Every finding on record at Dover Nursing & Rehabilitation Center

Based on observation, interview, record review, and review of the Resident Assessment Instrument (RAI), the facility failed to ensure an assessment accurately reflected the resident's status for 1 of 18 sampled residents, Resident (R) 52.Review of the admission Minimum Data Set (MDS) assessment, dated 08/18/2025, and review of the quarterly MDS assessment, dated 02/14/2026, revealed the facility failed to identify R52 had an indwelling catheter. The findings include:Review of the Long-Term Care (LTC) Facility Resident Assessment Instrument (RAI) 3.0, dated 10/2025, revealed the intent of the items in this section is to gather information on the use of bowel and bladder appliances, the use of and response to urinary toileting programs, urinary and bowel training programs, and bowel patterns. Each resident who is incontinent or at risk of developing incontinence should be identified, assessed, and provided with individualized treatment (medications, non-medicinal treatments and/or devices) and services to achieve or maintain as normal elimination function as possible. An indwelling catheter is maintained within the bladder for the purpose of continuous drainage of urine.Observation of R52 on 03/18/2026 at 9:31 AM, revealed the resident was dressed, sitting in his wheelchair with a catheter bag below, enclosed in a dignity bag. Review of R52's admission Record revealed the facility admitted the resident on 08/07/2025 with diagnoses to include dementia, anxiety, and urinary retention.Review of R52's admission MDS with an Assessment Reference Date (ARD) of 08/18/2025, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of nine out of 15, indicating the resident had moderate cognitive impairment. Further review revealed no documentation of the indwelling catheter.Review of R52's Physician Orders, dated 08/18/2025, revealed an order of an indwelling catheter size 16 French/10 cubic centimeters (cc). Review of R52's quarterly MDS with an ARD of 02/14/2026, revealed no documentation of the indwelling catheter.Review of R52's Treatment Assessment Record (TAR), dated 08/18/2025, 09/01/2025, 10/01/2025, 11/01/2025, 12/01/2025, 01/01/2026, 02/01/2026, and 03/01/2026, revealed the indwelling catheter 16 French/10 cc every shift for indwelling catheter care related to retention of urine.Review of R52's Care Plan, dated 09/23/2025, revealed the focus of urinary catheterization that specified use of a 16 French Foley catheter with a 10 milliliter (ml) balloon related to obstructive uropathy. Further review revealed the goal was the resident will be/remain free from catheter-related trauma through the review date. For the intervention catheter, position the catheter bag and tubing below the level of the bladder and away from entrance room door.In an interview with the Registered Nurse (RN) MDS on 03/19/2026 at 10:33 AM, she stated if R52 had an indwelling catheter upon admission, there should be documentation on the admission MDS and the quarterly MDS. She stated the MDS assessments should have had the catheter use indicated and it was currently inaccurate. In an interview with the Director of Nursing (DON) 03/19/2026 at 10:50 AM, she stated her expectation was all information about each resident should be captured in the MDS assessments in order to provide the appropriate care for the resident.In an interview with the Administrator on 03/19/2026 at 10:50 AM, she stated she expected the MDS assessments to be accurate and the indwelling catheter should have been captured on R52's MDS assessments.

Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure an ongoing program to support residents in their choice of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for 1 of 18 sampled residents, Resident (R) 70. The findings include:Review of the facility's policy titled, Activity Program, effective 08/04/2024, revealed the facility will provide an on-going activities program to support residents in their choice of activities and to meet the interests of and support the physical, mental, and psychosocial wellbeing of each resident. Review of the Long-Term Care (LTC) Facility Resident Assessment Instrument (RAI) 3.0, dated 10/2025, revealed the overall care plan should be oriented towards: 1. Assisting the resident in achieving their goals; and 2. Individualized interventions that honor the resident's preferences. Review of R70's admission Record revealed the facility admitted R70 on 07/14/2024 with diagnoses to include Parkinson's disease, polyneuropathy (breakdown of the peripheral nerves), and speech and language deficits.Review of R70's admission Minimum Data Set [MDS] with an Assessment Reference Date (ARD) of 07/18/2024, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 13 out of 15, which indicated R70 was cognitively intact.Review of R70's Care Plan, dated 07/14/2024, revealed under activities to provide an activity calendar. Further review revealed to provide assistance as needed getting to and from activities. Additionally, there was no activity listed regarding reading.Review of R70's Activity Log revealed: Reading Activity (group) from 01/01/2026 to 01/31/2026 was not checked; Activity Reading To/Talking Books for 02/01/2026 to 02/28/2026 was not checked; Activity Reading To/Talking Books for 03/01/2026 to 03/17/2026 was not checked.Observation on 03/17/2026 at 10:27 AM revealed R70 lying in bed and the television remote was lying on the bedside table within his reach.During immediate interview with R70 at the time of the observation he stated he was having trouble with the remote for the television. He stated the remote did not work and he stated he used to have books about horses.In an interview with Licensed Practical Nurse (LPN) 1 on 03/17/2026 at 2:15 PM, she stated she did not know if R70 had any books. She stated she would check with activities and see if they could get any books. She further stated R70 used to be a horse jockey.Observation on 03/18/2026 at 1:56 PM revealed R70 lying in bed with the television remote in his hands.During immediate interview with R70, he stated he liked to look at books. He further stated he had told staff he wanted books, and he had not received books. He also stated the activity sheet said today was library day and they did not take him to the library, but he would have gone to the library if staff had taken him. The SA Surveyor observed the activity sheet on R70's bedside table and library was listed.In an interview with State Registered Nurse Aide (SRNA) 2 on 03/18/2026 at 2:37 PM, she stated she did not know R70 liked to read or that he wanted to go to the library. In an interview with Activities Assistant (AA) 1 on 03/18/2026 at 3:25 PM, she stated the book cart goes around to every resident for the opportunity to select books. She could not verify the cart visited R70 on that date. She further stated she was not aware of R70's interest in reading.In an interview with the Activities Director on 03/18/2026 at 3:15 PM, she stated R70 was not visited on that date during the library time scheduled on the activities schedule. She stated she was unaware R70 liked books.In an interview with the Director of Nursing (DON) on 03/19/2026 at 11:02 AM, she stated the Activities Director oversaw the activities. She was unaware that R70 did not get to go to the library activity, and it was her expectation that the SRNAs would take the residents to the activity.In an interview with the Administrator on 03/19/2026 at 11:13 AM, she stated she expected staff to listen to each resident and provide activities specific for each resident. She further stated she was unaware there was an issue with activities for R70 and if she was given the information, she would have addressed the issue.

Based on observation, interview, and record review, the facility failed to ensure that each resident who needed respiratory care was provided with such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 18 sampled residents, Resident (R) 2.The findings include:In an interview with the Administrator on 03/19/2026 at 10:42 AM, she stated the facility did not have a policy related to oxygen administration for residents.Review of R2's Face Sheet revealed the facility admitted the resident on 11/26/2025 with diagnoses to include acute respiratory failure with hypercapnia, other chronic osteomyelitis right ankle and foot, and type 2 diabetes mellitus with other diabetic ophthalmic complications.Review of R2's quarterly Minimum Data Set [MDS] with an Assessment Reference Date (ARD) of 01/13/2026, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 14 out of 15, indicating the resident was cognitively intact.Review of R2's Physician Orders, dated 01/09/2026, revealed the resident was ordered oxygen at two liters per minute (LPM) via nasal cannula.Observation on 03/17/2026 at 11:10 AM revealed R2 was adjusting her oxygen concentrator to 3.5 LPM without an authorized facility staff member present.Observation on 03/17/2026 at 3:12 PM revealed R2's oxygen concentrator was controlled at 3.5 LPM.Observation on 03/18/2026 at 9:03 AM revealed R2's oxygen concentrator was controlled at 2.5 LPM.Observation on 03/18/2026 at 2:58 PM revealed R2's oxygen concentrator was controlled at 2.5 LPM.Observation on 03/18/2026 at 4:22 PM revealed no authorized facility staff member monitoring the concentration level of R2's oxygen liters.Observation on 03/19/2026 at 8:21 AM revealed R2's oxygen concentrator was controlled at 1.5 LPM.Observation on 03/19/2026 at 10:43 AM revealed R2's oxygen concentrator was controlled at 1.5 LPM.Review of R2's Care Plan, revised 11/26/2025, revealed oxygen therapy related to ineffective gas exchange, respiratory illness, chronic obstructive pulmonary diseases (COPD), unspecified, obstructive sleep apnea (adult (pediatric), and acute respiratory failure with hyper acapnia. Further review revealed no documented interventions to monitor the oxygen flow levels or to educate the resident about self-adjusting the flow levels.In an interview with Licensed Practical Nurse (LPN) 3, who was assigned to R2, on 03/18/2026 at 4:25 PM, she stated R2's oxygen order was for 3 LPM, further stating she would need to look at R2's care plan to verify. She stated she reviews residents' care plans daily before starting her shift. She stated she had not made any monitoring attempts to observe R2's oxygen concentrator and the LPM setting on that date.In an interview with the Advanced Practice Registered Nurse (APRN) on 03/19/2026 at 10:42 AM, she stated that every time she had observed the oxygen concentrator, it had been on the wrong liters/minutes due to R2 and her roommate making attempts to adjust the concentrator without medical consent or authorized from a facility staff member. She stated a resident with a diagnosis of COPD, whose oxygen level was increased, could cause their respiratory drive to decrease. She further stated that it could cause the resident to stop breathing as needed and could cause the resident to go into respiratory distress.In an interview with the Director of Nursing (DON) on 03/19/2026 at 11:13 AM, she stated she was unaware of R2 not receiving the correct oxygen LPM. She stated with the resident having a diagnosis of COPD, receiving too much oxygen could cause harm to the resident.In an interview with the Administrator on 03/19/2026 at 11:42 AM, she stated she was not informed R2 was adjusting her oxygen concentrator. She stated the resident could be harmed by receiving too much oxygen. She further stated her expectation was for all facility staff members to follow the residents' care plan and physician's orders. She stated if R2 was adjusting her own oxygen concentrator levels, there should be care plan interventions for resident education and staff monitoring.

Based on interview and review of the facility's documents, the facility failed to ensure nurse aides received a performance review at least once every 12 months for 1 of 4 employee files reviewed, State Registered Nurse Aide (SRNA) 6.The findings include:Review of the facility's policies revealed no documentation of a policy addressing staff performance evaluations.Review of SRNA6's employee file revealed the facility hired the employee on 06/04/2024; however, further review revealed no documentation of a performance evaluation completed within 12 months of the hire date.In an interview with SRNA6 on 03/18/2026 at 5:38 PM, she stated she thinks she had a performance evaluation in August of 2025, however, no documentation of a completed performance evaluation was available upon request.In an interview with the Administrator on 03/18/2026 at 2:50 PM, she stated she was unable to locate a performance evaluation or training records for SRNA6. She stated it could be misfiled, but was unable to produce any documentation.In further interview with the Administrator on 03/19/2026 at 9:12 AM, she stated I can't imagine I would have not completed a performance evaluation on her. However, she was unable to locate or provide documentation of a performance evaluation completed within 12 months of SRNA6's date of hire.

Based on observation, interview, record review, and review of the facility's policy, the facility failed to store food safely in two of two nourishment refrigerators as determined by observations on 12/09/2024, the nourishment refrigerators on the A Unit and the B Unit. The findings include: Review of the facility's policy titled, Food Brought in from Outside Sources and Personal Food Storage, dated 2019, revealed foods from outside sources that required refrigeration or freezing would be labeled with the resident's name and date and stored in the refrigerator/freezer. Per the policy, staff would monitor and document the unit refrigerator temperatures. 1. Observation of the B Unit nourishment refrigerator on 12/09/2024 at 1:42 PM revealed an opened container of applesauce and an opened pudding cup in the door of the refrigerator. Further observation revealed grapes and a container of Chinese food was not dated and not labeled. Also observed in the freezer door were two boxes of lemon glycerin swab sticks, one one-half cup of ice cream, and 36 popsicles that were not dated or labeled. Review of the facility's form Temperature Monitoring Log, dated 12/2024 and for the B Unit nourishment refrigerator, revealed there was no documentation of temperatures for 12/07/2024, 12/08/2024, and 12/09/2024. 2. Observation of the A Unit nourishment refrigerator on 12/09/2024 at 2:58 PM revealed it contained half a box of lemon glycerin swab sticks in the freezer. In an interview with the Dietary Manager on 12/12/2024 at 2:20 PM, she stated once weekly she removed food from the resident refrigerators that were not dated and had no resident name. She stated the nursing staff was responsible for recording the refrigerator and freezer temperatures. She stated if the temperatures were not recorded, the refrigerator and freezer might not be working, and the food could spoil. She stated the mouth swabs were not kept in the nourishment refrigerators, and the opened and not labeled or dated applesauce and pudding must be thrown away. In an interview with Licensed Practical Nurse (LPN) 1, A Unit Manager, and LPN5, B Unit Manager, on 12/12/2024 at 2:49 PM, both stated the nurses on the night shift were responsible for recording the nourishment refrigerator and freezer temperatures. Both stated if the temperatures were not recorded, the refrigerator and freezer could have abnormal temperatures, and food could thaw, refreeze, and spoil. Both stated there should not be any unidentified open containers kept in the nourishment refrigerators or any items from the medication cart stored with the residents' food. In an interview with the Director of Nursing on 12/12/2024 at 3:04 PM, she stated the night shift nurses recorded the nourishment refrigerator and freezer temperatures because if the temperatures were not recorded, the food could be spoiled. She stated the lemon glycerin swabs were kept in the freezer for Hospice residents because they liked the swabs cold, and there was no freezer in medication storage to store the glycerin swabs. She stated the glycerin swabs were not kept with food, and the applesauce and the pudding must be labeled and dated. She stated no opened food should be left in the refrigerator without a date and identification for a specific resident. She stated the applesauce and pudding should be thrown away because bacteria grew in food left open. In an interview with the Administrator on 12/12/2024 at 3:17 PM, she stated temperatures should be recorded for the refrigerator and freezer because if they were not in the correct range, the food could spoil. She stated the opened containers of applesauce and pudding should be thrown out.

