealed facility staff assessed Resident #2 to require extensive assistance of two staff persons for bed mobility, transfers, and when walking in the room. Further review revealed prior to admission the resident had a history of [REDACTED]." pain had limited the resident's day to day activities. A review of a quarterly MDS dated [DATE], revealed under the pain assessment the resident had not received a scheduled pain medication, an as needed pain medication, or a non-medication intervention for pain in the five days prior. When asked if the resident had pain or any hurting in the last five days according to the MDS the resident responded no. However, review of Resident #2's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A review of the plan of care developed by facility staff for Resident #2 and dated 01/18/12, revealed staff assessed the resident to have a "problem" area related to pain and developed interventions which included to evaluate the resident's pain in accordance with facility policy, administer pain medications as ordered, and evaluate the effectiveness of the pain medication. A review of a facility investigation, including an "Event Report" revealed on 03/27/12, facility staff heard Resident #2's safety alarms sounding and upon entering the resident's room observed the resident lying on the floor on his/her back. Resident #2 reported he/she hit her/his head and was having hip pain. Documentation revealed facility staff was unable to perform range of motion due to the resident's complaints of right hip/leg pain. Based on documentation, Resident #2 was sent to the hospital on [DATE], for evaluation and according to documentation dated 03/27/12, an x-ray was obtained and revealed no evidence of a fracture. A review of Resident #2's clinical pain assessment dated [DATE], revealed staff assessed the resident's pain during the five days (03/25/12 through 03/29/12) prior to the assessment date, and noted the resident had experienced pain almost constantly, which made it difficult for the resident to sleep at night, and limited the resident's day to day activities. The resident reported the pain was located in the right hip/back area and the resident described the pain as "sharp," "dull", "shooting," and "aching." In addition, the resident reported sitting down made the pain less intense, while walking/lying made the pain worse. Facility staff also assessed the resident's nonverbal indications of pain such as crying, whining, gasping, moaning, or groaning, and facial expressions such as grimaces, winces, wrinkled forehead, furrowed brow, clenched teeth, or jaw. Documentation revealed staff also observed during the five day look back period physical indications of the resident's pain such as protective body movements and/or postures (such as bracing, guarding, rubbing, or massaging a body part/area, clutching or holding a body part during movement). Continued review of the assessment revealed the resident should be repositioned often, have frequent rest periods with activity, Tylenol/[MEDICATION NAME] was to be administered "as needed," and staff was to contact the resident's physician with an increase in the resident's pain or pain that was not relieved with the administration of the "as needed" medications. A review of a pain roster established by facility staff to monitor Resident #2's pain revealed Resident #2 had been assessed for pain 78 times from 03/01/12 through 03/26/12, and prior to the resident's fall on 03/27/12, and the resident had only reported pain 6 of the 72 times. However, documentation on the pain assessment roster from the time of the resident's fall on 03/27/12 and through 04/03/12, revealed facility staff had assessed Resident #2 26 times for pain and the resident had reported pain on 9 occasions. In addition, a review of Resident #2's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Further review of the MAR indicated [REDACTED]. A review of a Physical Therapy updated plan of care dated 04/03/12, revealed Resident #2 experienced a fall on 03/27/12, and was transported to the hospital for an x-ray which revealed no evidence of a fracture. Documentation by Physical Therapist #1 revealed the resident had been extremely sore with a reported pain level of 9 out of 10. In addition, based on documentation in the therapist's notes, Resident #2 experienced a decline in status with greater assistance required with transfers and ambulation. Documentation in the medical record revealed Resident #2 experienced a decline in condition and an increase in pain after the fall sustained on 03/27/12. However, a review of nursing notes and physician's orders from 03/27/12 (the day of the fall) through 04/03/12, revealed no documentation that Resident #2's physician had been notified of Resident #2's increase in pain, requirement of pain medication daily, or the decline in the resident's function. While review of the medical record revealed facility staff assessed Resident #2's pain level and location of the pain prior to administering pain medication, there was no documentation that facility staff was attempting to find the origin of the pain and reason for the decline in function. Interview with Physical Therapist (PT) #1 on 06/21/12, at 12:14 PM, revealed since the resident was admitted on [DATE], Resident #2 had displayed progress related to mobility and functional status. The PT stated Resident #2 experienced an increase in pain, complaints of stiffness and soreness, and experienced a decline from the fall on 03/27/12 until the [DIAGNOSES REDACTED]. Further interview revealed the PT informed the resident's nurse during the week of 03/26/12 to 04/03/12, of the increase in pain and decline in function. PT #1 acknowledged that she had not called Resident #2's physician to inform him of the increase in pain and decline in function. Interview with Registered Nurse (RN) #1 on 06/21/12, at 11:17 AM, Certified Nursing Assistant (CNA) #1 on 06/21/12, at 11:37 AM, and CNA #2 on 06/21/12, at 11:38 AM, revealed they had observed Resident #2 experience an increase in pain and a decline in function after Resident #2's fall on 03/27/12. CNA #1 stated Resident #2 was "hurting really bad" after the fall on 03/27/12, and had a decline in his/her abilities such as getting out of bed. CNA #1 stated she informed the nurses and they administered pain medication to the resident. CNA #2 stated after the fall on 03/27/12, staff was no longer able to get Resident #2 from the bed into the bathtub; facility staff had to perform bed baths each day. CNA #2 stated prior to the fall Resident #2 had been ambulating in the hall, "doing well," and after the fall the resident was a total assist of two staff persons. In addition, RN #1 stated she kept "questioning" while talking to other facility staff the x-ray which indicated no fracture. RN #1 further stated after the resident's fall on 03/27/12, when staff assisted Resident #2 to a standing position, the resident would hold his/her side. RN #1 stated she could not remember if she contacted Resident #2's physician between 03/27/12 and 04/03/12, related to the increase in pain and decline in function. Interview with Resident #2's family member on 06/20/12, at 4:00 PM, revealed the resident was admitted to the facility for rehabilitation after a fall at home that resulted in a right [MEDICAL CONDITION]. In addition, the family member stated the resident fell on [DATE], at the facility and was sent to the hospital for an x-ray which revealed no evidence of a fracture. According to the family member, during the week following the fall, Resident #2 experienced an increase in pain and went from ambulating in the hall with assistance of one staff person to not ambulating at all. The family member stated she had spoken to the physical therapist during the week of 03/27/12 to 04/03/12, and was told if Resident #2 did not start showing improvement and a decrease in pain, the facility would "need to do something." Further interview revealed the resident's family member accompanied Resident #2 to a previously scheduled appointment to the resident's orthopedic surgeon on 04/03/12, to follow up from the right [MEDICAL CONDITION] that had occurred prior to admission. The resident's family member stated he/she informed the surgeon of the resident's fall on 03/27/12, and the increase in pain and decrease in function. According to the family member, the surgeon performed another x-ray and diagnosed Resident #2 with a fractured right pelvic bone. A review of an evaluation from Resident #2's follow-up visit on 04/03/12, with the orthopedic surgeon revealed the resident fell about a week ago and had experienced pain in the groin area, difficulty standing, and a hard time walking since the fall. Further review revealed an x-ray was taken on 04/03/12, which showed a right inferior pubic rami (a part of the pelvic bone) fracture. Interview with Resident #2's attending physician on 06/21/12, at 5:00 PM, revealed the physician could not recall if the facility staff had informed him the resident experienced an increase in pain and/or a decline in physical functioning after the fall sustained on 03/27/12. The resident's attending physician stated that facility staff would either call or fax him regarding reports or updates of resident conditions and would usually fax him a form with any information he needed to be aware of regarding the residents. The attending physician stated he was unable to find any faxed information from facility staff related to the resident's increase in pain and decline in function after the fall sustained on 03/27/12. Interview further revealed it was not uncommon for a fracture to not show up on the first x-ray. The physician stated sometimes it takes time for the swelling to go down and the fracture to show up on the x-ray.