Based on observation, interview, review of the package insert for latanoprost ophthalmic solution, and review of the facility's policy, the facility failed to ensure that medications were secure and inaccessible to unauthorized staff and residents and were stored properly for one of four medication carts, the B Wing Upper medication cart. 1. Observation on [DATE] of the B Wing Upper medication cart revealed it was unlocked and unattended. The staff member who was working with the cart was not in the area. 2. Observation on [DATE] of the B Wing Upper medication cart revealed it contained an unopened box of latanoprost ophthalmic solution 0.005% (used to treat glaucoma) belonging to Resident (R) 3, which was labeled refrigerate. There was also an opened box of latanoprost 0.005% belonging to R3, and neither the box nor bottle were dated. The findings include: Review of the facility's policy titled Medication Storage in the Facility, dated [DATE], revealed medications and biologicals were stored safely, securely, and properly, following manufacturer's recommendations. Per the policy, the medication supply was accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications, and medication carts were locked when not attended by persons with authorized access. The policy stated medications requiring refrigeration were kept in a refrigerator at temperatures between 36 degrees Fahrenheit (F) to 46 degrees F. Per the policy, drugs dispensed in the manufacturer's original container would be labeled with the manufacturer's expiration date. 1. Observation on [DATE] at 1:40 PM revealed the B Wing Upper medication cart was unlocked and unattended. Further observation revealed there was no staff in the area. In an interview with Registered Nurse (RN) 2 on [DATE] at 1:45 PM, she stated she was assigned to the B Wing Upper medication cart and was unaware she had left it unlocked when she went into a resident's room. RN2 stated it was expected that the medication cart be locked at all times when not preparing medications and when unattended. RN2 stated it was important to keep all medication carts secured because any resident, visitor, or staff member could potentially open the cart and take medications. In an interview with the Assistant Director of Nursing (ADON) on [DATE] at 2:37 PM, she stated it was the expectation for all licensed staff assigned to medication carts to keep them locked at all times when not actively preparing medications so that unauthorized persons could not access them. In an interview with the Director of Nursing (DON) on [DATE] at 3:00 PM, she stated it was the expectation for all licensed staff assigned to medication carts to keep them locked at all times when not actively preparing medications so that unauthorized persons could not access the carts. The DON stated if a cart was found to be unlocked and unattended it would be immediately secured, the assigned employee would be located and informed, an immediate audit of the medication cart would be performed, and appropriate corrective action would be taken. In an interview with the Administrator on [DATE] at 3:58 PM, she stated the expectation for medication storage and securement was that all licensed staff was to follow the facility's policy. 2. Review of the package insert information for latanoprost ophthalmic solution 0.005% at https://www.accessdata.fda.gov, revealed to store unopened bottles under refrigeration at 36 degrees to 46 degrees F. Further, once a bottle was opened, it could be stored at room temperature for six weeks. Observation on [DATE] at 2:49 PM of the B Wing Upper medication cart revealed R3's unopened box of latanoprost 0.005% ophthalmic solution labeled refrigerate, and R3's opened box where neither the box nor the bottle were dated. During interview with RN3 at the time of the observation, she stated she would not have used the unopened box of latanoprost and would have requested a refill that the facility would pay for. She also stated she did not open the bottle of latanoprost, so she did not know when it was opened. She stated she saw on the label the bottle was dispensed [DATE], so she knew it was not expired. During interview with Licensed Practical Nurse (LPN) 5, who was also the Unit Manager of the B Wing, on [DATE] at 10:40 AM, she stated she always dated medications when she opened them. She stated the medications might not be effective if they were expired. She also stated staff went through the medication carts regularly and disposed of any undated or expired medication. She stated the unrefrigerated and undated latanoprost were just overlooked. During interview with the Pharmacist on [DATE] at 2:16 PM, she stated the shelf life of latanoprost after it was removed from the refrigerator was 42 days (six weeks). She stated if latanoprost was used after 42 days the medication might not be effective. During interview with the DON on [DATE] at 11:09 AM, she stated when nursing staff received medication from pharmacy, they always refrigerated medications if needed. She stated the unrefrigerated latanoprost was an oversight. She stated the medication might not be effective if it were used after the expiration date, and the resident could potentially be harmed. During interview with the Administrator on [DATE] at 11:14 AM, she stated she relied on the management staff to make sure medications were stored properly. She stated she was not notified of unrefrigerated medications in the medication cart. She further stated she was going to take the issue to the Quality Assurance Performance Improvement (QAPI) meeting, and they would discuss the best way to assure medications were stored appropriately. She stated the unrefrigerated and undated bottle of latanoprost would be disposed of and two new bottles would be ordered for R3 and paid for by the facility.

Based on interviews, record reviews, and facility policy review, it was determined the facility failed to protect 9 of 15 sampled residents from abuse and neglect. Specifically, the facility failed to protect Residents #79, #5, #63, #18, and #48 from staff-to-resident verbal and/or physical abuse and Resident #21 from staff neglect. In addition, the facility and failed to protect Residents #63, #34, #49, and #231 from resident-to-resident physical and/or verbal abuse. The findings included: Review of the facility's policy titled Resident Protection Plan, dated 09/15/2022, revealed, Our facility does not condone resident abuse by anyone, including staff members, physicians, consultants, volunteers, staff of other agencies serving the resident, family members, legal guardians, sponsors, other residents, friends, or other individuals. Further review of the policy revealed, Verbal Abuse - is defined as any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, to describe residents, regardless of their age, ability to comprehend, or disability. Physical Abuse - is defined as hitting, slapping, pinching, kicking, etc. It also includes controlling behavior through corporal punishment. Neglect - is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental or emotional anguish. 1. Review of Resident #79's Admission Record revealed the facility admitted the resident on 09/13/2023 with diagnoses that included chronic obstructive pulmonary disease (COPD), dysphagia, diverticulosis of the large intestine, and gastrostomy status. A review of Resident #79's Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/14/2023, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Further review of the MDS revealed Resident #79 required limited assistance with toilet use and personal hygiene and received nutrition and hydration through a feeding tube. Review of Resident #79's care plan revealed a focus statement initiated on 10/19/2023 that indicated the resident had bowel and bladder incontinence. Interventions directed staff to frequently check the resident for incontinence and indicated the resident was to wear briefs or pull-ups (adult underwear for incontinence). Review of the Long Term Care Facility Self-Reported Incident Form Initial Report, dated 10/17/2023, revealed that Family Member (FM) #41 reported to the Administrator and the Director of Nursing (DON) that State Registered Nurse Aide (SRNA) #40 had been rough with Resident #79 during incontinence care provided on 10/15/2023. A telephone interview was held with FM #41 on 12/06/2023 at 1:00 PM. FM #41 stated they were unable to remember the exact date of the incident but recalled that it was in November 2023. FM #41 stated that during a visit with Resident #79, two staff members came into the resident's room to provide incontinence care. FM #41 stated when the resident's brief was removed, FM #41 noticed Resident #79's perineal area was red and excoriated. FM #41 stated staff used disposable wipes to cleanse the resident, and when the FM suggested using warm, wet washcloths, the staff was condescending. The FM stated the staff members acted as if they did not care. FM #41 said the staff was wiping Resident #79 roughly and causing the resident pain, and the resident started crying. FM #41 stated that even though Resident #79 was crying, the staff continued providing the incontinence care with no compassion and did not care that they were hurting the resident's sore, reddened skin. FM #41 stated no one should be treated as Resident #79 had been treated. A telephone interview was held with SRNA #34 on 12/07/2023 at 11:11 AM. SRNA #34 stated she had been assigned to provide care for Resident #79 on the day the incident occurred. SRNA #34 stated the resident's call light was on; she answered the light, and FM #41 told her Resident #79 required incontinence care. SRNA #34 stated FM #41 informed her that the resident said the call light had been on for two hours. The SRNA stated FM #41 then told her she was incompetent because the resident's skin was excoriated and red. SRNA #34 said when she realized how upset FM #41 was, she had Licensed Practical Nurse (LPN) #22 and SRNA #40 go into the resident's room with her to provide the incontinence care. SRNA #34 stated that SRNA #40 was the person who was accused of being too rough with Resident #79, and she agreed that during the incontinence care, SRNA #40 had been rough with the resident. SRNA #34 stated she held Resident #79 in position on his/her side while SRNA #40 provided the incontinence care. She stated that SRNA #40 used so much force to cleanse the resident she could feel the force pushing on her as she held the resident on his/her side during care. SRNA #34 stated FM #41 wanted Resident #79 to wear pull-ups, but SRNA #40 got upset and told FM #41 a brief would be easier. SRNA #34 stated SRNA #40 had been so rough she would call what happened abuse. SRNA #34 stated Resident #79 was crying and saying, Ouch! Ouch! The resident told SRNA #40 that the care was hurting, but SRNA #40 did not stop. A phone interview was held with LPN #22 on 12/07/2023 at 12:12 PM. LPN #22 acknowledged she had been working when the incident occurred between Resident #79 and SRNA #40. She stated another staff member asked her to go into the resident's room because the staff member had not thought the interaction was going well. LPN #22 stated the resident's buttocks were red due to incontinence and chronic diarrhea that Resident #79 had experienced since admission. The LPN stated she knew other staff were saying SRNA #40 had been rough with Resident #79, but she did not see it that way. LPN #22 added that she may not have been standing close enough to see if SRNA #40 was rough with the resident. She said she had been standing three to four feet from Resident #79's bed and near the foot of their roommate's bed. LPN #22 stated Resident #79 was wincing, but she thought that was because the resident was sore and not necessarily because SRNA #40 was doing anything wrong. LPN #22 stated that SRNA #40 apologized to Resident #79 the entire time she was providing incontinence care. A phone call was placed to SRNA #40 on 12/07/2023 at 11:22 AM, and the phone was out of service. An interview with the DON was held on 12/11/2023 at 12:48 PM. The DON stated the incident between Resident #79 and SRNA #40 had occurred on 10/15/2023 at 5:00 PM. She stated the facility's administration found out about the incident on 10/17/2023 at 1:00 PM when FM #41 reported the incident to her and the Administrator. The DON stated interviews were conducted with the alleged abuser, the reporter, the nurse on duty, and the SRNA who was in the room with the alleged abuser. The DON stated SRNA #34, who had been in the room, agreed that SRNA #40 had been rough with Resident #79 during incontinence care. She stated SRNA #40 denied all allegations, and LPN #22 stated she had no concerns with the care given by SRNA #40. The DON stated SRNA #40 had been immediately suspended. The Administrator was interviewed on 12/12/2023 at 10:31 AM. The Administrator stated she found out about the incident on 10/17/2023 from FM #41, who reported SRNA #40 had been rough with Resident #79 during incontinence care. The Administrator stated SRNA #40 was immediately suspended. 2. A review of Resident #5's Admission Record revealed the facility admitted the resident on 08/08/2023 with diagnoses that included secondary malignant neoplasm of the large intestine and rectum (colon cancer) with colostomy and adult failure to thrive. A review of Resident #5's Admission MDS, with an ARD of 08/20/2023, revealed the resident had a BIMS score of 15, which indicated the resident was cognitively intact. Further review of the MDS revealed Resident #5 required extensive assistance with toilet use and personal hygiene. The MDS revealed Resident #5 was always incontinent of urine, and bowel continence was not rated due to the presence of an ostomy. A review of Resident #5's care plan revealed a focus statement initiated on 08/08/2023 that indicated Resident #5 had bladder incontinence. Interventions directed staff to provide incontinence checks every two hours and keep the call light within the resident's reach. A review of a Long Term Care Facility Self-Reported Incident Form Initial Report dated 10/25/2023 revealed that on 10/25/2023 at approximately 7:15 AM, SRNA #34 reported to the DON that Resident #5 stated that SRNA #35 yanked Resident #5's brief while checking for incontinence and made the resident feel belittled. A review of a Grievance Form, dated 10/25/2023, indicated Resident #5 told the DON the agency SRNA (SRNA #35) refused to change his/her brief. The grievance form indicated that when Resident #5 called and requested that his/her brief be changed, SRNA #35 pulled the bed covers back and told the resident they did not need to be changed due to not being incontinent. The form indicated Kentucky Medication Aide (KMA) #13 overheard the conversation and got another staff member to change Resident #5's brief. A telephone interview was held with SRNA #34 on 12/07/2023 at 11:04 AM. SRNA #34 stated Resident #5 reported to her that another SRNA had been rough during care. The SRNA stated Resident #5 was cognitively intact and described the following incident. SRNA #34 stated Resident #5 said that when they called for help, SRNA #35 answered the call light, and Resident #5 told SRNA #35 they needed incontinence care. SRNA #34 stated that the resident said SRNA #35 pulled the bed covers back, shook the resident's brief, and told the resident they had not been incontinent. Telephone calls and voice messages were left for SRNA #35 on 12/07/2023 at 12:33 PM, 12/07/2023 at 7:15 PM, and 12/09/2023 at 8:47 AM. SRNA #35 did not return the calls. A telephone interview was held with KMA #13 on 12/07/2023 at 12:01 PM. The KMA recalled that on the day of the event, Resident #5 used their call light to request assistance a few times. She said SRNA #35 went into the resident's room and told Resident #5 they did not require incontinence care because the lines (indicators) on the brief had not changed colors; therefore, the resident had not been incontinent, and she was not changing the resident's brief. KMA #13 stated she had reported the incident to LPN #37, who was the nurse that day. KMA #13 stated LPN #37 went into Resident #5's room and told the resident that if they required changing the SRNA needed to change them regardless of whether the lines on the brief had changed colors. During an interview on 12/08/2023 at 1:54 PM, LPN #37 stated she had been working when the incident with Resident #5 occurred. LPN #37 stated Resident #5 called her into their room and wanted to know about the lines on the adult briefs. LPN #37 stated she told the resident that when the lines on the briefs changed colors, that meant there had been incontinence. LPN #37 stated she also told Resident #5 that because he/she was cognitively intact, staff should change their briefs when requested. She stated at that time, Resident #5 told her SRNA #35 said the lines on his/her brief had not changed color and did not warrant the resident being changed. LPN #37 stated she made Resident #5 an offer to switch SRNA #35's assignment with another staff member, and the resident told her they just wanted the nurse to know about the incident. The LPN stated Resident #5 had not communicated any rough treatment or pulling of the brief during care. LPN #37 stated that after the conversation with the resident, she explained to SRNA #35 that it was the expectation that she change a resident's brief as requested regardless of the color of the indicator lines on the brief. The DON was interviewed on 12/11/2023 at 11:16 AM. The DON stated that on 10/25/2023, SRNA #34 walked into her office and told her she had something important to tell her. SRNA #34 reported that on 10/22/2023, Resident #5 stated that at around 5:00 PM, SRNA #35 yanked Resident #5's brief and made the resident feel belittled while checking to see if the resident had been incontinent. The DON stated she gathered witness statements from SRNA #34 and SRNA #35, who denied the allegation; LPN #37, the nurse assigned that day, who stated she was unaware the incident occurred; and Resident #5. The DON stated Resident #5 reported that SRNA #35 yanked their brief while she checked the resident for incontinence and made the resident feel belittled. The DON stated Resident #5 told her that SRNA #35 checked the lines on the brief, told the resident they had not been incontinent, and refused to change the brief. She stated she called the agency on 10/25/2023 and requested SRNA #35 not return to the facility. The DON stated SRNA #35 had only worked in the facility since 10/22/2023. She stated the allegation of abuse for Resident #5 was substantiated. The Administrator was interviewed on 12/12/2023 at 9:40 AM. She stated she found out about the incident concerning Resident #5 and SRNA #35 on 10/25/2023 when an employee reported to the DON that an agency employee had yanked Resident #5's brief on 10/22/2023. 3. A review of Resident #63's Admission Record revealed the facility admitted the resident on 06/28/2022 with diagnoses that included unspecified mood (affective) disorder, bipolar disorder, intellectual disabilities, and depression. A review of Resident #63's Quarterly MDS, with an ARD of 08/16/2023, revealed Resident #63 had a BIMS' score of 11, which indicated the resident had moderate cognitive impairment. The MDS revealed Resident #63 had physical behavioral symptoms directed toward others and rejected care for one to three days during the review period. The MDS revealed Resident #63 required extensive assistance with bed mobility, locomotion, and dressing and was dependent on staff for transfers, toilet use, and personal hygiene. A review of Resident #63's care plan revealed a focus statement with a revision date of 08/08/2022 that indicated Resident #63 displayed behavioral symptoms that included biting, hitting, screaming, shouting, yelling, refusing medications, being disruptive, and lashing out during physician's visits, using foul language and racial expletives, and throwing objects from their bedside table. Interventions directed staff to attempt interventions before behavioral symptoms begin, not seat Resident #63 around others who would disturb them, help the resident avoid people or situations that would disturb them, offer the resident diversions they enjoy, refer the resident to a psychologist/psychiatrist as needed, give medications as ordered, and remove the resident from an activity when negative behaviors begin, returning/resuming the activity when the behavior subsides. A review of a Long Term Care Facility Self-Reported Incident Form Initial Report, dated 11/09/2023, revealed Resident #63 made an allegation of staff-to-resident verbal abuse. Further review of the report revealed that Dietary Aide (DA) #45 overheard SRNA #46 being verbally abusive to Resident #63. DA #45 reported that on 11/08/2023 at approximately 6:30 PM, SRNA #46 was heard saying to Resident #63, I don't know who is stupid enough to buy these nails [artificial fingernails]. If you don't hold the [expletive] still, then I'm not going to put it back on you. A review of an incident report dated 11/09/2023 revealed that Resident #63 reported that SRNA #46 cussed at me. Review of the incident Progress Notes, dated 11/09/2023, revealed that Resident #63 stated he/she was cussed at by an SRNA. The notes indicated the resident was placed on 72-hour monitoring, and the provider was notified. Review of the Progress Notes, dated 11/09/2023, revealed Resident #63 exhibited increased nervousness due to an event with an SRNA. The notes indicated the primary purpose of the visit was to evaluate the mental state of Resident #63 after an incident with a staff member. The notes indicated Resident #63 was relatively calm as the provider spoke with the resident and responded appropriately to questions asked. There was no change in the resident's treatment plan. Review of acute monitoring nursing Progress Notes, dated 11/09/2023, revealed that Resident #63 screamed and cursed at staff off and on all shift because his/her artificial fingernails kept falling off and staff had no glue to reapply the fingernails. The note indicated staff had tried to explain the situation to Resident #63, who continued to scream and curse at staff. Review of a timesheet for SRNA #46 indicated she worked 12 hours on 11/08/2023, which was the date of the alleged incident, and worked on 11/09/2023 for 1 hour and 50 minutes. DA #45 was interviewed on 12/07/2023 at 2:11 PM. DA #45 stated that on the day of the incident, Resident #63 was wearing artificial fingernails that kept falling off, which made the resident upset. DA #45 stated she overheard SRNA #46 tell Resident #63 that if the resident did not [expletive] quit, she was not going to put the fingernails back on. DA #45 stated she left Resident #63's room, returned to the kitchen, and notified the Administrator and Director of Nursing (DON) within five minutes of the event. DA #45 stated there had been no physical abuse observed, and she had left the room because she had not liked how SRNA #46 had spoken to the resident. She stated that at the time of the incident, Resident #63 was upset, and she knew that because when the resident got upset, the resident's voice got louder, and at that time, the resident's voice got louder. The DON was interviewed on 12/11/2023 at 11:16 AM. The DON stated the incident between Resident #63 and SRNA #46 occurred on 11/08/2023 at 6:30 PM, and she became aware of the incident on 11/09/2023 at 8:45 AM. The DON stated her understanding of what happened was that SRNA #46 cursed at Resident #63 because the resident was calling out for the artificial fingernails to be reapplied, and the calling out became a bother to the SRNA. The DON stated DA #45 had stated SRNA #46 had her back to the door and had not seen the DA standing there and had not realized the DA overheard what she said to Resident #63. The DON stated that on 11/09/2023 after the facility's administration was made aware, SRNA #46 was removed from the floor and suspended pending the outcome of the investigation. The Administrator was interviewed on 12/12/2023 at 9:52 AM and stated DA #45 reported the incident between SRNA #46 and Resident #63 the day after the incident occurred, not immediately following the incident. According to the Administrator, DA #45 reported the incident to the Activity Director (AD), and then the AD reported the incident to the Administrator. The Administrator stated SRNA #46 had left shortly after the event with Resident #63 since it was near the end of their shift. The Administrator stated SRNA #46 returned the next day but spent most of the time in the facility, discussing the incident with her and the DON. 4. A review of Resident #48's Admission Record revealed the facility initially admitted the resident on 08/03/2023 and most recently readmitted the resident on 10/11/2023 with diagnoses that included bladder neck obstruction, calculus (stones) in the bladder, and pneumonia. Review of Resident #48's significant change in status MDS, with an ARD of 10/31/2023, revealed Resident #48 had a BIMS score of 0, which indicated the resident had severe cognitive impairment. The MDS did not indicate the resident had behavioral symptoms. Review of Resident #48's care plan revealed a focus statement initiated on 08/04/2023 that indicated the resident had behavioral symptoms that included hitting and refusing care. The care plan indicated the resident preferred a quieter environment. Interventions directed staff to allow for a quiet environment, convey acceptance during periods of inappropriate behavior, and keep the environment as calm as possible. Review of a facility Grievance Form, dated 11/07/2023, revealed the AD had been approached by another employee who reported a conversation they heard between Resident #48 and SRNA #46. The grievance revealed Resident #48 was crying, and SRNA #46 told the resident they had been in the building long enough to know better and added she was not going to put up with the resident's [expletive]. The grievance revealed SRNA #46 was educated and received disciplinary action. Review of the timesheet for SRNA #46 indicated she had completed her shift on 11/08/2023 and returned to work on 11/09/2023. A telephone interview was held with Housekeeping Supervisor (HS) #32 on 12/11/2023 at 9:30 AM. Prior to 12/04/2023, HS #32 had been the Activity Director. HS #32 stated the incident had occurred over a weekend and had been reported to her the next Monday when she had returned to work. She stated that when Housekeeper (HSKP) #56 came to her with the information about the incident, she immediately reported the incident to the Social Services Director (SSD) and the Administrator. HS #32 stated HSKP #56 reported that SRNA #46 told Resident #48 to quit crying and told the resident she was not putting up with their [expletive]. HSKP #56 was interviewed on 12/11/2023 at 9:52 AM. HSKP #56 stated she had overheard the conversation between SRNA #46 and Resident #48 a few days before she reported the incident. HSKP #56 stated she had been cleaning the bathroom that adjoined Resident #48's room, and SRNA #46 did not know she was there. HSKP #56 stated Resident #48 was crying, and SRNA #46 shut the resident's room door to the hall and then yelled at the resident, asking the resident why they were crying and stating, You're a grown [expletive] person, and there is no reason for you to be crying. HSKP #56 stated Resident #48 said something, but she was unable to understand what the resident said. HSKP #56 stated that SRNA #46 replied, I'm getting ready to because I'm not putting up with your [expletive]. HSKP #56 stated she had not confronted the SRNA but went back after the SRNA left and checked on Resident #48, who was fine. HSKP #56 stated that on her next day back at work, she reported the incident to HS #32, who was then the Activity Director. HSKP #56 stated the Administrator spoke with her and told her to immediately call her if something like that happened again and gave HSKP #56 her phone number. HSKP #56 stated she thought SRNA #46 had verbally abused Resident #48. The DON was interviewed on 12/11/2023 at 12:34 PM. The DON stated she considered the grievance related to Resident #48 that occurred on 11/07/2023 to be verbal abuse from the staff member to the resident. The DON stated any time a staff member cursed a resident, it was considered abuse. The Administrator was interviewed on 12/12/2023 at 10:15 AM. The Administrator stated she had spoken to HSKP #56 and HS #32 again and now felt she should have reported the incident between Resident #48 and SRNA #46 to the state as an allegation of abuse. She stated that at the time of the incident, she thought the SRNA was trying to console the resident, and what had been said was taken out of context. She stated the interviews received in the past few days with the staff provided further information and were different than what was initially reported. The Administrator said that disciplinary action was taken against the SRNA at the time of the incident. 