Based on observation, interview, record review, policy review, and review of the facility's investigation, it was determined the facility failed to ensure adequate supervision and assistive devices were provided to prevent accidents for one of three sampled residents (Resident #1). Resident #1 was assessed by facility staff to be at risk for falls, and facility staff had developed a care plan for the resident that included the use of foot pedals to the resident's wheelchair. On 04/25/12, staff failed to ensure the foot pedals were in place on the resident's wheelchair and the resident sustained [REDACTED]. A review of documentation revealed Resident #1 was diagnosed with [REDACTED]. The findings include: A review of the facility's policy, "Falling Stars" (not dated) revealed a fall risk assessment was required to be completed on all residents upon admission, quarterly, when a change of status occurred, and after a fall. The policy indicated if a resident scored "high risk" the resident would be placed on the "Falling Stars" program and staff would be alerted to the resident's status and the need for possible interventions by a "gold star" placed on the resident's door. Continued review of the policy revealed it was the responsibility of all staff members to monitor all residents assessed to be in the "Falling Star" program and that all falls would be addressed and investigated for any/all factors by the interdisciplinary team. According to the policy, if a resident experienced a fall an assessment and updated interventions would be discussed and documented by the interdisciplinary team or fall prevention team. In addition, the policy indicated residents in the "Falling Star" program were to be monitored closely when transferring from one surface to another, ambulating or attempting to ambulate, attending activities, and standing up after they had been sitting or lying down for a while. A review of Resident #1's medical record revealed the facility admitted the resident on 01/15/12, with [DIAGNOSES REDACTED]. A review of Resident #1's plan of care with a date of 01/18/12, revealed facility staff assessed Resident #1 on 01/18/12, to have an alteration in mobility related to the risk for falls and [DIAGNOSES REDACTED]. Based on the plan of care, Resident #1 required extensive assistance with bed mobility, transfers, locomotion on/off the units, and was nonambulatory and a high risk for falls. The plan of care revealed a foot rest was to be used on Resident #1's wheelchair and was to be kept at the nurses' station while not in use, and staff was to be instructed on the appropriate use of assistive/supportive devices. A review of the Certified Nurse Aide (CNA) care plan for April 2012 also revealed the resident was to have a wheelchair foot rest on the wheelchair and the foot rest was to be kept at the nurses' desk when the wheelchair was not in use. In addition, a review of Resident #1's physician's orders [REDACTED]. A review of a fall risk assessment dated [DATE], revealed Resident #1 had an assessment score of 100 and was at risk for falls. According to the fall risk assessment a score of 65 or greater meant the resident was at a high risk for falls. A review of Resident #1's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #1 to be moderately cognitively impaired. Further review of the assessment revealed the resident required extensive assistance of two staff persons for transfers and the extensive assistance of one for locomotion to areas off the unit, such as the dining room. Further review revealed the resident was assessed to have upper extremity impairment, used a wheelchair, and had experienced two falls since the prior assessment that resulted in no injuries. A review of the facility "Event Report Investigation" revealed on 04/25/12, at 11:15 AM, Resident #1 sustained a fall from the wheelchair. According to the report, Resident #1 was seated in a wheelchair and CNA #3 was pushing the resident's wheelchair to the dining room when the resident put his/her feet down on the floor causing the wheelchair to tip and the resident fell forward to the floor. The resident was noted with a slightly swollen and darker right eye. Continued review of the investigation revealed Resident #1 had a physician's orders [REDACTED]. Further review of the investigation revealed CNA #3 received a verbal warning for not following the resident's plan of care by not having the foot pedals on the wheelchair when she wheeled the resident in the wheelchair to the dining room. Interview with CNA #3 on 06/20/12, at 12:55 PM, revealed Resident #1 was a high risk for falls due to previous falls. CNA #3 stated each resident's care plan stated what interventions facility staff had put into place to prevent falls, and each resident's care plan was "back there to look at." CNA #3 stated she was pushing Resident #1 in the wheelchair to the dining room on 04/25/12, and the resident put his/her feet on the floor while being wheeled. According to CNA #3, Resident #1 had non-skid shoes on and when he/she put his/her feet down while being wheeled, the wheelchair tipped and the resident fell to the floor. CNA #3 further stated she tried to stop the resident from falling out of the wheelchair by holding his/her shoulders but could not keep the resident from hitting the floor. Interview further revealed Resident #1 did not have foot pedals on the wheelchair at the time of the fall. CNA #3 stated "honestly" she "didn't know (Resident #1) had them, had never seen (the pedals) on (his/her) wheelchair, didn't know (the pedals) was on the care plan till after" the fall occurred. CNA #3 further stated Resident #1 had foot pedals for the wheelchair previously but was not aware the resident still required the use of the foot pedals. Interview with the Restorative Coordinator on 06/20/12, at 2:45 PM, revealed Resident #1 was assessed to require the wheelchair foot pedals when staff was transporting the resident in the wheelchair. The Coordinator stated Resident #1 wheeled him/herself at times and there was a possibility the resident would get his/her feet caught in the foot pedals and fall, and it had been decided the foot pedals were to be kept at the nurses' desk when staff was not transporting the resident. According to the Restorative Coordinator, facility staff was to place the foot pedals on the wheelchair when they assisted the resident in the wheelchair and acknowledged CNA #3 failed to place the foot pedals on at the time of the fall on 04/25/12. Interview with Resident #1 on 06/21/12, at 2:41 PM, revealed staff did not offer to put the foot pedals on the wheelchair the day the resident fell . Resident #1 stated facility staff was pushing the resident in the wheelchair to the dining room when the resident put his/her feet down and fell out of the wheelchair. The resident further stated he/she did not need the foot pedals on the wheelchair and facility staff never attempted to the put the pedals on the wheelchair. A review of the hospital record dated 04/25/12, revealed Resident #1 was diagnosed with [REDACTED].

Based on interviews and record review, it was determined the facility Administrator failed to administer the facility in a manner that enabled the facility to use resources effectively and efficiently to attain or maintain the highest practicable physical well-being of residents. On November 27, 2010, ten (10) of twenty (20) sampled residents' (residents #1, 2, 3, 5, 6, 11, 13, 14, 15, and 16) narcotic medication packages had been tampered with and the narcotic medications had been replaced with other medications ([MEDICATION NAME], and [MEDICATION NAME]) which were similar in color, shape, and size. The facility Administrator failed to ensure residents' physicians and responsible parties were notified of the incident, failed to ensure residents were assessed for complications and/or changes in condition, failed to have a system for reconciling narcotic medications, and failed to thoroughly investigate and report allegations of misappropriation of property. In addition, the facility Administrator failed to protect residents by not removing the alleged perpetrator(s) (refer to F157, F225, F309, F425, and F520). The facility Administrator's failure to administer the facility, thoroughly investigate and report allegations of misappropriation of resident property, and protect facility residents placed residents at risk for serious injury, harm, impairment, or death. The findings include: Interviews with the Administrator on December 7, 2010, at 5:41 p.m., the Director of Nursing Services (DON) on December 7, 2010, at 2:43 p.m., Registered Nurse #1 on December 7, 2010, at 10:09 a.m., Registered Nurse #2 on December 6, 2010, at 6:20 p.m., CMA #2 on December 7, 2010, at 9:49 a.m., LPN #1 on December 6, 2010, at 5:29 p.m., and LPN #3 on December 8, 2010, at 5:20 p.m., revealed on November 27, 2010, the facility became aware of discrepancies in resident medications. According to the interviews, staff discovered the narcotic medications for ten residents (residents #1, #2, #3, #5, #6, #11, #13, #14, #15, and #16) had been tampered with and replaced with other medications with similar color, shape, and size. The narcotic medications ([MEDICATION NAME] and [MEDICATION NAME]) were replaced with [MEDICATION NAME], or [MEDICATION NAME] medications. Interviews with the Pharmacist on December 8, 2010, at 9:30 a.m., the Medical Director on December 9, 2010, at 4:09 p.m., and an attending physician on December 8, 2010, at 9:50 a.m., revealed the medications [MEDICATION NAME], and [MEDICATION NAME] could be dangerous/harmful if administered to residents for whom they were not prescribed. According to the Medical Director, the medication [MEDICATION NAME] could cause a resident to have nausea/vomiting, arrhythmias, and [MEDICATION NAME] toxicity, and the medication [MEDICATION NAME] could cause a resident to suffer from [MEDICAL CONDITION]. The attending physician stated [MEDICATION NAME] could cause a resident with a [DIAGNOSES REDACTED]. Interviews with the Director of Nursing (DON) on December 7, 2010, at 2:20 p.m. and December 8, 2010, at 10:30 a.m., revealed the DON reported the discrepancies in the residents' narcotics to the Administrator and the Nurse Consultant on November 27, 2010. According to the DON, the DON was instructed by the Nurse Consultant to notify the local police department regarding the missing narcotics but the Nurse Consultant informed the DON it was not necessary to notify the State Agency because the incident was a criminal matter. The DON further stated a formal investigation regarding the residents' missing narcotics was not completed and incident reports/medication error reports were not completed because the facility did not know if the residents had received any of the medications that were used to replace the narcotics. According to the DON, no statements were obtained from staff regarding the discrepancies in resident medications and the alleged perpetrator was allowed to continue to provide resident care and administer resident medications after November 27, 2010. The DON stated the facility could not determine who had tampered with the resident medications and therefore no employees were suspended. In addition, the Director of Nursing (DON) stated administrative staff conducted periodic random narcotics counts for residents' medications to ensure the appropriate number of medications were present in the package and coincided with the narcotics sign-out sheet. The DON stated he/she was aware narcotics packages were being taped, on the foil backing, with surgical tape because the packages were