5. Review of Resident #63's Admission Record revealed the facility admitted the resident on 06/28/2022 with diagnoses that included unspecified mood (affective) disorder, bipolar disorder, intellectual disabilities, and depression. A review of Resident #34's Admission Record revealed the facility initially admitted the resident on 08/08/2019 and readmitted the resident on 02/03/2020 with diagnoses that included unspecified dementia, major depressive disorder, obsessive-compulsive disorder, and hypertension. A review of Resident #34's Quarterly MDS, with an ARD of 08/28/2023, revealed Resident #34 had a BIMS' score of three (3), which indicated the resident had severe cognitive impairment. The MDS revealed Resident #34 had no behavioral symptoms. Further review of the MDS revealed Resident #34 required the extensive assistance with ambulation and locomotion and used a wheelchair or walker for mobility. A review of Resident #34's care plan revealed a focus statement, with a revision date of 05/10/2022, that indicated the resident had behavioral symptoms that included attempting to clean the floor, rearranging furniture, cleaning and fixing the bed, and refusing assistance. A review of Resident #49's Admission Record revealed the facility admitted the resident on 10/27/2023 with diagnoses that included severe vascular dementia with anxiety. A review of Resident #49's Admission MDS, with an ARD of 11/08/2023, revealed Resident #49 had a BIMS' score of 0, which indicated the resident had severe cognitive impairment. The MDS revealed Resident #49 wandered for four to six days during the assessment period and used a walker for mobility. A review of Resident #49's care plan revealed a focus statement initiated on 10/28/2023 that indicated the resident was at risk of falls due to dementia with poor safety awareness. A review of Resident #63's acute monitoring Progress Notes, dated 11/29/2023 and written by LPN #6, revealed Resident #63 was in their wheelchair in front of the nurses' station and was observed kicking and cursing other residents. The note indicated Resident #63 was redirected to not curse and kick other residents. LPN #6 was interviewed on 12/04/2023 at 11:52 AM. LPN #6 reported she had seen Resident #63 kicking and hitting Resident #34 and Resident #49. LPN #6 stated she tried to explain to Resident #63 that they should not hit other residents, and then Resident #63 reached out and scratched her. LPN #6 stated she had reported her observations to LPN #39 (the unit manager) and the Assistant Director of Nursing (ADON) but was not sure what else had been done about the incident. LPN #6 stated it was considered abuse when one resident hit another, but for Resident #63, it was considered a behavior. LPN #6 added that Resident #6 called other residents' expletives and used obscene hand gestures toward other residents. She stated that after she had observed Resident #63 hitting and kicking the other residents, she returned the resident to their room and told the resident they had to be good. The Administrator was interviewed on 12/06/2023 at 2:07 PM and stated she had not been informed that Resident #63 had hit and kicked other residents. The Administrator stated she expected staff to report any type of abuse immediately. The Administrator stated the state agency would be notified that day (12/06/2023) about Resident #63's abuse toward the other residents. LPN #39 was interviewed on 12/06/2023 at 2:28 PM. LPN #39 read the notes written by LPN #6 and stated LPN #6 had reported to her that Resident #63 had kicked at the other residents but had not made contact. The ADON was interviewed on 12/06/2023 at 2:54 PM. The ADON read the 11/29/2023 note written by LPN #6 and stated she was unaware of the incident between Resident #63 and the other residents. The Director of Nursing (DON) was interviewed on 12/11/2023 at 11:16 AM and stated the initial report to the state agency regarding Resident #63's abuse of Resident #34 and Resident #49 was submitted on 12/06/2023. The DON stated the progress note dated 11/29/2023 at 2:06 PM indicated residents had been kicked by Resident #63. The DON stated that LPN #6 said she may have told LPN #39 or the ADON about the incident, but when the DON interviewed LPN #39 and the ADON, they reported they were not made aware that physical contact had occurred between the residents. The DON stated it was her responsibility to review progress notes, but on that day, she had been absent and stated the responsibility for review of the notes fell on the ADON. The ADON had reported to the DON that she had reviewed the progress notes but had missed LPN #6's documentation about Resident #63's abuse. The Administrator was interviewed on 12/12/2023 at 9:56 AM. The Administrator stated LPN #6 should have called her immediately for direction after witnessing the incident between Resident #63, Resident #34, and Resident #49. The Administrator stated that following the incident, LPN #6 had been trained on immediately reporting allegations of abuse and received disciplinary action. 6. A review of Resident #73's Admission Record revealed the facility admitted the resident on 09/18/2023 with diagnoses that included cerebral infarction (stroke), cognitive-communication deficit, dementia of unspecified severity without behavioral disturbance, and delirium due to a known physiological condition. A review of Resident #73's Admission MDS, with ARD of 09/24/2023, revealed Resident #73 had a BIMS' score of three (3), which indicated the resident had severe cognitive impairment. The MDS revealed the resident had no behavioral symptoms. A review of Resident #73's care plan revealed a focus statement initiated on 09/19/2023 that indicated the resident was at risk for falls and a safety risk due to the resident's dementia with poor safety awareness/insight. Review of the Long Term Care Facility Self-Reported Incident Form Initial Report, dated 10/29/2023, indicated the state survey agency was notified of a resident-to-resident abuse allegation involving Resident #73 and Resident #63 on 10/29/2023 at 10:40 PM. Review of an incident report dated 10/29/2023 at 9:22 PM revealed staff responded to yelling in Resident #73's room. The report revealed upon entering the room, Resident #73 was seen standing over their roommate's bed, hitting their roommate, Resident #63, repeatedly on the face with a book. The report indicated the residents were immediately separated. Further review revealed Resident #73 stated he/she was tired of Resident #63 screaming, and that was why he/she had hit him/her. The report indicated the nurse who responded to the incident explained to Resident #73 that it was not okay to strike another resident and added that after a few moments, Resident #73 was unable to remember what happened. According to the incident report, Resident #73 was moved to another room and placed on 15-minute monitoring/checks. An interview was held with Resident #73 on 12/07/2023 at 8:56 AM. The resident was unable to recall any disturbances with another resident. A telephone interview was held with LPN #20 on 12/07/2023 at 10:35 AM. LPN #20 stated she was working in the hallway when the incident occurred between Resident #73 and Resident #63. LPN #20 stated an SRNA came out of the room with Resident #73 and told LPN #20 she had observed Resident #73 hitting Resident #63 over the head with a book. LPN #20 stated that she assessed both residents and found no injuries. LPN #20 stated she then notified the DON and Administrator, and based on their recommendations, Resident #73 was placed in a private room with monitoring to be conducted every 15 minutes. A telephone interview was held with SRNA #58 on 12/08/2023 at 3:41 PM. SRNA #58 stated she and another SRNA, whose name she could not recall, were rounding and heard screaming. SRNA #58 stated they went to the resident's room and saw Resident #73 hitting Resident #63 on top of the head and on the arms with a book. SRNA #58 stated they removed Resident #73 from the room and reported the issue to the nurse. SRNA #58 stated that after the incident, staff kept the residents separated and increased visual checks on the residents. The DON was interviewed on 12/10/2023 at 10:17 AM. The DON stated she found out about the incident from the ADON, who was on-call at the time of the incident. She stated the residents were [TRUNCATED]

Based on observation, interview, and record review, it was determined the facility failed to post the contact information needed for residents to file concerns with the State Survey Agency (SSA). This deficient practice had the potential to affect eighty-one (81) residents. The findings include: Review of the Resident Council Meeting Minutes covering the timeframe from January 2023 through November 2023 included a list of residents' rights. The resident rights included, The resident has the right to receive information from the agencies acting as client advocates, and be afforded the opportunity to contact these agencies. Observation on 12/09/2023 at 10:08 AM, revealed there was no information on how to contact the SSA to submit grievances was posted in the facility. During an interview on 12/07/2023 at 1:27 PM, Resident #51 stated they had no idea how to contact the SSA to file concerns and had no idea where the number for the SSA was located. During an interview on 12/09/2023 at 10:38 AM, Resident #2 stated they did not know how to contact the SSA and added they had no idea where to find the contact information for the SSA. During an interview on 12/09/2023 at 11:00 AM, Resident #40 stated that when they were admitted , no one had told them how to contact the SSA to file a complaint. The resident stated he/she did not know where to locate the number for the SSA. During an interview with Resident #50 and Resident #15 on 12/09/2023 at 11:18 AM, Resident #50 stated they had no idea how to contact the SSA and Resident #15 stated they were unsure how to contact the SSA and added there was no phone number posted. Family member (FM) #50, FM for Resident #58, was interviewed on 12/09/2023 at 11:35 AM. FM #50 stated she had not been given information on how to contact the SSA to file a complaint and would not know where to find a phone number for the SSA. During an interview on 12/09/2023 at 12:09 PM, the Social Service Director (SSD) stated the SSA number was located in the admission packet and that the number was posted. Observations made with the SSD revealed the number was not posted. The SSD stated she guessed' it was her responsibility to make sure residents and family members knew the SSA telephone number. During an interview on 12/11/2023 at 1:25 PM, the Director of Nursing (DON) stated it was expected that the facility posted the number for the SSA.

Based on observations, interviews, and facility document and policy review, it was determined the facility failed to act promptly on grievances from individual residents and from the Resident Council related to call light response times, receiving scheduled showers, and food concerns involving nine (9) of thirty (30) sampled residents (Residents #2, #13, #14, #35, #42, #50, #51, #54, and #58) with the potential to affect eighty-one (81) residents. The findings include: Review of the facility's policy titled Grievances, dated 11/28/2017, revealed the facility would make prompt efforts to resolve grievances. It further stated the facility wourl ensure all written grievance decisions would include the date the grievance was received, a summary of the resident grievance, the steps taken to investigate, and a summary of the conclusion. 1. During an observation and interview with Resident #2 on 12/09/2023 at 10:38 AM, the resident stated they had activated their call light at 10:30 AM, per the clock in their room, because they required incontinence care. Resident #2 stated most of the time, it usually took staff a long time to answer the call lights. At 11:02 AM, the Regional Nurse Consultant came to the doorway and asked what the resident needed and stated she would find Resident #2's assigned State Registered Nurse Aide (SRNA). At 11:07 AM, three (3) SRNAs came into the resident's room. SRNA #49 stated she was responsible for Resident #2's care and stated she was unsure who was answering the call lights. SRNA #49 stated she was unaware the resident's light had been on for over 35 minutes. Review of the Resident Council Meeting Minutes dated 03/31/2023 revealed the residents stated that SRNAs were not answering call lights. The residents stated if staff responded to a call light, the SRNA stated they would be right back; however, they did not return for more than 45 minutes. In addition, the residents stated SRNAs told them they were unable to help residents when meal trays were on the hall. The minutes revealed the nursing department was responsible for the issue; however, a plan was not completed. Review of the Department Response to Issues revealed staff signed the form on 04/03/2023; however, the nursing department did not respond to the issue and the Administrator had not signed the form. A review of Resident Council Meeting Minutes dated 04/27/2023 revealed a review of last month's issues/resolutions included SRNA response being poor. No resolution from the past month was documented. During the April 2023 meeting, residents stated call lights not being answered continued to be an issue. The minutes revealed the residents felt if something bad was needed they would be in trouble. The minutes revealed the nursing department was responsible for the issue; however, a plan was not completed. A review of the Department Response to Issues dated 04/27/2023 revealed the nursing department did not respond to the issue and the Administrator had not signed the form. A review of a facility Grievance Form for the timeframe from August 2023 through October 2023 revealed that untimely responses to call lights continued to be a concern. Four resident grievances (Resident #184, Resident #16, and two unsampled residents) were filed related to an untimely staff response to call lights. An interview on 12/09/2023 at 11:18 AM with Resident #50 (who had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident's cognition was intact, per a Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/27/2023). An interview on 12/09/2023 at 11:18 AM, with Resident #15 (who had a BIMS score of 15 per a Quarterly MDS with an ARD of 08/16/2023), and an interview on 12/09/2023 at 11:00 AM with Resident #40 (who had a BIMS score of 13 per an Admission MDS with an ARD of 10/26/2023) revealed call light response times continued to be an issue. During an interview with Resident #51 on 12/07/2023 at 1:27 PM (who had a BIMS score of 15 per a Quarterly MDS with an ARD of 09/05/2023), Resident #51 stated during the Resident Council meetings, residents complained about not receiving incontinence care. Resident #51 stated at times, they activated the call light, and it was two to three hours before staff came to assist the resident's roommate. Resident #51 stated that SRNAs also entered resident rooms, turned off the light, and never returned. 2. Review of Resident Council Meeting Minutes, dated 04/27/2023, revealed residents reported they were not receiving enough showers. Continued review of the minutes revealed the nursing department was responsible; however, a plan to address the issue was not completed. A review of the Department Response to Issues revealed the form was signed on 04/27/2023; however, the nursing department did not respond to the issue, and the Administrator had not signed the form. A review of a Department Response to Issues form that referred to a Resident Council meeting conducted on 06/29/2023 revealed residents stated they received a shower every two weeks and wanted at least one shower per week. The department response, dated 07/05/2023, indicated an on the spot in-service would be completed with nurses and SRNAs related to following shower schedules. A review of Resident Council Meeting Minutes dated 08/17/2023, revealed residents reported they continued to not get showers as scheduled. A review of the Department Response to Issues signed on 08/17/2023 revealed the nursing department's response was to have each nurse leader round on their wing and would add to check in with the SRNAs. A review of a facility Grievance Form for the timeframe from June 2023 through November 2023 revealed showers continued to be a concern for residents. Seven residents (Resident #13, #35, #58, #14, #2, and two unsampled residents) had filed grievances related to not receiving showers. An interview with Resident #58 on 12/04/2023 at 9:57 AM (who had a BIMS score of 14, which indicated the resident's cognition was intact, per a Quarterly MDS with an ARD of 09/29/2023) and Resident #2 on 12/04/2023 at 10:34 AM (who had a BIMS score of 15 per a Quarterly MDS with an ARD date of 09/27/2023), revealed showers were still not being provided as scheduled. During an interview on 12/04/2023 at 12:33 PM, Resident #17 (who had a BIMS score of 15 per an Admission MDS with an ARD date of 08/23/2023) stated that on days when a shower was scheduled, they did not even receive a bed bath, which made them feel dirty. 