fragile. However, according to the DON, the facility did not monitor the packages to ensure the narcotics had not been tampered with nor did the facility have a system to reconcile narcotic medications including the frequency they were administered and who was administering the medications. Interview with the Administrator on December 7, 2010, at 5:30 p.m., revealed the Administrator was informed of the discrepancies in the residents' narcotic medications by the DON. The Administrator instructed the DON to conduct drug screenings of all employees who had access to medications on November 27, 2010, to contact the local police regarding the medication discrepancies, and to notify the Nurse Consultant of the incident. The Administrator explained the facility became aware RN #1 was named as an alleged perpetrator regarding the missing narcotics on December 3, 2010; however, the facility did not suspend the alleged perpetrator from direct resident care and administering resident medications because the facility had no proof the alleged perpetrator was guilty. The Administrator stated he/she was aware the facility policy required that an alleged perpetrator be suspended from employment regarding allegations of misappropriation of resident property but the facility considered this incident a criminal matter and not misappropriation. According to the Administrator, the facility did not have comprehensive documentation of the events surrounding the missing narcotics. **An acceptable allegation of compliance related to the Immediate Jeopardy was submitted by the facility on December 14, 2010, which alleged removal of Immediate Jeopardy on December 16, 2010. An extended survey was conducted on December 17, 2010, which determined the Immediate Jeopardy was removed on December 16, 2010. A review of the allegation of compliance revealed the following: The Administrator suspended the alleged perpetrator on December 9, 2010. Internal investigation findings were reviewed by the Administrator with the conclusion that the person for narcotics discrepancies could not be determined. Disciplinary action was taken for medication administration staff that was identified during the investigation process as not complying with facility narcotics administration documentation policies and procedures. The Administrator was provided in-service education by the Nurse Consultant on December 9, 2010, on the need to consider any identified missing medications misappropriation of resident property, and to follow the facility policy and procedure for the reporting of the misappropriation to appropriate state agencies. The survey team validated the corrective actions taken by the facility as follows: An interview with the Administrator and review of facility documentation, on December 17, 2010, revealed the Administrator was in-serviced on December 9, 2010, regarding the need to consider any identified missing medications as misappropriation of resident property and follow the facility policy and procedure for reporting allegations of misappropriation of resident property to the appropriate state agencies, and to protect residents from abuse, neglect, and misappropriation of property. A review of the facility policy for medication storage in the facility dated December 7, 2010, revealed the following revisions: three medication administration staff persons will be required to visually observe all narcotic medications at the change of shift; and with transfer of medication keys from staff member to staff member; and the use of any type of tape on medication packaging will be prohibited. Based on the above findings, it was determined the Immediate Jeopardy was removed on December 16, 2010. Noncompliance continued with scope and severity lowered to "F" based on the facility's need to evaluate the effectiveness of CQI activities related to the implementation of policies and procedures for administration regarding the following: investigating, reporting, protection of residents from abuse, neglect, misappropriation of resident property; resident assessments for changes of condition and pain management; notification of physician and responsible party and accountability of resident medications.

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. There was no evidence the facility Quality Assurance Committee identified that narcotic medication packaging had been tampered with and replaced with non-prescribed medications. In addition, the quality assurance committee failed to identify that incidents of misappropriation of resident property were not being investigated, reported to appropriate state agencies, and residents were not being protected per facility policy (refer to F157, F225, F309, F425, and F520). The facility's failure to ensure a Quality Assurance Committee was in place that identified quality concerns in the facility, and implemented action plans to correct the concerns placed residents at risk for serious injury, harm, impairment, or death. The findings include: A review of the facility Continuous Quality Improvement Program (not dated) revealed the facility would have a systematic, structured, and documented CQI process in place that would focus on continually improving the delivery of care/services to residents. The policy revealed the CQI Committee met monthly and reviewed and analyzed data gathered by the interdisciplinary action teams. According to the policy, if data analysis showed a problem and/or potential problem the CQI Committee charged the interdisciplinary action team with correction, or appointed a special project team. Interviews with the Administrator on [DATE], at 5:41 p.m., the Director of Nursing Services (DON) on [DATE], at 2:43 p.m., Registered Nurse #1 on [DATE], at 10:09 a.m., Registered Nurse #2 on [DATE], at 6:20 p.m., CMA #2 on [DATE], at 9:49 a.m., LPN #1 on [DATE], at 5:29 p.m., and LPN #3 on [DATE], at 5:20 p.m., revealed that on [DATE], the facility became aware of discrepancies in resident medications. According to the interviews, staff discovered that the narcotic medications for ten residents (residents #1, #2, #3, #5, #6, #11, #13, #14, #15, and #16) had been tampered with and replaced with other medications with similar color, shape, and size. The narcotic medications ([MEDICATION NAME] and [MEDICATION NAME]) were replaced with [MEDICATION NAME], and [MEDICATION NAME] medications. Interviews with the Pharmacist on [DATE], at 9:30 a.m., the Medical Director on [DATE], at 4:09 p.m., and an attending physician on [DATE], at 9:50 a.m., revealed the medications [MEDICATION NAME], and [MEDICATION NAME] could be dangerous/harmful if administered to residents for whom they were not prescribed. According to the Medical Director, the medication [MEDICATION NAME] could cause a resident to have nausea/vomiting, arrhythmias, and [MEDICATION NAME] toxicity, and the medication [MEDICATION NAME] could cause a resident to suffer from [MEDICAL CONDITION]. The attending physician stated [MEDICATION NAME] could cause a resident with a [DIAGNOSES REDACTED]. On [DATE], at 4:00 p.m., an interview was conducted with the Compliance staff, which was responsible for the facility's CQI program. The Compliance staff member stated the facility identified quality concerns through resident council, complaints from residents/staff, and the standardized CQI monitoring tools. The Compliance staff stated the facility monitored abuse and neglect allegations to ensure appropriate action was taken; however, the facility had not identified misappropriation as a concern and did not monitor misappropriation of resident property as a part of the CQI process. In addition, the Compliance staff member explained the facility monitored medication carts as a part of the CQI process to ensure medications were labeled properly, stored appropriately, and expired medication and discontinued medications were removed. According to the CQI staff member, the facility did address narcotic medications as part of the CQI program. **An acceptable allegation of compliance related to the Immediate Jeopardy was submitted by the facility on [DATE], which alleged removal of Immediate Jeopardy on [DATE]. An extended survey was conducted on [DATE], which determined the Immediate Jeopardy was removed on [DATE]. A review of the allegation of compliance revealed the following: Twenty-four hour monitoring by administrative licensed nursing staff and or Nurse Consultants was implemented on [DATE]. This monitoring includes continuous rounds of the facility to observe medication preparation and administration, reassessing of residents for pain relief after pain medication administration, and reassessing residents and monitoring staff's response to changes in resident status. The DON, ADON, MDS Coordinator, Training Coordinator, Restorative Coordinator, Medical Records Nurse, or ,[DATE] Supervisor will conduct reviews of narcotic medication packages, narcotics sheets and administration logs for two medication carts daily for two weeks, weekly for four weeks, and then monthly thereafter to determine compliance with the revised medication policies and procedures. The Pharmacy consultant will include reviews of two medication carts of the narcotic medication packages, narcotics count sheets, and narcotics administration logs weekly for one month, then bi-weekly for one month, and then monthly in the pharmacy visit report. The pharmacy consultant will also conduct complete medication audits monthly for three months and then as indicated by monthly observations. The nursing consultant will review narcotics count and administration log documentation for two medication carts monthly, and will review the monthly pharmacy consultant reports to identify any follow-up interventions necessary. The CQI indicator for auditing of medication room/carts will be utilized on each of the two medication rooms and two medication carts monthly for two months and then quarterly as per the established CQI calendar under the supervision of the DON. The CQI indicator for auditing the notification of change will be utilized on five medical records monthly for two months, and then quarterly as per the established CQI calendar under the supervision of the DON. The CQI indicator for the completion of medication pass observations was completed on all medication administration staff on [DATE]-15, 2010, to determine that all staff administered medications with less than 5 percent error rate, as conducted by the DON, MDS Coordinator, ,[DATE] Supervisor, Restorative Coordinator, Training Coordinator, Unit Supervisor, Medical Records Nurse, and Nurse Consultant. The survey team validated the corrective actions taken by the facility as follows: An interview with the DON and Nurse Consultant and review of facility documentation on [DATE], revealed Continuous Quality Improvement (CQI) tools were reviewed and revised to include the following: auditing of medication room carts, medication pass observations, notification of physician/responsible party, and resident change in condition assessments. Based on the above findings, it was determined the Immediate Jeopardy was removed on [DATE]. Noncompliance continued with scope and severity lowered to "F" based on the facility's need to evaluate the effectiveness of CQI activities related to the implementation of policies and procedures for administration regarding the following: investigating, reporting, protection of residents from abuse, neglect, misappropriation of resident property; resident assessments for changes of condition and pain management; notification of physician and responsible party; and accountability of resident medications.

Based on interview and record review, the facility failed to immediately inform the resident, the resident's physician, and the resident's legal representative, as per facility policy, when there was an accident/incident involving the resident which had the potential for requiring physician intervention for ten (10) of twenty (20) sampled residents (residents #1, #2, #3, #5, #6, #11, #13, #14, #15, and #16). On November 27, 2010, staff found that the narcotic medication packages ([MEDICATION NAME] and [MEDICATION NAME]) for residents #1, #2, #3, #5, #6, #11, #13, #14, #15, and #16 had been tampered with and the narcotic medications had been replaced with other medications ([MEDICATION NAME]) which were similar in color, shape, and size. The facility failed to inform the residents, physicians, and responsible parties of this incident. The facility's failure to notify the residents, physicians, and responsible parties of these ten (10) residents regarding the discrepancies in the resident medication placed residents at risk for serious injury, harm, impairment, or death. The findings include: Review of the facility policy regarding resident incident/accident reports dated December 6, 2010, revealed the licensed nurse was required to notify the attending physician immediately when a resident was involved in an incident/accident. According to the policy, the nurse was required to document the physician's recommendations/decisions on the incident/accident report and in the resident's medical record for the shift in which the incident/accident occurred. Further, the licensed nurse was required by facility policy to promptly notify the family or guardian when a resident was involved in an incident/accident. Interviews with the Administrator on December 7, 2010, at 5:41 p.m., the Director of Nursing Services (DON) on December 7, 2010, at 2:43 p.m., Registered Nurse #1 on December 7, 2010, at 10:09 a.m., Registered Nurse #2 on December 6, 2010, at 6:20 p.m., CMA #2 on December 7, 2010, at 9:49 a.m., LPN #1 on December 6, 2010, at 5:29 p.m., and LPN #3 on December 8, 2010, at 5:20 p.m., revealed on November 27, 2010, the facility became aware of discrepancies in residents' medications. According to the interviews, staff discovered the narcotic medications for ten residents (residents #1, #2, #3, #5, #6, #11, #13, #14, #15, and #16) had been tampered with and replaced with other medications with similar color, shape, and size. The narcotic medications ([MEDICATION NAME] and [MEDICATION NAME]) were replaced with [MEDICATION NAME], and [MEDICATION NAME] medications. Interviews with the Pharmacist on December 8, 2010, at 9:30 a.m., the Medical Director on December 9, 2010, at 4:09 p.m., and an attending physician on December 8, 2010, at 9:50 a.m., revealed the medications [MEDICATION NAME], and [MEDICATION NAME] could be dangerous/harmful if administered to residents for whom they were not prescribed. According to the Medical Director, the medication [MEDICATION NAME] could cause a resident to have nausea/vomiting, arrhythmias, and [MEDICATION NAME] toxicity, and the medication [MEDICATION NAME] could cause a resident to suffer from [MEDICAL CONDITION]. The attending physician stated [MEDICATION NAME] could cause a resident with a [DIAGNOSES REDACTED]. Review of the medical records for residents #1, #2, #3, #5, #6, #11, #13, #14, #15, and #16, revealed no documentation that the physician or responsible party was contacted concerning the narcotics discrepancy and the possibility that these ten residents may have received medications that were not prescribed for them. Interviews with the Director of Nursing (DON) and the Nurse Consultant on December 7, 2010, at 9:30 a.m., confirmed the facility did not notify the residents, attending physicians, and responsible parties of the narcotics discrepancy and the possibility that these ten residents received the wrong medications. **An acceptable allegation of compliance related to the Immediate Jeopardy was submitted by the facility on December 14, 2010, which alleged removal of Immediate Jeopardy on December 16, 2010. An extended survey was conducted on December 17, 2010, which determined the Immediate Jeopardy was removed on December 16, 2010. A review of the allegation of compliance revealed the following: Upon notification by facility staff on November 27, 2010, the facility Director of Nursing (DON) began an internal investigation of the narcotic medication discrepancies. The local law enforcement agency was contacted by the DON on November 27, 2010. The attending physician and responsible parties for residents #1, #2, #3, #5, #6, #11, #13, #14, #15, and #16 were notified of the narcotic medication discrepancies by the DON/ADON/Medical Records Nurse on December 8, 2010, with follow-up interventions implemented as ordered. All registered Nurses, Licensed Practical Nurses, and Certified Medication technicians received in-service education beginning December 1, 2010, and completed on December 8, 2010, on notification of resident's physician and responsible party. In addition any new employee will be in-serviced upon hire and employees who were off work will be in-serviced upon returning to work. According to the allegation of compliance a Continuous Quality Improvement (CQI) indicator for auditing notification of change would be utilized on five medical records monthly for two months, then quarterly as per the established CQI calendar under the supervision of the DON. The survey team validated the corrective actions taken by the facility as follows: Record reviews for residents #1, #2, #3, #5, #6, #11, #13, #14, #15, and #16 on December 8, 2010, revealed the attending physician and responsible party were notified of the narcotic medication discrepancies, with follow-up interventions as ordered. Interviews conducted with RNs #4 and #7, LPNs #1, #6, and #7, the DON, and the Administrator on December 17, 2010, revealed in-services related to notification of the physician and responsible party were completed from December 1-8, 2010. Interviews conducted with nurses revealed they were knowledgeable of the information received in the in-services related to notification of the physician/responsible party. Further interview with the Administrator revealed that new hires would be in-serviced upon employment and staff that was off work would be in-serviced upon return to work. Additional review of residents #21, #22, #23, and #24 revealed no concerns related to notification of physician and responsible party. Interview with the Administrator and review of the facility record on December 17, 2010, revealed a Continuous Quality Improvement (CQI) indicator auditing tool was completed on December 16, 2010, for five resident records related to physician/responsible party notification with no concerns noted. Based on the above findings, it was determined the Immediate Jeopardy was removed on December 16, 2010. Noncompliance continued with scope and severity lowered to "E" based on the facility's need to evaluate the effectiveness of CQI activities related to the implementation of policies and procedures for notification of resident's physician/responsible party.