3. A review of Resident Council Meeting Minutes dated 01/26/2023 revealed issues from the previous month's meeting, which included food being served cold and a resident (not named) who did not want pork but was being served pork. The minutes revealed the resident stated the facility continued to serve pork, but not as often. According to the minutes, the residents stated the meat served was hard, and they were unable to cut it. A review of the Department Response to Issues dated 01/27/2023 revealed the facility's response was dietary was marinating meats that tended to be tough, and they were buying different meats that were more tender. There was no documented response for the resident who continued to be served pork. A review of the Department Response to Issues from the 06/29/2023 Resident Council meeting revealed residents were receiving meals late and the food was cold. The dietary department responded on 07/05/2023 and indicated temperatures were taken before food was served and new food service carts were ordered. A review of Resident Council Meeting Minutes, dated 09/12/2023, revealed residents reported current issues, which included food not being hot and not receiving assistance with meal set-up. A review of the Department Response to Issues dated 10/17/2023 indicated the dietary representative had tested several trays, and the food had the correct temperature. The dietary representative indicated that floor staff were leaving the door to the meal cart open, and the food cart was left untouched for 30 minutes or more. The document revealed the staff member had educated staff several times, and concerns were reported to the Director of Nursing (DON). A review of the Department Response to Issues dated 10/17/2023, in response to the Resident Council meeting on 09/26/2023, revealed residents reported they were not receiving condiments, straws, napkins, or utensils on meal trays delivered to the residents' rooms. The dietary department's response revealed an audit had been completed, and the dietary representative had to correct a lot of trays. The document revealed an in-service on tray accuracy would be given. A review of Resident Council Meeting Minutes dated 11/07/2023 revealed there was no resolution to condiments being on meal trays. A review of the Department Response to Issues dated 11/17/2023 in response to a Resident Council meeting on 11/16/2023 revealed residents continued to have concerns that the food was usually cold and voiced concerns that there were no condiments on meal trays. Residents also had concerns that the alternative food menu options had been reduced. Residents stated the food was cold, burnt, or tough. The facility's response revealed that all issues were discussed and would be taken care of to the best of our ability. A review of a facility Grievance Form for the timeframe from September 2023 through November 2023 revealed food concerns continued to be an issue for six residents (Resident #51, #42, #54, #50, and two unsampled residents). According to Resident #50's grievance dated 11/10/2023, the food was horrible, and You are going to have a resident riot. During an interview with Resident #51 on 12/07/2023 at 1:27 PM (who had a BIMS score of 15 per a quarterly MDS with an ARD of 09/05/2023), revealed concerns at the monthly Resident Council meetings included lack of showers, food concerns, and concerns of staff not answering call lights. Resident #51 stated the three concerns were voiced at every Resident Council meeting. Resident #51 stated staff would say the concerns were addressed, but no one had returned to the Resident Council meeting with a plan to address the issues, and there had been no follow-up for the concerns. Resident #51 added that now and then, the DON or the Administrator would attend a Resident Council meeting and would say they would make sure showers were given. Resident #51 stated that as far as the resident knew, there was no plan in place to make sure residents received showers. Resident #51 added that if there was a plan in place, no one made sure the plan was followed. Resident #51 stated no plan to correct the lack of showers/baths had been presented to the Resident Council. Resident #51 stated the food was good that week, but they thought it was because state was at the facility. Resident #51 stated that normally, the food was overcooked, and the meat served was hard. During an interview with the Dietary Manager (DM) on 12/07/2023 at 2:21 PM, the DM stated residents asked to meet with dietary staff about cold food, receiving food they disliked, and tough meats. The DM stated that the residents also wanted more salads on the menu. She stated residents filled the dining room during the meeting (in November 2023), and residents were encouraged to voice their opinions. However, according to the DM, no one had gone back to the Resident Council president to propose how to correct the resident's concerns. During an interview on 12/08/2023 at 8:40 AM, Housekeeping Supervisor (HS) #32, who was the Activities Director until 12/04/2023, revealed grievances communicated during a Resident Council meeting were provided to the appropriate department manager. HS #32 stated the department manager had three to five days to resolve the grievance. HS #32 stated residents were not notified of resolutions until the next monthly Resident Council meeting. HS #32 stated the department managers did not usually attend the meetings nor provide a plan for correcting the grievances. She added that common concerns at meetings included cold food, tough meat, no condiments, small food portions, and not receiving showers. HS #32 stated concerns regarding showers had been given to the DON, who was to check residents' shower days and educate the SRNAs about providing showers. HS #32 stated she was not sure about the DON's follow-up and acknowledged she continued to receive concerns from residents about not receiving showers. HS #32 stated that due to continued complaints, she thought the shower issues had not been resolved. HS #32 stated residents had also voiced concerns that when they turned on their call light for incontinence care, SRNAs would turn the light off and tell the residents they would be back. HS #32 stated residents reported it would take four hours for the SRNA to return, if they returned at all. HS #32 stated this concern was also given to the DON, whose resolution was education for the SRNAs. HS #32 stated Resident #50 had verbalized concern, and the resident was still reporting call lights were not being answered. HS #32 stated that, to the best of her knowledge, no one addressed the issue with Resident #50 individually. HS #32 stated she did not think there was a good grievance process, adding she had seen a lack of resolution on many issues and continued to get complaints over and over. She stated the complaints she received in February 2023 continued through December 2023. HS #32 stated the Social Services Director (SSD) was the grievance official. During an interview on 12/09/2023 at 12:09 PM, the SSD stated concerns related to resident showers had been given to the nursing department. The SSD acknowledged that if a grievance was resolved, the issue should not continue in monthly Resident Council meetings. The SSD stated that if showers were discussed almost monthly in the Resident Council meeting, the issue with showers had not been resolved, and the grievance program was ineffective. The SSD stated food concerns included burned foot, hard toast, cold food, and the general consistency of food. The SSD stated there had been no written plan to correct the food issues, including the time the food carts sat in the halls or the amount of time it took for the SRNAs to pass the trays to residents. During an interview on 12/11/2023 at 1:25 PM, the DON stated she had not attended Resident Council meetings to speak to the residents about showers. The DON stated showers were discussed daily during her rounds of the facility, but there seemed to be a lack of oversight. During an interview on 12/12/2023 at 10:47 AM, the Administrator stated residents' concerns were addressed in a November 2023 Resident Council meeting. The Administrator stated she took full responsibility for not making HS #32 (former Activity Director) report the residents' issues to the team. The Administrator stated a plan and follow-up for the residents' issues had not been presented to the Resident Council. The Administrator stated the dietary department indicated the cold food was due to the SRNAs. 44524

Based on observations, interviews, and facility document and policy review, it was determined the facility failed to label and date food items in the reach-in and walk-in coolers; failed to ensure stored cookware was free of food particles and debris; failed to ensure staff maintained the appropriate parts per million (ppm) of available sanitizer for dishes; and failed to ensure staff utilized proper hand hygiene practices and the appropriate use of gloves to prevent food contamination. This deficient practice had the potential to affect 81 residents. The findings included: 1. Review of the facility's policy titled Food Safety and Sanitation, dated 2019, revealed, All time and temperature control for safety (TCS) foods (including leftovers) should be labeled, covered, and dated when stored. Observation of the kitchen on [DATE] at 8:44 AM, accompanied by the Dietary Manager (DM), revealed the following items were in the kitchen: - A container of leftover ribs in the walk-in cooler with no date or label; - A fruit cup in the reach-in cooler with no date; - 25 cups of dessert in the reach-in cooler with no date or label; and - 12 cups of slaw in the reach-in cooler with no date or label. During an interview on [DATE] at 8:54 AM, Cook #31 stated the slaw and desserts were left over from dinner served on [DATE], and no one had placed dates on the cups. Cook #31 stated the dietary aides who worked the night before should have dated the items before placing them in the cooler. During an interview on [DATE] at 3:20 PM, Dietary Aide (DA) #54 stated she worked on Sunday night ([DATE]). DA #54 acknowledged the desserts and slaw were undated. DA #54 was unaware that items placed in the reach-in cooler had to be dated. During an interview with the DM on [DATE] at 3:18 PM, in the presence of the Regional Dietary Manager (RDM), the DM stated if the foods were not dated or labeled, there was a risk of food being expired and causing bacterial growth. During an interview on [DATE] at 1:20 PM, the Director of Nursing (DON) stated her expectation was for staff to label and date all stored foods in the reach-in and walk-in coolers. 2. Review of the facility's policy titled Cleaning Dishes/Dish Machine, dated 2019, revealed, All flatware, serving dishes, and cookware will be cleaned, rinsed, and sanitized after each use. The policy revealed, Staff will follow these procedures for washing dishes: 10. Inspect for cleanliness and dryness and put dishes away if clean (be sure clean hands or gloves are used). Observation of the kitchen on [DATE] at 8:44 AM, accompanied by the DM, revealed the following dishes were stored ready for use: - Nine (9) of eighteen (18) cups were stored with food particles or a dry white/gray residue; - Five (5) of nine (9) steam table pans were stored with dried food residue; - The shelves on a metal rack where ready-to-use pans were stored had a build-up of a dried white substance; and - Two (2) of five (5) baking pans were stored with visible grease. During an interview on [DATE] at 3:20 PM, DA #54 stated that before items were placed in storage for use, staff should make sure they were clean. She was unsure who had put the pans and other items away with food debris on them. During an interview with the DM on [DATE] at 3:18 PM, in the presence of the RDM, the DM stated she expected staff to ensure all food particles and build-up were removed before the dishes were stored for use. The DM stated if food particles or build-up were present, she expected staff to rewash the dishes. The DM added if food particles were present, there was a risk of bacteria and cross-contamination. During an interview on [DATE] at 1:20 PM, the DON stated dishes ready for use should be clean and free of food debris. 3. Review of the facility's policy titled Cleaning Dishes - Manual Dishwashing dated 2019 revealed, Dishes and cookware will be cleaned and sanitized after each meal. The policy revealed, 5. Check sanitation sink frequently using a test strip to assure the level of sanitizing solution is appropriate. Follow chemical manufacturer's guidelines to prepare sanitizing solution. Further review revealed when sanitizing 2. Test the sanitizing solution in the sink using the manufacturer's suggested test strips to assure appropriate level. Observation of the kitchen on [DATE] at 8:44 AM, accompanied by the DM, revealed two (2) of two (2) sanitizer buckets tested ,d+[DATE] PPM. An observation of a bucket of sanitizing solution on [DATE] at 10:07 AM revealed the solution reached 150 PPM. The DM tested the sanitizer compartment of the sink, and when compared to the controls on the bottle of strips, the solution reached 150 PPM. During an interview with the DM on [DATE] at 3:18 PM, in the presence of the RDM, the DM stated the sanitizing solution should have been 250 PPM. The DM stated she expected the sanitizing solution to be freshly prepared each morning and checked every two hours to make sure the solution was maintained at 250 PPM. She stated if the solution was not maintained at 250 PPM, the solution was not killing germs on the food preparation surfaces as it should. 4. A review of the facility's policy titled Employee Sanitary Practices, dated 2019, revealed All employees will: 2. Wash hands before handling food, using posted hand-washing procedures. The policy also indicated that all employees will 5. Use utensils to handle food, avoiding bare hand contact with food. Disposable gloves are a single use items and should be discarded after each use. Hands must be washed prior to using gloves and after removing gloves. During an observation and interview on [DATE] at 11:20 AM, Cook #31 was observed during the lunch meal preparation picking up a bag of bread stuffing with gloved hands. Cook #31 then took the lid off the food processor with gloved hands and poured the bread stuffing into the food processor to make breadcrumbs. Cook #31 donned an oven mitt over the same gloved hands, placed a pan of spinach into the oven, and then removed the oven mitt. After a few minutes, Cook #31 donned the oven mitt again over the gloved hand, removed the spinach from the oven, and removed the oven mitt. Without changing gloves or washing her hands, Cook #31 removed the top from the food processor and, using the gloved hand, scooped bread crumbs from the food processor and sprinkled the bread crumbs on top of the spinach. Cook #31, then removed the gloves. During an interview at the time of the observation, Cook #31 stated she had used the same gloves to touch the bag of stuffing, touch the food processor, placed her gloved hands into the oven mitts, removed the oven mitts, and used the same gloves to remove breadcrumbs from the food processor and sprinkled the breadcrumbs on top of the baked spinach. Cook #31 stated she should have washed her hands and changed gloves between touching the bag of bread stuffing, placing her hands in the oven mitts, touching the food processor, and before she touched and took the breadcrumbs out of the food processor and sprinkled the crumbs onto the baked spinach. The Dietary Manager was interviewed on [DATE] at 3:18 PM and stated the dietary staff were all learning the glove policy. The DM stated she expected staff to wear gloves when coming into contact with food items, remove the gloves, and wash their hands when going from one task to another to prevent the risk of transferring bacteria from one surface to another. During an interview on [DATE] at 1:20 PM, the DON stated gloves were expected to be changed between dirty and clean tasks.