Based on observation, interview, and record review the facility failed to ensure all violations involving misappropriation of resident property were immediately reported to the appropriate state agencies. The facility failed to thoroughly investigate violations of misappropriation of resident property and failed to take action to prevent further potential abuse while the investigation was in progress for eleven (11) of twenty-six (26) sampled residents (residents #1, #2, #3, #5, #6, #11, #13, #14, #15, and #16) . In addition, resident #17's pain medication patch was found with an altered date when the resident was transferred to the local hospital for uncontrolled pain/discomfort on November 26, 2010. The facility failed to follow the "Abuse/Neglect/Misappropriation of Resident property" policy and procedure. On November 27, 2010, staff found that the narcotic medication packages ([MEDICATION NAME] and [MEDICATION NAME]) for ten residents (residents #1, #2, #3, #5, #6, #11, #13, #14, #15, and #16) had been tampered with and the narcotic medications had been replaced with other medications ([MEDICATION NAME]) which were similar in color, shape, and size. The facility failed to immediately notify the appropriate state agencies and failed to thoroughly investigate this incident. The facility became aware of the name of an alleged perpetrator on December 3, 2010, but failed to protect the residents from further potential harm by failing to remove the alleged perpetrator from direct resident care in accordance with facility policy. The alleged perpetrator was observed providing direct resident care on December 7 and 9, 2010. The facility's failure to immediately report this incident to the appropriate state agencies, failure to thoroughly investigate the incident, and failure to protect these ten residents from further potential harm during the investigation regarding discrepancies in the residents' medications placed residents at risk for serious injury, harm, impairment, or death. The findings include: 1. Review of the facility policy regarding Abuse/Neglect/Misappropriation of Resident Property (policy not dated) revealed the facility Administrator was responsible to immediately notify State agencies of all alleged incidents of abuse, to include misappropriation of resident property. The facility policy defined misappropriation of resident property as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. The policy further stated if the incident involved an employee, the employee would immediately be placed on suspension until the facility investigation had been completed, but the policy did not address the steps the facility would complete to thoroughly investigate the incident. Review of an Abuse/Neglect/Misappropriation Checklist (document not dated) revealed the facility was required to obtain a statement from the residents affected, witnesses to the incident, and the staff involved when an allegation/incident occurred. Interviews with the Administrator on December 7, 2010, at 5:41 p.m., the Director of Nursing Services (DON) on December 7, 2010, at 2:43 p.m., Registered Nurse #1 on December 7, 2010, at 10:09 a.m., Registered Nurse #2 on December 6, 2010, at 6:20 p.m., CMA #2 on December 7, 2010, at 9:49 a.m., LPN #1 on December 6, 2010, at 5:29 p.m., and LPN #3 on December 8, 2010, at 5:20 p.m., revealed that on November 27, 2010, the facility became aware of discrepancies in resident medications. According to the interviews, staff discovered the narcotic medications for ten residents (residents #1, #2, #3, #5, #6, #11, #13, #14, #15, and #16) had been tampered with and replaced with other medications with similar color, shape, and size. The narcotic medications ([MEDICATION NAME] and [MEDICATION NAME]) were replaced with [MEDICATION NAME], and [MEDICATION NAME] medications. Interviews with the Pharmacist on December 8, 2010, at 9:30 a.m., the Medical Director on December 9, 2010, at 4:09 p.m., and an attending physician on December 8, 2010, at 9:50 a.m., revealed the medications [MEDICATION NAME] and [MEDICATION NAME] could be dangerous/harmful if administered to residents for whom they were not prescribed. According to the Medical Director, the medication [MEDICATION NAME] could cause a resident to have nausea/vomiting, arrhythmias, and [MEDICATION NAME] toxicity, and the medication [MEDICATION NAME] could cause a resident to suffer from [MEDICAL CONDITION]. The attending physician stated [MEDICATION NAME] could cause a resident with a [DIAGNOSES REDACTED]. Review of the medical records for residents #1, #2, #3, #5, #6, #11, #13, #14, #15, and #16, and review of the accident/incident reports revealed no evidence the facility had immediately reported the misappropriation of resident property/discrepancies in the resident's narcotics to the appropriate state agencies. In addition, resident #17 was sent to the local hospital for examination on November 26, 2010. The attending physician for resident #17 notified the nursing facility that the narcotic [MEDICATION NAME] Patch for resident #17 appeared to have been tampered with/re-used. The emergency room physician reported the findings to the facility administrative staff. There was no evidence the facility investigated the incident or notified the state regulatory agencies regarding the incident. Interviews with the Director of Nursing (DON) on December 7, 2010, at 2:20 p.m. and December 8, 2010, at 10:30 a.m., revealed the DON reported the discrepancies in the residents' narcotics to the Administrator and the Nurse Consultant on November 27, 2010. According to the DON, he/she was instructed by the Nurse Consultant to notify the local police department regarding the missing narcotics but the Nurse Consultant informed the DON it was not necessary to notify the State Agency, because the incident was a criminal matter. The DON further stated a formal investigation regarding the residents' missing narcotics was not completed and incident reports/medication error reports were not completed because the facility did not know if the residents had received any of the medications used to replace the narcotics. According to the DON, no statements were obtained from staff regarding the discrepancies in resident medications and the alleged perpetrator was allowed to continue to provide resident care and administer resident medications after November 27, 2010. The DON stated the facility could not determine who had tampered with the resident medications and therefore no employees were suspended. Interview with the Administrator on December 7, 2010, at 5:30 p.m., revealed the Administrator was informed of discrepancies in the residents' narcotic medications by the DON. The Administrator instructed the DON to conduct drug screenings of all employees who had access to medications on November 27, 2010, to contact the local police regarding the medication discrepancies, and to notify the Nurse Consultant of the incident. The Administrator informed the DON to review the security cameras in the facility in an effort to determine which staff was involved; however, the cameras were not functioning on November 26-27, 2010. The Administrator became aware RN #1 was named as an alleged perpetrator regarding the missing narcotics on December 3, 2010, but did not suspend the alleged perpetrator from direct resident care and administering resident medications because the facility had no proof the alleged perpetrator was guilty. The Administrator stated he/she was aware the facility policy required that an alleged perpetrator be suspended from employment regarding allegations of misappropriation of resident property but the facility considered this incident a criminal matter and not misappropriation. According to the Administrator, the facility did not have comprehensive documentation of the events surrounding the missing narcotics. Interview with the Nurse Consultant on December 7, 2010, at 4:40 p.m., revealed the Nurse Consultant was made aware of the incident on November 27, 2010, by the DON but determined the incident was of a criminal nature and was not required to be immediately reported to the State Agency. The Nurse Consultant stated because the facility had replaced the resident's narcotic medications without cost to the residents, the incident was not considered misappropriation of resident property, and a formal investigation was not required. Interviews with LPN #1 on December 6, 2010, at 5:29 p.m., RN #2 on December 6, 2010, at 6:20 p.m., CMA #2 on December 7, 2010, at 9:49 a.m., RN #1 on December 7, 2010, at 10:00 a.m., and LPN #4 on December 7, 2010, at 12:20 p.m., revealed these staff persons had access and/or administered resident medications on November 26-27, 2010, but had never been interviewed by administrative staff as part of a facility investigation. Review of the staffing schedules for November and December 2010 revealed RN #1 was scheduled to work and provide direct resident care on November 26 and 30, 2010, and again on December 1, 4, 7, 8, and 9, 2010. The staffing schedule further revealed RN #1 was "on call" (to work if needed) for the facility on December 3, 2010, and had called in sick on December 5, 2010. RN #1's regularly scheduled days off were November 27, 28, and 29, 2010 and December 2 and 6, 2010, according to the staffing schedule. Review of "Hours Worked Detail Report" for RN #1 revealed this RN worked, providing direct resident care, for 16.50 hours on December 8, 2010. On December 7 and 9, 2010, RN #1 was observed in the facility hallway, at the nursing station, and was scheduled to provide direct resident care. At 9:45 a.m. on December 7, 2010, RN #1 was observed at the nursing station obtaining physician's orders via telephone for resident #11. On December 9, 2010, at 7:40 p.m., RN #1 was observed at nursing station #1 documenting in a resident's medical record. Review of the medical records for residents #4 and #7 revealed RN #1 had worked at the facility and provided direct care for both residents on December 4, 2010, and had provided care for residents #14 and #15 on December 7, 2010. Interview with the local police officer on December 9, 2010, at 5:45 p.m., and with LPN #1 on December 6, 2010, at 5:29 p.m., revealed according to the medication records RN #1 had signed out (signed as administered) more narcotics for residents than any other staff member. 