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to report allegations of abuse to the State Survey Agency (SSA) within the mandated timeframes for seven (7) of fifteen (15) residents sampled for allegations of abuse (Residents #184, #79, #5, #63, #48, #34 and #49). The findings include: Review of the facility's policy titled, Resident Protection Plan, dated 09/15/2022, revealed, Any individual observing an incident of abuse or suspecting abuse must immediately report such incident to the Administrator or Director of Nursing Services. Further review of the policy revealed, Should a suspected violation or substantial incident or mistreatment, neglect, injuries of an unknown source, or abuse (including resident to resident abuse) be reported, the facility's Administrator, or his/her designee will promptly notify the following persons or agencies (verbally and written) of such incident: a. The state licensing/certification agency responsible for surveying/licensing the facility. The policy indicated, 3. All alleged violations must be reported immediately, but not later than 2 [two] hours after the allegations is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Administrator of the facility and to the State Survey Agency and Adult Protective Services. 1. Review of Resident #184's Admission Record revealed the facility admitted the resident on 08/03/2023 with diagnoses that included bipolar disorder, depression, and anxiety. Review of an Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/06/2023, revealed Resident #184 had a Brief Interview for Mental Status (BIMS) score of nine (9), which indicated the resident was moderately cognitively impaired. Further review of the MDS revealed the resident had no delirium, psychosis, or behavioral symptoms. Review of Resident #184's Care Plan revealed a focus statement with an initiation date of 08/17/2023 that indicated the resident had behavioral symptoms that included making false accusations toward staff. Prior to 08/17/2023, behavioral symptoms were not addressed in the resident's Care Plan. Review of a facility Grievance Form, dated 08/07/2023, revealed the form was completed by the Social Services Director (SSD) for a complaint made by Resident #184. Resident #184 reported that State Registered Nurse Aide (SRNA) #48 made rude statements. During an interview on 12/07/2023 at 9:47 AM, the Director of Nursing (DON) stated when she walked past SRNA #48 at approximately midnight on 08/03/2023, the SRNA's speech, demeanor, body language, and tone were unprofessional. The DON stated she verbally educated SRNA #48 on professionalism. The DON stated the next day, 08/04/2023, they received an allegation from another resident about SRNA #48 being rude and stating the resident complained too much. The DON stated after receiving the allegation, I said, well I'm not surprised. The DON confirmed that SRNA #48 had been suspended and then terminated from employment on 08/10/2023. During an interview on 12/07/2023 at 3:19 PM, the Administrator stated Resident #184's complaint had to have come from an experience with SRNA #48 that occurred on 08/03/2023 or before, because the SRNA was suspended on 08/04/2023 and did not work after that. During an interview on 12/07/2023 at 4:22 PM, the Social Service Director (SSD) stated she checked on Resident #184 on 08/07/2023, and the resident complained about an SRNA matching SRNA #48's description. The SSD stated the SRNA was later confirmed to be SRNA #48. She stated she informed the DON and the Administrator about the grievance. She stated it was her responsibility to write out the grievance, but the decision to investigate a grievance as an allegation of abuse and report the allegation to the SSA came from the DON and the Administrator. During an interview on 12/12/2023 at 3:29 PM, the Administrator stated the facility should have completed a state report and initiated an abuse investigation for Resident #184's allegation, but they did not. 22445 2. Review of Resident #79's Admission Record revealed the facility admitted the resident on 09/13/2023 with diagnoses that included chronic obstructive pulmonary disease (COPD), dysphagia, diverticulosis of the large intestine, and gastrostomy status. Review of Resident #79's Admission MDS, with an ARD of 09/14/2023, revealed the resident had a BIMS' score of fifteen (15), which indicated the resident was cognitively intact. Further review of the MDS revealed Resident #79 required limited assistance with toilet use and personal hygiene and received nutrition and hydration through a feeding tube. Review of Resident #79's Care Plan revealed a focus statement with an initiation date of 10/19/2023 that indicated the resident had bowel and bladder incontinence. Interventions directed staff to frequently check the resident for incontinence and indicated the resident was to wear briefs or pull-ups (adult underwear for incontinence). Review of the Long Term Care Facility Self-Reported Incident Form Initial Report, dated 10/17/2023, revealed that Family Member (FM) #41 reported to the Administrator and the DON that SRNA #40 had been rough with Resident #79 during incontinence care provided on 10/15/2023. Review of an email from facility staff to the SSA indicated the initial report had been submitted on 10/17/2023 at 5:26 PM, which was not submitted timely. Review of a Grievance Form, dated 10/17/2023, revealed FM #41 reported she had witnessed SRNA #40 being rough with Resident #79 during incontinence care. During an interview with SRNA #34 on 12/07/2023 at 11:11 AM, she stated she had been assigned to provide care for Resident #79 on the day the incident occurred. The SRNA stated the resident's call light was on, she answered the light, and FM #41 told her Resident #79 required incontinence care. FM #41 informed SRNA #34 that the resident said the call light had been on for two (2) hours. The SRNA stated FM #41 told her that she was incompetent because the resident's skin was excoriated and red. SRNA #34 stated when she realized how upset FM #41 was, she had Licensed Practical Nurse (LPN) #22 and SRNA #40 go into the resident's room with her to provide the incontinence care. SRNA #34 stated SRNA #40 was the person who was accused of being too rough with Resident #79 and she agreed that during the incontinence care SRNA #40 had been rough with the resident. SRNA #34 stated Resident #79 was crying and saying, Ouch! Ouch! According to SRNA #34, the resident told SRNA #40 the care was hurting but SRNA #40 did not stop. SRNA #34 did not state why she had not reported the care given by SRNA #40 to administrative staff if she had considered the care to be abusive. During an interview with the DON on 12/11/2023 at 12:48 PM, she stated the incident between Resident #79 and SRNA #40 occurred on 10/15/2023 at 5:00 PM and the facility's administration found out about the incident on 10/17/2023 at 1:00 PM when FM #41 reported the incident to her and the Administrator. The DON stated interviews were conducted with the alleged abuser, the reporter, the nurse on duty, and the SRNA that was in the room with the alleged abuser. The DON stated SRNA #34, who had been in the room, agreed SRNA #40 had been rough with Resident #79 during incontinence care. She stated SRNA #40 denied all allegations and LPN #22 stated she had no concerns with the care given by SRNA #40. The DON stated SRNA #40 had been immediately suspended. The DON stated SRNA #34 was asked why she had not reported the incident if she thought SRNA #40 had been too rough. The DON stated SRNA #34 stated she had not understood the process. During and interview with the Administrator on 12/12/2023 at 10:31 AM, she stated she found out about the incident on 10/17/2023 from FM #41, who reported SRNA #40 had been rough with Resident #79. She stated SRNA #40 was immediately suspended. The Administrator stated SRNA #34's statement indicated she thought SRNA #40 had been rough with Resident #79, and SRNA #34 had not reported the rough incontinence care due to not thinking the rough care was considered abuse. 3. Review of Resident #5's Admission Record revealed the facility admitted the resident on 08/08/2023 with diagnoses that included secondary malignant neoplasm of the large intestine and rectum (colon cancer) with colostomy and adult failure to thrive. Review of Resident #5's Admission MDS, with an ARD of 08/20/2023, revealed the resident had a BIMS' score of fifteen (15), which indicated the resident was cognitively intact. Further review of the MDS revealed Resident #5 required extensive assistance with toilet use and personal hygiene. The MDS indicated Resident #5 was always incontinent of urine, and bowel continence was not rated due to the presence of an ostomy. Review of Resident #5's Care Plan revealed a focus statement with an initiation date of 08/08/2023 that indicated Resident #5 had bladder incontinence. Interventions directed staff to provide incontinence checks every two (2) hours and keep the call light within the resident's reach. Review of the Long Term Care Facility Self-Reported Incident Form Initial Report, dated 10/25/2023, indicated the SSA was notified of an abuse allegation on 10/25/2023 at 9:25 AM, which was not submitted to the SSA timely. Further review of the report revealed that on 10/25/2023 at approximately 7:15 AM, SRNA #34 reported to the DON that Resident #5 stated SRNA #35 yanked Resident #5's brief while checking for incontinence and made the resident feel belittled. Review of a Grievance Form, dated 10/25/2023, indicated Resident #5 told the DON the agency SRNA (SRNA #35) refused to change the resident's brief on 10/22/2023. The grievance form indicated when Resident #5 called and requested that his/her brief be changed, SRNA #35 pulled the bed covers back and told the resident that he/she did not need to be changed due to not being incontinent. The form indicated Kentucky Medication Aide (KMA) #13 overheard the conversation and got another staff member to change Resident #5's brief. During an interview with SRNA #34 on 12/07/2023 at 11:04 AM, she stated Resident #5 reported to her that another SRNA had been rough during care. The SRNA stated Resident #5 was cognitively intact and described the following incident. Resident #5 stated when he/she called for help, SRNA #35 answered the call light, and Resident #5 told the SRNA he/she needed incontinence care. SRNA #35 pulled the bed covers back, shook the resident's brief, and told the resident they had not been incontinent. SRNA #34 stated she told the DON about the incident Resident #5 reported. She stated she waited to tell the DON because she did not know the DON's or Administrator's telephone number. She stated the DON and the Administrator told her she had not reported the incident involving Resident #5 timely. During an interview with KMA #13 on 12/07/2023 at 12:01 PM, she recalled that on the day of the event Resident #5 used his/her call light to request assistance a few times. She stated SRNA #35 went into the resident's room and told Resident #5 they did not require incontinence care because the lines (indicators) on the brief had not changed colors; therefore, the resident had not been incontinent, and she was not changing the resident's brief. The KMA stated she had reported the incident to LPN #37, who was the nurse that day. The KMA stated LPN #37 went into Resident #5's room and told the resident if he/she required changing the SRNA needed to change him/her regardless of whether the lines on the brief had changed colors. KMA #13 stated she had reported the incident to LPN #37 and had not thought she needed to report the incident to anyone else. During an interview with LPN #37 on 12/08/2023 at 1:54 PM, she stated she had been working when the incident with Resident #5 occurred. The LPN stated Resident #5 called her into his/her room and wanted to know about the lines on the adult briefs. LPN #37 stated she told the resident that when the lines on the briefs changed colors that meant there had been incontinence. LPN #37 stated she also told Resident #5 that because he/she was cognitively intact, staff should change their briefs when requested. At that time, Resident #5 told her that SRNA #35 said the lines on the resident's brief had not changed color and did not warrant the resident being changed. LPN #37 stated Resident #5 had not communicated any rough treatment or pulling of the brief during care. LPN #37 stated after the conversation with the resident, she explained to SRNA #35 it was the expectation that she change a resident's brief as requested regardless of the color of the indicator lines on the brief. During and interview with the DON on 12/11/2023 at 11:16 AM, she stated on 10/25/2023, SRNA #34 walked into her office and told her she had something important to tell her. SRNA #34 reported that on 10/22/2023 Resident #5 stated around 5:00 PM, SRNA #35 yanked Resident #5's brief and made the resident feel belittled while checking to see if the resident had been incontinent. The DON stated when she asked SRNA #34 why she had waited so long to report the incident, the SRNA was unable to give a reason for the length of time and apologized for the delay. The DON stated after this incident, staff education that included prompt reporting of allegations of abuse was initiated on 10/25/2023 at 2:00 PM. During an interview with the Administrator on 12/12/2023 at 9:40 AM, she stated she expected all allegations of abuse to be reported immediately. The Administrator stated she found out about the incident on 10/25/2023 when an employee reported to the DON that an agency employee had yanked Resident #5's brief on 10/22/2023. She stated the three-day lapse in reporting put all residents at risk. She stated SRNA #34 received disciplinary action due to the late reporting of the incident. The Administrator stated the delay in the SRNA reporting made the facility late in reporting to the SSA. 4. Review of Resident #63's Admission Record revealed the facility admitted the resident on 06/28/2022 with diagnoses that included unspecified mood (affective) disorder, bipolar disorder, intellectual disabilities, and depression. Review of a Quarterly MDS, with an ARD of 08/16/2023, revealed Resident #63 had a BIMS' score of eleven (11), which indicated the resident was moderately cognitively impaired. The MDS indicated Resident #63 had physical behavioral symptoms directed toward others and rejected care one (1) to three (3) days during the review period. The MDS indicated Resident #63 