2. Review of a hospital medical record and incident report for resident #17 dated November 26, 2010, at 7:43 p.m., revealed the resident was transferred to the hospital via ambulance with a complaint of increased pain. The resident had a [MEDICATION NAME] attached to the resident's skin with two dates noted on the patch. According to the hospital records, the date of November 24, 2010, appeared to be written over the date of November 21, 2010, on the patch and the patch appeared to be very dirty and old in appearance. The hospital records stated that resident #17 was in severe pain and was yelling. Interview with the Medical Director on December 9, 2010, at 4:00 p.m., revealed resident #17 presented to the emergency roiagnom on [DATE], due to the resident's pain. The Medical Director stated this resident had physician's orders for a [MEDICATION NAME] to be applied to the resident's skin every three days. According to the Medical Director, when the resident arrived at the hospital, the [MEDICATION NAME] on the resident's skin appeared to have had the date altered from November 21, 2010, with a mark across the numeral 1 to make the date appear to be November 24, 2010. The Medical Director, who was present in the emergency room at the time resident #17 presented, stated the resident was screaming with intense pain. The Medical Director explained that the old pain patch was removed, a new [MEDICATION NAME] was applied to the resident's skin and 30 minutes later the resident was calm and in less pain. The Medical Director was concerned about this incident and contacted the DON of the nursing facility to report the incident. The Medical Director requested that the Administrator and DON come to the hospital to evaluate the resident regarding the resident's medical condition. Interview with the Administrator on December 8, 2010, at 5:30 p.m., revealed the facility did not report this incident of neglect to the appropriate state agencies. The Administrator stated the caregiver was neglectful of the resident but the facility had not neglected the resident and therefore the allegation was not immediately reported to state agencies. **An acceptable allegation of compliance related to the Immediate Jeopardy was submitted by the facility on December 14, 2010, which alleged removal of Immediate Jeopardy on December 16, 2010. An extended survey was conducted on December 17, 2010, which determined the Immediate Jeopardy was removed on December 16, 2010. A review of the allegation of compliance revealed the following: Upon notification by facility staff on November 27, 2010, the facility Director of Nursing (DON) began an internal investigation of the narcotic medication discrepancies. The local law enforcement agency was contacted by the DON on November 27, 2010. Drug testing was conducted on medication administration staff that had direct access to each of the medication carts containing the narcotic medication packages with in the 24 hours prior to the identification of the narcotics discrepancies on November 27, 2010, December 3, 2010, and December 8, 2010. The alleged perpetrator, RN #1, was suspended on December 9, 2010. The Nurse Consultant received in-service education on the abuse/neglect/misappropriation of resident property by an expert in long-term care regulations on December 10, 2010. The Administrator and DON were in-serviced by the Nurse Consultant on December 9, 2010, on the need to consider any identified missing medications as misappropriation of resident property and to follow the facility policy and procedure for the reporting of the misappropriation to the correct state agencies. The facility staff received in-service education on the abuse/neglect/misappropriation of resident property policy and procedures on December 10, 2010. Twenty-four hour monitoring by administrative licensed nursing staff and/Nurse Consultants was implemented on December 11, 2010, to observe medication preparation and administration. The survey team validated the corrective actions taken by the facility as follows: Interview with the DON, Nurse Consultant, and Administrator on December 6-9, 2010, revealed an internal investigation began on November 27, 2010, with the local law enforcement being contacted. In addition, drug testing of all nursing staff present in the building was conducted on November 27, 2010, December 3, 2010, and December 8, 2010, and narcotic medications were inspected to identify discrepancies for all residents. Ten residents (residents #1, #2, #3, #5, #6, #11, #13, #14, #15, and #16) were identified as having narcotics replaced with non-prescribed medications. Interview with the local law enforcement on December 9, 2010, revealed an investigation was initiated on November 27, 2010, and was ongoing. An interview with the Administrator and review of the employee change of status form on December 9, 2010, revealed the alleged perpetrator was suspended on that date pending the outcome of the investigation. An interview with the Administrator, DON, and Nurse Consultant, and review of facility records, on December 17, 2010, revealed that an in-service was conducted for the Administrator, DON, ADON, and Social Worker on December 9, 2010, by the Nurse Consultant regarding the need to consider any identified missing medications as misappropriation of residents' property, and to report misappropriation of resident property to the appropriate state agencies. Further interview and record review revealed on December 10, 2010, the expert in Long-Term Care regulations (consultant to the Kentucky Association of Health Care Facilities) reviewed and verified the accuracy of the in-service information provided by the Nurse Consultant. Interview with the Administrator, DON, Nurse Consultant, CMTs #3 and #5, LPNs #1, #6, and #7, and RNs #4, #5, #6, and #7, and review of facility in-service records revealed facility staff received in-service education regarding abuse, neglect, and misappropriation of property on December 10, 2010. Interviews with CMTs #3 and #5, LPNs #1, #6, and #7, and RNs #4, #5, #6, and #7 on December 17, 2010, confirmed the staff attended the in-service, and was knowledgeable of the information received in the in-service. Further interview with the Administrator revealed that new hires would be in-serviced upon employment and staff that was off work would be in-serviced upon return to work. An interview with the Administrator and DON and review of facility records on December 17, 2010, revealed continuous monitoring of all medication passes by Registered Nurses was implemented on December 11, 2010, and was ongoing. Observations on December 17, 2010, revealed continuous monitoring was in progress. Interview with Registered Nurses performing continuous monitoring on December 17, 2010, revealed nurses were knowledgeable of monitoring of medication preparation and administration. Based on the above findings, it was determined the Immediate Jeopardy was removed on December 16, 2010. Noncompliance continued with scope and severity lowered to "E" based on the facility's need to evaluate the effectiveness of CQI activities related to the implementation of policies and procedures for investigating allegations, protecting residents, and notifying appropriate state agencies of misappropriation of property.

Based on interview and record review, the facility failed to conduct physical assessments, per their policy and procedure, for ten (10) residents (residents #1, #2, #3, #5, #6, #11, #13, #14, #15, and #16) after the facility discovered on November 27, 2010, that narcotic medications ([MEDICATION NAME] and [MEDICATION NAME]) had been replaced with other medications of similar color, shape, and size ([MEDICATION NAME], and [MEDICATION NAME]). Interviews with the Medical Director, the Pharmacist, and an attending physician revealed these medications could be dangerous/harmful if administered to residents for whom they were not prescribed. In addition, resident #11 was not assessed for the effectiveness of the resident's pain medication. The failure of the facility to conduct physical assessments placed residents at risk for serious injury, harm, impairment, or death. The findings include: Review of the facility policy regarding Abuse/Neglect/Misappropriation of Resident Property (policy not dated) revealed when an allegation of alleged abuse/misappropriation of resident property was received the facility was required to conduct a thorough examination of the resident to determine if any injury occurred as a result of the incident. Interviews with the Administrator on December 7, 2010, at 5:41 p.m., the Director of Nursing Services (DON) on December 7, 2010, at 2:43 p.m., Registered Nurse #1 on December 7, 2010, at 10:09 a.m., Registered Nurse #2 on December 6, 2010, at 6:20 p.m., CMA #2 on December 7, 2010, at 9:49 a.m., LPN #1 on December 6, 2010, at 5:29 p.m., and LPN #3 on December 8, 2010, at 5:20 p.m., revealed on November 27, 2010, the facility became aware of discrepancies in resident medications. According to the interviews, staff discovered the narcotic medications for ten residents (residents #1, #2, #3, #5, #6, #11, #13, #14, #15, and #16) had been tampered with and replaced with other medications with similar color, shape, and size. The narcotic medications ([MEDICATION NAME] and [MEDICATION NAME]) were replaced with [MEDICATION NAME], and [MEDICATION NAME] medications. Interviews with the Pharmacist on December 8, 2010, at 9:30 a.m., the Medical Director on December 9, 2010, at 4:09 p.m., and an attending physician on December 8, 2010, at 9:50 a.m., revealed the medications [MEDICATION NAME], and [MEDICATION NAME] could be dangerous/harmful if administered to residents for whom they were not prescribed. According to the Medical Director, the medication [MEDICATION NAME] could cause a resident to have nausea/vomiting, arrhythmias, and [MEDICATION NAME] toxicity, and the medication [MEDICATION NAME] could cause a resident to suffer from [MEDICAL CONDITION]. The attending physician stated [MEDICATION NAME] could cause a resident with a [DIAGNOSES REDACTED]. Review of the medical records for residents #1, #2, #3, #5, #6, #11, #13, #14, #15, and #16, and review of the accident/incident reports revealed no evidence the facility conducted physical assessments of these residents to determine if the residents had sustained injury/harm as a result of the incident. The medical records revealed residents #1, #3, #4, #6, #13, #14, #15, and #16 had [DIAGNOSES REDACTED]. Interview with resident #11 on December 9, 2010, at 9:30 a.m., revealed the resident had physician's orders for [MEDICATION NAME] 7.5 milligrams to be administered before meals and at bedtime. According to the resident, the pain medication was prescribed for abdominal pain and the medication had been administered at times which did not relieve the resident's pain (five of resident #11's [MEDICATION NAME] 7.5 milligrams were found to have been replaced with [MEDICATION NAME] on November 27, 2010). Although the resident had physician's orders for pain medications to be administered for "break through" pain ([MEDICATION NAME] 7.5 milligrams 1/2 tablet), this medication had not been administered to the resident in October, November, or December 2010 according to the medication administration records. Interview with the Director of Nursing on December 7, 2010, at 2:20 p.m., revealed after the narcotic medications were found to be replaced with other medications the DON instructed staff to monitor residents for changes in physical condition; however, no physical assessments of the residents were conducted. According to the DON, total physical assessments of these residents were not completed until December 7, 2010, after surveyors entered the facility. Interview with the Nurse Consultant on December 7, 2010, at 12:40 p.m., revealed physical assessments were not conducted for residents as the facility could not determine, and did not believe, the residents had received the unprescribed replacement medications ([MEDICATION NAME], and [MEDICATION NAME]). Interview with LPN #4 on December 7, 2010, at 12:20 p.m., revealed no resident assessments were conducted on November 27, 2010, after the facility discovered the narcotics had been replaced with other medications. **An acceptable allegation of compliance related to the Immediate Jeopardy was submitted by the facility on December 14, 2010, which alleged removal of Immediate Jeopardy on December 16, 2010. An extended survey was conducted on December 17, 2010, which determined the Immediate Jeopardy was removed on December 16, 2010. A review of the allegation of compliance revealed the following: Residents #1, #2, #3, #5, #6, #11, #13, #14, #15, and #16, who had identified narcotic medication discrepancies, had documented assessments of their status and/or interview by the DON as to their status per the nursing notes on November 27, 2010. In addition a complete assessment for these residents was conducted by the MDS Coordinator, Training Coordinator, and 3-11 Supervisor on December 7, 2010. RNs and LPNs received in-service education beginning on December 1, 2010, and completed on December 8, 2010, related to conducting resident assessments as provided by the DON/ADON/3-11 Supervisor. Twenty-four hour monitoring by the licensed nursing staff and or nursing consultants was implemented on December 11, 2010, to ensure residents were being assessed and to monitor staff's response to changes in residents' status. A Continuous Quality Improvement indicator for auditing notification of change will be utilized on five medical records monthly for two months, and then quarterly as per established CQI calendar under the supervision of the DON which included assessments of the resident. The survey team validated the corrective actions taken by the facility as follows: An interview with the DON and Nurse Consultant on December 6-9, 2010, revealed assessments for residents #1, #2, #3, #5, #6, #11, #13, #14, #15, and #16 were conducted on December 7, 2010, with interventions implemented as ordered. A review of the physical assessment forms completed on December 7, 2010, revealed the assessments were completed and no concerns were identified. An interview with the DON and Nurse Consultant and review of facility records on December 17, 2010, revealed in-services for nursing staff were completed on December 9, 2010, regarding resident assessments related to change in status and pain management. Interviews with nursing staff on December 17, 2010, revealed the nursing staff attended the in-services and was knowledgeable of the information received. Further interview with the Administrator revealed that new hires would be in-serviced upon employment and staff that was off work would be in-serviced upon return to work. An interview with the DON, Administrator, and Nurse Consultant, and review of facility records on December 17, 2010, revealed continuous monitoring of resident assessments for pain and changes of status by licensed nursing staff and/or Nurse Consultants were implemented on December 11, 2010, and were ongoing. Observations on December 17, 2010, revealed continuous monitoring was in progress with no concerns. Interview with RNs #5 and #6 who performed continuous monitoring on December 17, 2010, revealed the consultants were knowledgeable of monitoring of resident assessments for pain management and changes of condition. Based on the above findings, it was determined the Immediate Jeopardy was removed on December 16, 2010. Noncompliance continued with scope and severity lowered to "E" based on the facility's need to evaluate the effectiveness of CQI activities related to the implementation of policies and procedures for assessments of residents related to pain management and change in condition.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to ensure the accurate administration of all drugs to meet the needs of each resident. On November 27, 2010, staff found that the narcotic medication packages (Lortab and Vicodin) for ten (10) residents (residents #1, #2, #3, #5, #6, #11, #13, #14, #15, and #16) had been tampered with and the narcotic medications had been replaced with other medications (Theophylline, Naproxen, and Robaxin) which were similar in color, shape, and size. The facility was aware narcotic medication packages were being taped to hold medications in place; however, the facility failed to have an effective system to ensure the medications were not being tampered with and replaced with other non-prescribed medications. The facility's failure to provide pharmaceutical services to ensure the accurate administration of drugs to residents placed residents at risk for serious injury, harm, impairment, or death. The findings include: Interviews with the Administrator on December 7, 2010, at 5:41 p.m., the Director of Nursing Services (DON) on December 7, 2010, at 2:43 p.m., Registered Nurse #1 on December 7, 2010, at 10:09 a.m., Registered Nurse #2 on December 6, 2010, at 6:20 p.m., CMA #2 on December 7, 2010, at 9:49 a.m., LPN #1 on December 6, 2010, at 5:29 p.m., and LPN #3 on December 8, 2010, at 5:20 p.m., revealed on November 27, 2010, the facility became aware of discrepancies in resident medications. According to the interviews, staff discovered the narcotic medications for ten residents (residents #1, #2, #3, #5, #6, #11, #13, #14, #15, and #16) had been tampered with and replaced with other medications with similar color, shape, and size. The narcotic medications (Lortab and Vicodin) were replaced with Theophylline, Naproxen, and Robaxin medications. A review of resident #1's medical record revealed the resident had a physician's order for Lortab 7.5/500 mg to be administered every four hours as needed for pain. According to the facility's investigation and observations of the medication packages on December 7, 2010, at 4:40 p.m., resident #1 had ten Lortab 7.5/500 mg tablets that had been replaced with Theophylline medication and the package had been taped on the back, across the foil backing. A review of resident #2's medical record revealed the resident had a physician's order for Lortab 5/500 mg to be administered every six hours as needed for pain. According to the facility's investigation and observations of resident #2's medication packages on December 7, 2010, at 4:40 p.m., the resident had 11 Lortab tablets replaced with Robaxin. According to the facility's investigation, resident #2's Lortab (60 tablets) was delivered to the facility on [DATE]. Resident #3 had physician's orders for Hydrocodone 5/500 mg every four hours as needed for pain. The facility's investigation and observation of the medication packages on December 7, 2010, at 4:40 p.m., revealed two of the resident's Hydrocodone had been replaced with Theophylline and the medication package had been taped on the back of the package. According to the facility's investigation, resident #3's Hydrocodone was delivered to the facility on [DATE]. The medical record for resident #5 revealed the resident had physician's orders for Hydrocodone 5/500 mg every four hours as needed for pain. The facility's investigation and observation of the medication packages on December 7, 2010, at 4:40 p.m., revealed six of the resident's Hydrocodone had been replaced with Robaxin and the medication package had been taped on the back. According to the facility's investigation, resident #5's Hydrocodone was delivered to the facility on [DATE]. Resident #6 had physician's orders for Lortab 5/500 mg every four hours as needed for pain. The facility's investigation and observation of the medication packages on December 7, 2010, at 4:40 p.m., revealed 11 of the resident's Hydrocodone had been replaced with Robaxin and the medication package had been taped on the back. According to the facility's investigation, resident #6's Hydrocodone was delivered to the facility on [DATE]. A review of resident #11's medical record revealed the resident had physician's orders for Hydrocodone 7.5/500 mg scheduled before meals and at bedtime, and half of a tablet as needed for pain. The facility's investigation and observation of the medication packages on December 7, 2010, at 4:40 p.m., revealed five of the resident's Hydrocodone had been replaced with Theophylline and the medication package had been taped on the back. According to the facility's investigation, resident #11's Hydrocodone was delivered to the facility on [DATE]. Resident #13 had physician's orders for Hydrocodone 5/325 mg every four hours as needed for pain. The facility's investigation and observation of the medication packages on December 7, 2010, at 4:40 p.m., revealed two of the resident's Hydrocodone had been replaced with Naproxen 500 mg and the medication package had been taped on the back of the package. According to the facility's