required extensive assistance with bed mobility, locomotion, and dressing and was totally dependent on staff for transfers, toilet use, and personal hygiene. Review of Resident #63's Care Plan revealed a focus statement with a revision date of 08/08/2022 that indicated Resident #63 displayed behavioral symptoms that included biting, hitting, screaming, shouting, yelling, refusing medications, being disruptive and lashing out during physician's visits, using foul language and racial expletives, and throwing objects from their bedside table. Interventions directed staff to attempt interventions before behavioral symptoms began, not seat Resident #63 around others who would disturb him/her, help the resident avoid people or situations that would disturb them, offer the resident diversions they enjoyed, refer the resident to a psychologist/psychiatrist as needed, give medications as ordered, and remove the resident from an activity when negative behaviors began, returning/resuming the activity when the behavior subsided. Review of an Incident Report dated 11/09/2023 revealed that Resident #63 reported that SRNA #46 cussed at me. Review of the Long Term Care Facility Self-Reported Incident Form Initial Report, dated 11/09/2023, revealed Dietary Aide (DA) #45 overheard SRNA #46 being verbally abusive to Resident #63. DA #45 reported on 11/08/2023 at approximately 6:30 PM, that SRNA #46 was heard saying to Resident #63, I don't know who is stupid enough to buy these nails [artificial fingernails]. If you don't hold the [expletive] still, then I'm not going to put it back on you. The report indicated the SSA was notified of the abuse allegation on 11/09/2023 at 10:45 PM, which was not submitted to the SSA timely. During an interview with DA #45 on 12/07/2023 at 2:11 PM, she stated on the day of the incident, Resident #63 was wearing artificial fingernails that kept falling off, which made the resident upset. DA #45 stated she overheard SRNA #46 tell Resident #63 that if the resident did not [expletive] quit she was not going to put the fingernails back on. The DA stated she left Resident #63's room and went back to the kitchen and then notified the Administrator and DON within five (5) minutes of the event. The DA stated there had been no physical abuse observed and she had left the room because she had not liked how SRNA #46 had spoken to the resident. She stated that at the time of the incident Resident #63 was upset and she knew that because when the resident got upset the resident's voice got louder, and at that time the resident's voice got louder. During and interview with the DON on 12/11/2023 at 11:16 AM, she stated the incident between Resident #63 and SRNA #46 occurred on 11/08/2023 at 6:30 PM and she became aware of the incident on 11/09/2023 at 8:45 AM. The DON stated her understanding of what happened was that SRNA #46 cursed at Resident #63 because the resident was calling out for the artificial fingernails to be re-applied and the calling out became a bother to the SRNA. The DON stated DA #45 had stated SRNA #46 had her back to the door and had not seen the DA standing there and had not realized the DA overheard what the SRNA said to Resident #63. The DON stated DA #45 should have immediately reported the incident. She stated DA #45 had not felt comfortable addressing the issue directly with SRNA #46 because the SRNA had intimidated the DA previously during smoke breaks. The DON stated prior to the incident, administration had no knowledge that SRNA #46 intimidated other employees. The DON stated that on 11/09/2023, after the facility's administration was made aware, SRNA #46 was removed from the floor and suspended pending the outcome of the investigation. During an interview with the Administrator on 12/12/2023 at 9:52 AM, she stated DA #45 reported the incident between SRNA #46 and Resident #63 the day after the incident occurred, not immediately following the incident. According to the Administrator, DA #45 reported the incident to the Activity Director (AD) and then the AD reported the incident to the Administrator. The Administrator stated DA #45 stated the reason she had not immediately reported the incident was the event had triggered bad memories for her and she started crying. The Administrator stated that even at the time of the incident the DA had been given her number, knew she was the abuse coordinator, and knew she was supposed to call immediately. The Administrator stated that with the dietary aide not reporting timely, it made the report to the state late. 5. Review of Resident #48's Admission Record revealed the facility initially admitted the resident on 08/03/2023 and most recently readmitted the resident on 10/11/2023 with diagnoses that included bladder neck obstruction, calculus (stones) in the bladder, and pneumonia. Review of Resident #48's significant change in status MDS, with an ARD of 10/31/2023, indicated Resident #48 had a BIMS' score of zero (0), which indicated the resident was severely cognitively impaired. The MDS did not indicate the resident had behavioral symptoms. Review of Resident #48's Care Plan revealed a focus statement with an initiation date of 08/04/2023 that indicated the resident had behavioral symptoms that included hitting and refusing care. The care plan indicated the resident preferred a quieter environment. Interventions directed staff to allow for a quiet environment, convey acceptance during periods of inappropriate behavior, and keep the environment as calm as possible. Review of a facility Grievance Form, dated 11/07/2023, indicated the AD had been approached by another employee who reported a conversation they heard between Resident #48 and SRNA #46. The grievance indicated Resident #48 was crying and SRNA #46 told the resident they had been in the building long enough to know better and added she was not going to put up with the resident's [expletive]. The grievance indicated SRNA #46 was educated and received disciplinary action. Review of the timesheet for SRNA #46 indicated she had completed her shift on 11/08/2023 and returned to work on 11/09/2023. During an interview with the Administrator on 12/06/2023 at 2:18 PM, she stated she had heard about the incident between Resident #48 and SRNA #46 but was unaware the grievance form indicated the SRNA had cursed at the resident. The Administrator stated she had not reported the incident because her understanding was that the resident was upset and the SRNA had tried to calm the resident. She stated SRNA #46 had denied speaking rudely to Resident #48. The Administrator stated in retrospect she should have reported the grievance as an allegation of abuse and added the allegation would be reported that day (12/06/2023) and an investigation would be initiated. During an interview with Housekeeping Supervisor (HS) #32 on 12/11/2023 at 9:30 AM, she stated that prior to 12/04/2023 she had been the AD. She stated the incident had occurred over a weekend and had been reported to her the next Monday when she had returned to work. She stated that when Housekeeper (HSKP) #56 had come to her with the information about the incident she immediately reported the incident to the Social Services Director (SSD) and the Administrator. HS #32 stated HSKP #56 reported that SRNA #46 told Resident #48 to quit crying and told the resident she was not putting up with their [expletive]. During an interview with HSKP #56 on 12/11/2023 at 9:52 AM, she stated she had overheard the conversation between SRNA #46 and Resident #48 a few days before she reported the incident. HSKP #56 stated she had been cleaning the bathroom that adjoined Resident #48's room and SRNA #46 had not known she was there. The HSKP stated Resident #48 was crying and SRNA #46 shut the resident's room door to the hall and then yelled at the resident, asking the resident why he/she was crying and stating, You're a grown [expletive] person and there is no reason for you to be crying. HSKP #56 stated Resident #48 said something, but she was unable to understand what the resident said. SRNA #46 replied, I'm getting ready to because I'm not putting up with your [expletive]. HSKP #56 stated she had not confronted the SRNA but went back after the SRNA left and checked on Resident #48, who was fine. HSKP #56 stated that on her next day back at work she reported the incident to HS #32, who was then the AD. HSKP #56 stated the Administrator spoke with her and told her if something like that happened again to immediately call her and gave HSKP #56 her phone number. HSKP #56 stated she thought SRNA #46 had verbally abused Resident #48. HSKP #56 stated that even after reporting the incident, SRNA #46 returned to work and bragged she was a bully but still had her job. During further interview with the DON on 12/11/2023 at 12:34 PM, she stated she considered the grievance related to Resident #48 that occurred on 11/07/2023 to be verbal abuse from the staff member to the resident. The DON stated any time a staff member cursed a resident it was considered abuse. During further interview with the Administrator on 12/12/2023 at 10:15 AM, she stated she had spoken to HSKP #56 and HS #32 again and now felt she should have reported the incident between Resident #48 and SRNA #46 to the state as an allegation of abuse. She stated that at the time of the incident she thought the SRNA was trying to console the resident and what had been said was taken out of context. She stated the interviews received in the past few days with the staff had provided further information and were different than what was initially reported. The Administrator said that at the time of the incident, disciplinary action was taken against the SRNA. 6. Review of Resident #63's Admission Record revealed the facility admitted the resident on 06/28/2022 with diagnoses that included unspecified mood (affective) disorder, bipolar disorder, intellectual disabilities, and depression. Review of a Quarterly MDS, with an ARD of 08/16/2023, revealed Resident #63 had a BIMS' score of eleven (11), which indicated the resident was moderately cognitively impaired. The MDS indicated Resident #63 had physical behavioral symptoms directed toward others and rejected care one (1) to three (3) days during the review period. The MDS indicated Resident #63 required extensive assistance with bed mobility, locomotion, and dressing, and was totally dependent on staff for transfers, toilet use, and personal hygiene. Review of Resident #63's Care Plan revealed a focus statement with a revision date of 08/08/2022 that indicated Resident #63 displayed behaviors that included biting, hitting, screaming, shouting, yelling, refusing medications, being disruptive and lashing out during physician's visits, using foul language and racial expletives, and throwing objects from their bedside table. Interventions directed staff to attempt interventions before behavioral symptoms begin, not seat Resident #63 around others who would disturb them, help the resident avoid people or situations that would disturb them, offer the resident diversions they enjoy, refer the resident to a psychologist/psychiatrist as needed, give medications as ordered, and remove the resident from an activity when negative behaviors begin, returning/resuming the activity when the behavior subsides. Review of Resident #34's Admission Record revealed the facility initially admitted the resident on 08/08/2019 and readmitted the resident on 02/03/2020 with diagnoses that included unspecified dementia, major depressive disorder, obsessive-compulsive disorder, and hypertension. Review of a Quarterly MDS, with an ARD of 08/28/2023, revealed Resident #34 had a BIMS score of three (3), which indicated the resident was severely cognitively impaired. The MDS indicated Resident #34 had no behavioral symptoms. Further review of the MDS indicated Resident #34 required extensive assistance with ambulation and locomotion and used a wheelchair or walker for mobility. Review of Resident #34's Care Plan revealed a focus statement, with a revision date of 05/10/2022, that indicated the resident had behavioral symptoms which included attempting to clean the floor, rearranging furniture, cleaning and fixing the bed, and refusing assistance. Review of Resident #49's Admission Record revealed the facility admitted the resident on 10/27/2023 with diagnoses that included severe vascular dementia with anxiety. Review of the Admission MDS, with an ARD of 11/08/2023, revealed Resident #49 had a BIMS score of zero (0), which indicated the resident was severely cognitively impaired. The MDS indicated Resident #49 wandered four (4) to six (6) days during the assessment period and used a walker for mobility. Review of Resident #49's Care Plan revealed a focus statement, with an initiation date of 10/28/2023, that indicated the resident was at a risk of falls due to dementia with poor safety awareness. Review of Resident #63's acute monitoring Progress Notes, dated 11/29/2023 and written by LPN #6, indicated Resident #63 was in their wheelchair in front of the nurses' station and was observed kicking and cursing other residents. The note indicated Resident #63 was redirected to not curse and kick other residents. During an interview with LPN #6 on 12/04/2023 at 11:52 AM, she stated she had seen Resident #63 kicking and hitting Resident #34 and Resident #49. LPN #6 stated she tried to explain to Resident #63 that they should not hit other residents and then Resident #63 reached out and scratched her. The LPN stated she had reported her observations to LPN #39 (the unit manager) and the Assistant Director of Nursing (ADON), but was not sure what else had been done about the incident. LPN #6 stated it was considered abuse when one resident hit another but for Resident #63 it was considered a behavior. During an interview with the Administrator on 12/06/2023 at 2:07 PM, she stated she had spoken to the nurse who documented Resident #63 had kicked and hit other residents. The Administrator stated she expected staff to report any type of abuse immediately. The Administrator stated she was unaware the resident had hit and kicked other residents. She said her expectation was that the ADON and LPN #39 would have reported the incident to her. The Administrator stated the SSA would be notified that day (12/06/2023) about Resident #63's abuse toward the other residents. During an interview with the DON on 12/11/2023 at 11:16 AM, she stated the initial report to the SSA regarding Resident #63's abuse of Resident #34 and Resident #49 was submitted on 12/06/2023. The DON stated the progress note dated 11/29/2023 at 2:06 PM indicated residents had been kicked by Resident #63. The DON stated LPN #6 said she may have told LPN #39 or the ADON about the incident but when the DON interviewed LPN #39 and the ADON, they reported they were not made aware that physical contact had occurred between the residents. The DON stated LPN #6 had not reported Resident #63's abuse toward other residents timely. During further interview with the Administrator on 12/12/2023 at 9:56 AM, she stated LPN #6 should have called her immediately for direction after witnessing the incident between Resident #63, Resident #34, and Resident #49. The Administrator stated following the incident, LPN #6 had been trained on immediately reporting allegations of abuse and received disciplinary action.