investigation, resident #11's Hydrocodone was delivered to the facility on [DATE]. A review of resident #14's physician's orders revealed an order for [REDACTED]. had been replaced with Theophylline and the medication package had been taped on the back. According to the facility's investigation, resident #14's Hydrocodone was delivered to the facility on [DATE]. Resident #15 had physician's orders for Vicodin 5/500 mg every four hours as needed for pain. The facility's investigation and observation of the medication packages on December 7, 2010, at 4:40 p.m., revealed two packages of the resident's Hydrocodone had been tampered with and twenty-three Vicodin had been replaced with Robaxin and the medication package had been taped on the back. According to the facility's investigation, resident #15's Hydrocodone was delivered to the facility on [DATE]. A review of resident #16's medical record revealed physician's orders for Hydrocodone 7.5/500 mg every six hours as needed for pain. The facility's investigation and observation of the medication packages on December 7, 2010, at 4:40 p.m., revealed two of the resident's Hydrocodone had been replaced with Theophylline and the medication package had been taped on the back. According to the facility's investigation, resident #3's Hydrocodone was delivered to the facility on [DATE]. Further review of physician's orders for residents #1, #2, #3, #5, #6, #11, #13, #14, #15, and #16 revealed the residents did not have orders for Theophylline, Robaxin, or Naproxen. A review of Medications Administration Policy revised July 16, 2000, revealed drugs "shall be kept and stored in the labeled dispensing container. Drugs may not be transferred from one container to another. This may be done only by a pharmacist." A review of the Facility Agreement with the Consultant Pharmacist signed on August 27, 2010, revealed the consultant's responsibilities included preparing a monthly summary report for the Administrator and pharmacy and a quarterly report on the status of the facility's pharmaceutical services and staff performance. In addition, the Consultant Pharmacist was responsible for meeting "all other responsibilities required of a consultant pharmacist as set forth in federal, state, and local laws, regulations, or rules." An interview with the Consultant Pharmacist on December 8, 2010, at 9:30 a.m., revealed the consultant had been providing services for the facility since September 1, 2010. The pharmacist stated he had visited the facility three times and had conducted random narcotics counts and drug regimen reviews. According to the consultant pharmacist, he/she had not identified narcotic medication packages were being taped on the back of the package, and had not observed a discrepancy in resident medications. Interview with a local police officer on December 9, 2010, at 5:45 p.m., and with LPN #1 on December 6, 2010, at 5:29 p.m., revealed according to the medication records, RN #1 had signed out more narcotics for residents than any other staff member. Interview with RN #2 on December 6, 2010, at 6:20 p.m., revealed that RN #2 had suspected and reported to the Assistant Director of Nursing (ADON) that residents were not receiving pain medications when RN #1 was on duty. In addition interviews with the night shift supervisor on December 8, 2010, at 5:20 p.m., and the ADON on December 9, 2010, at 2:24 p.m., revealed they had reviewed Medication Administration Records (MARs) and Narcotic Sign Out Logs after receiving complaints related to RN #1's medication practices. According to LPN #3 and the ADON, RN #1 signed out more narcotic pain medication for residents who did not normally require pain medication than any other nurse. An interview with the Director of Nursing (DON) on December 7, 2010, at 2:20 p.m., revealed administrative staff conducted periodic random narcotics counts for resident medications to ensure the appropriate number of medications were present in the package and coincided with the narcotics sign-out sheet. The DON stated he/she was aware narcotics packages were being taped with surgical tape by staff because the packages were fragile. However, according to the DON, the facility did not monitor the packages to ensure the narcotics had not been replaced nor did the facility have a system to reconcile narcotic medications including the frequency they were administered and who was administering the medications. **An acceptable allegation of compliance related to the Immediate Jeopardy was submitted by the facility on December 14, 2010, which alleged removal of Immediate Jeopardy on December 16, 2010. An extended survey was conducted on December 17, 2010, which determined the Immediate Jeopardy was removed on December 16, 2010. A review of the allegation of compliance revealed the following: Ten residents were identified with evidence of discrepancies in their narcotic medication packages (residents #1, #2, #3, #5, #6, #11, #13, #14, #15, and #16) on November 27, 2010. All narcotic medication packages were inspected by the DON on November 27, 2010, and again by the MDS Coordinators/DON/ADON/Training Coordinator, and 3-11 Supervisor on December 7, 2010, and any medications identified with evidence of tape present on the packaging were destroyed. The facility policies and procedures for the delivery, monitoring, and documentation of narcotic medications were reviewed/revised to include the following revisions: three medication administration staff persons were required to visually observe all narcotic medications at the change of shift and with transfer of medication keys from staff member to staff member. In addition the use of any type of tape on medication packaging was prohibited. Tamper-evident packaging was obtained for all narcotic medications packaging on December 10, 2010. The medication administration staff was in-serviced by the DON, ADON, Training Coordinator, and 3-11 Supervisor on the revised facility medication policies and procedures on December 8, 2010. Twenty-four hour monitoring to observe medication preparation and administration of medications by administrative licensed nursing staff and/or Nurse Consultants was implemented on December 11, 2010. The DON, ADON, MDS Coordinator, Training Coordinator, Restorative Coordinator, Medical Records Nurse, or 3-11 Supervisor would conduct reviews of narcotic medication packages, narcotics count sheets, and narcotics administration logs for two medication carts daily for two weeks, weekly for four weeks, then monthly thereafter to determine compliance with the revised medication policies and procedures. The pharmacy consultant will include reviews of two medication carts of narcotic medication packages, narcotics count sheets, and narcotics administration logs weekly for one month, then bi-weekly for one month, and then monthly. The pharmacy consultant will also conduct complete medication cart audits monthly for three months, and then as indicated by monthly observations. The nursing consultant will review narcotics count and administration log documentation for two medication carts monthly, and will review the monthly pharmacy consultant reports to identify any follow-up interventions necessary. The Continuous Quality Improvement indicator for auditing of the medication room/carts will be utilized on each of the two medication rooms and two medication carts monthly for two months, and then quarterly as per the established CQI calendar and monitored by the DON. The CQI indicator for the completion of medication pass observations was completed for all medication administration staff on December 13-15, 2010, by the DON, MDS Coordinator, 3-11 Supervisor, Restorative Coordinator, Training Coordinator, Unit Supervisors, Medical Records Nurse, and the Nurse Consultant. The survey team validated the corrective actions taken by the facility as follows: A review of the consultant pharmacist's written statement of monitoring/audit of medication carts completed on December 16, 2010, revealed audit/monitoring was completed with no discrepancies identified. An interview with the DON, Administrator, and Nurse Consultant, review of facility record, and observations on December 17, 2010, revealed 24-hour monitoring by administrative licensed nursing staff and or nursing consultants was implemented on December 11, 2010. Observations on December 17, 2010, revealed Nurse Consultants monitoring all medication preparation and administration (including narcotics). A review of the facility policy for medication storage in the facility dated December 7, 2010, revealed the following revisions: three medication administration staff persons will be required to visually observe all narcotic medications at the change of shift, with transfer of medication keys from staff member to staff member, and the use of any type of tape on medication packaging will be prohibited. Interviews with the DON, Administrator, Nurse Consultant, CMAs #3 and #5, LPNs #1, #6, and #7, and RNs #4, #5, #6, and #7 on December 17, 2010, revealed in-services regarding policy revision and medication administration were conducted for all medication staff on December 8-11, 2010. Interviews with facility nurses and CMTs on December 17, 2010, revealed all facility medication staff attended the in-services and was knowledgeable of the subject matter. Observations of medication rooms and medication carts on December 17, 2010, revealed no concerns with accountability of narcotic medications. Tamper-proof packaging for narcotics was observed to be in place for the facility. Interview with the DON and the Nurse Consultant, and review of facility documents on December 17, 2010, revealed narcotics audits by administrative staff were initiated on December 11, 2010, and were ongoing with no concerns identified. A review of the Continuous Quality Improvement (CQI) tool on December 17, 2010, revealed each medical staff person working at the facility had a competency check completed by December 15, 2010, regarding medication administration. Based on the above findings, it was determined the Immediate Jeopardy was removed on December 16, 2010. Noncompliance continued with scope and severity lowered to "E" based on the facility's need to evaluate the effectiveness of CQI activities related to the implementation of policies and procedures for notification of administration and accountability of resident medications.