Based on observations, record reviews, interviews, review of facility policies, and review of the Centers for Disease Control and Prevention (CDC) article titled Injection Safety, Infection Prevention during Blood Glucose Monitoring and Insulin Administration, the facility failed to ensure staff performed proper hand hygiene practices and disinfected contaminated scissors during wound care for one (1) of four (4) sampled residents reviewed for pressure ulcers (Resident #21). In addition, the facility failed to ensure staff donned appropriate personal protective equipment (PPE) when interacting with one (1) of four (4) sampled residents reviewed for transmission-based precautions (Resident #76). The facility failed to ensure nursing staff wore gloves while conducting a finger stick blood glucose test and while administering an insulin injection to one (1) (Resident #51) of two (2) residents observed for finger stick blood glucose testing and insulin injections. The findings included: 1. A review of Resident #21's Admission Record revealed the facility admitted the resident on 02/25/2022. According to the Admission Record, the resident had a medical history that included diagnoses of hemiplegia and hemiparesis following cerebral infarction (stroke) affecting left non-dominant side, contracture of muscle (multiple sites), pressure-induced deep tissue damage of other site, and osteoporosis. A review of Resident #21's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/29/2023, revealed Resident #21 had a Brief Interview for Mental Status (BIMS) score of 0, which indicated the resident had severe cognitive impairment. According to the MDS, the resident had two (2) stage four (4) pressure ulcers and received ulcer care, along with the application of nonsurgical dressings. A review of Resident #21's comprehensive care plan revealed a Focus area initiated on 04/18/2022, that indicated the resident had a stage four (4) pressure ulcer to their left great toe. An intervention dated 06/26/2023 directed staff to provide treatments as ordered. A review of Resident #21's Order Summary Report revealed an active order started on 11/28/2023 to clean the resident's left great toe with normal saline, apply calcium alginate, and cover with rolled gauze. During a concurrent observation and interview on 12/09/2023 at 11:32 AM, Licensed Practical Nurse (LPN) #29 prepared supplies to complete Resident #21's wound care treatment to the resident's left great toe. Before entering the resident's room, LPN #29 dropped the scissors on the floor and then picked them up. LPN #29 did not disinfect the scissors. LPN #29 placed the treatment supplies, including the scissors, on the resident's overbed table then put on gloves. LPN #29 then cleansed the wound with normal saline-soaked gauze. After cleaning the wound, LPN #29 applied the calcium alginate to the wound bed and wrapped the resident's foot in rolled gauze, without performing hand hygiene or changing gloves. Then, without disinfecting the scissors she previously dropped on the floor, she used the scissors to cut the rolled gauze used to wrap the resident's foot. After the treatment was completed, LPN #29 stated she should have changed her gloves after cleaning the wound and acknowledged that she did not. She also stated she should have sanitized the scissors before using them during the treatment. During an interview on 12/11/2023 at 9:01 AM, the Director of Nursing (DON) stated that during pressure ulcer care, staff should perform hand hygiene and apply new gloves after their gloves become dirty, before touching anything else. The DON stated that if staff was to drop scissors, they should disinfect them prior to use. During an interview on 12/11/2023 at 1:37 PM, the Administrator stated that during pressure ulcer care, staff should change their gloves after cleansing the wound and before doing another task. The Administrator stated that if staff was to drop scissors, they should sanitize them prior to use. A review of the facility policy titled Infection Prevention Manual for Long Term Care, revised on 09/27/2022, revealed section X. Managing Residents with Suspected/Confirmed COVID-19 [Coronavirus Disease 2019) Infection/Outbreak Status, Resident Monitoring and Placement specified, B. Implement droplet precautions and 10. All employees caring for residents with suspected or confirmed COVID-19 should use full PPE (gowns, gloves, eye protection, and a NIOSH [National Institute for Occupational Safety and Health]-approved N95). 2. A review of Resident #76's Admission Record revealed the facility admitted the resident on 10/19/2023 with diagnoses that included chronic obstructive pulmonary disease, tobacco use, and acute kidney failure. A review of Resident #76's Admission MDS, with an ARD of 10/26/2023, revealed Resident #76 had a BIMS score of 13, which indicated the resident was cognitively intact. A review of a COVID-19 testing log revealed Resident #76 tested positive for COVID-19 on 12/04/2023, after the facility was informed their roommate tested positive at the hospital. A review of Resident #76's Order Summary Report, listing active orders as of 12/08/2023, revealed the resident had orders dated 12/04/2023 for COVID precautions related to testing positive for COVID-19 and isolation precautions. A review of Resident #76's comprehensive care plan revealed a Focus area, initiated on 12/04/2023, that indicated the resident tested positive for COVID-19. An intervention dated 12/04/2023 indicated Isolation/ Droplet precautions were initiated. During an interview on 12/04/2023 at 4:26 PM, the DON stated she was notified Resident #76 was positive for COVID-19 around 2:30 PM on 12/04/2023. The DON stated Resident #76 should be on transmission-based precautions. During a concurrent observation and interview on 12/04/2023 at 4:57 PM, Resident #76 was being wheeled down the hall by the Assistant Director of Nursing (ADON). The resident was wearing a mask, but the ADON was not wearing any PPE. The ADON wheeled the resident into the resident's room and then exited the room. At 4:58 PM, the ADON stated the resident was on isolation for COVID-19. The ADON stated she was notified around 2:00 PM to 3:00 PM on 12/04/2023 that Resident #76 was positive for COVID-19. The ADON stated staff must wear a face shield or goggles, an N95 mask, a gown, and gloves when interacting with Resident #76. The ADON stated she did not wear any PPE when she was wheeling the resident down the hall or when she went into the resident's room. The ADON said since the resident had a mask on, she did not think about donning the required PPE. During an interview on 12/05/2023 at 9:32 AM, the Administrator and DON stated if a resident had signs and symptoms of COVID-19 or tested positive for COVID-19, they initiated transmission-based precautions. They stated when interacting with residents on transmission-based precautions for COVID-19, staff should wear a face shield or goggles, a gown, an N95 mask, and gloves. 22445 A review of a CDC article titled Infection Prevention during Blood Glucose Monitoring and Insulin Administration, last reviewed on 03/02/2011, revealed the section titled Hand Hygiene specified staff should Wear gloves during blood glucose monitoring and during any other procedure that involves potential exposure to blood or body fluids. 3. A review of Resident #51's Admission Record revealed the facility admitted the resident on 03/26/2020 with a diagnosis of type two diabetes mellitus. A review of Resident #51's Quarterly MDS, dated [DATE], revealed Resident #51 had a BIMS score of 15, which indicated the resident was cognitively intact. During an observation on 12/07/2023 at 1:39 PM, LPN #6 performed a finger stick blood glucose test on Resident #51 without wearing gloves. LPN #6 then returned to the medication cart to prepare the resident's insulin, and at 1:43 PM, LPN #6 administered an insulin injection into Resident #51's left lower abdomen without wearing gloves. During an interview on 12/08/2023 at 10:40 AM, the Regional Director of Operations (RDO) stated a nurse was expected to wear gloves while completing a fingerstick blood glucose test to prevent possible contamination from blood. During a telephone interview on 12/08/2023 at 11:46 AM, LPN #6 stated the policy was to wear gloves when conducting a fingerstick blood glucose test on a resident. LPN #6 stated she did not wear gloves when she checked Resident #51's blood glucose or when she administered the resident's insulin. LPN #6 stated she sometimes forgot to wear gloves. During an interview on 12/11/2023 at 1:15 PM, the DON stated that staff should wear gloves when testing a resident's blood glucose to prevent staff from potentially transferring bloodborne pathogens. During an interview on 12/12/2023 at 10:39 AM, the Administrator stated that nurses should wear gloves when conducting a finger stick blood glucose test to protect against blood being transferred.

Based on observations, interviews, record review, and facility document and policy review, the facility failed to promote the dignity for two (2) of thirty (30) sampled residents (Resident #2 and Resident #48). The findings include: Review of the facility's policy titled, Dignity H5MAPL1201, dated 08/01/2013, revealed, each resident would be cared for in a manner that promoted and enhanced quality of life, dignity, respect and individuality. Further review revealed, demeaning practices and standards of care that compromise dignity were prohibited. The policy stated staff would promote dignity and assist residents as needed by, b). Promptly responding to the resident's request for toileting assistance. The Administrator reported on 12/10/2023 at 12:02 PM that the facility had no policy specifically related to call lights or answering call lights. 1. A review of Resident #48's Admission Record revealed the facility admitted the resident on 08/03/2023. According to the Admission Record, the resident had a medical history that included diagnoses of conversion disorder with seizures or convulsions, mild dementia with anxiety, and senile degeneration of the brain. A review of Resident #48's significant change in status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/31/2023, revealed Resident #48 had a Brief Interview for Mental Status (BIMS) score of 0, which indicated the resident was severely cognitively impaired. The MDS revealed Resident #48 required substantial/maximum assistance from staff with eating, oral hygiene, toileting hygiene, showering/bathing, and upper body dressing and was dependent on staff for lower body dressing, putting on and taking off footwear, and personal hygiene. The MDS revealed Resident #48 was always incontinent of bowel and bladder. A review of Resident #48's care plan revealed a focus area, initiated on 08/04/2023, which indicated the resident had a potential for skin integrity issues. Interventions directed staff to follow the facility skin care protocol, use pressure management devices and a pressure relief/reduction mattress, and turn and position the resident every two hours and as needed. On 12/04/2023, Resident #48's care plan was revised to include a focus area addressing the resident's bowel and bladder incontinence. Interventions directed staff to check the resident every two (2) hours and as required for incontinence. The care plan also indicated staff should wash, rinse, and dry the resident's perineum and change clothing as needed after incontinence episodes. During an interview on 12/06/2023 at 10:43 AM, State Registered Nursing Aide (SRNA) #47 stated he had last checked on Resident #48 around 8:00 AM before breakfast and had found the resident soiled. He stated someone had placed an oversized brief on Resident #48. SRNA #47 stated he did not provide incontinence care at that time because other residents required assistance and the breakfast trays were on the hall. SRNA #47 stated Resident #48 had eaten breakfast in a soiled brief. SRNA #47 stated he knew that sitting in wet/soiled briefs could cause blisters or bedsores and considered eating while sitting in a soiled/wet brief a dignity issue. SRNA #47 stated he could not find assistance and had to pass most of the breakfast trays by himself. SRNA #47 stated he had not told the Director of Nursing (DON) or the Administrator that he needed help because they were busy with their own stuff, and he had not told the nurse on the hall he needed assistance. An observation was made on 12/06/2023 at 11:00 AM of Resident #48, accompanied by SRNA #47. SRNA #47 removed Resident #48's brief, and a large amount of BM was observed on the resident's buttocks and perineum. During an interview on 12/06/2023 at 11:35 AM, SRNA #9 stated staff had been told they were not allowed to change residents when meal trays were on the hall because it was an infection control issue. SRNA #9 was unable to identify who had instructed staff not to change soiled residents but added it was the people she worked with. SRNA #9 stated she had not been told it was a dignity issue for residents to eat while sitting in wet or soiled briefs. During an interview on 12/06/2023 at 11:55 AM, Licensed Practical Nurse (LPN) #7 stated she was unsure if residents' soiled briefs could be changed when the meal trays were on the hall and would have to check the policy. LPN #7 stated she expected residents to be changed and clean before eating. LPN #7 stated she had not received any reports that Resident #48 was soiled, and staff were unable to change the resident. Registered Nurse (RN) #19, the hospice nurse assigned to Resident #48, was interviewed on 12/07/2023 at 11:33 AM. RN #19 stated she expected Resident #48 to be checked for incontinence and changed every two (2) hours and as needed. RN #19 stated she would have expected SRNA #47 to change Resident #48 when he realized the resident was soiled. During an interview on 12/08/2023 at 2:18 PM, LPN #37 stated she expected an SRNA to provide care when a resident had a BM. LPN #37 stated that knowing a resident was soiled and not changing the resident for three (3) hours was a dignity issue. LPN #37 stated it was the staff's job to keep residents clean to avoid skin breakdown. During an interview on 12/11/2023 at 1:05 PM, the Director of Nursing (DON) stated she expected the SRNAs to make rounds a minimum of every two (2) hours or as needed. The DON stated she expected immediate care to be provided if it was noted a resident was soiled or wet. The DON stated she was disappointed that SRNA #47 had left Resident #48 soiled for three hours and had the resident eat while soiled. During an interview on 12/12/2023 at 10:19 AM, the Administrator stated she expected incontinence care to be provided every two hours and as needed and added it was not acceptable for a staff member to see a resident was soiled, allow the resident to eat while soiled, and not change the resident for three hours. The Administrator stated there was no facility policy that indicated a resident could not be changed during meals. The Administrator stated it was a dignity issue for a resident to eat meals while soiled. A review of Resident Council minutes for the timeframe from 06/01/2023 through 11/30/2023 revealed concerns related to call bell response times addressed on 03/31/2023, 04/03/2023, 04/27/2023, 09/26/2023, and 10/10/2023. 2. An interview with Resident #2 was held on 12/09/2023 at 10:38 PM. The resident's call light was on when the surveyor entered the resident's room. Resident #2 stated he/she had activated the call light at 10:30 AM because he/she needed incontinence care. Resident #2 stated the last time he/she had received incontinence care was before the night shift left at 7:00 AM. Observation, on 12/09/2023 at 10:39 PM, revealed the surveyor was positioned behind the resident's door unable to be seen by staff in the hall. While sitting in Resident #2's room, which was adjacent to the door leading outside to the smoking area, the door opened and closed more than twelve (12) times. At 10:47 AM, staff were heard in the hall outside the resident's room congratulating a staff member. Staff did not enter the resident's room to see what the resident needed. At 11:02 AM, the Regional Nurse Consultant (RNC) came to the resident's door and asked what was needed. The RNC stated she would find someone to help the resident. At 11:07 AM, three State Registered Nursing Assistants (SRNAs) came into the room. SRNA #49 stated all three of the SRNAs were making rounds together on the unit. Further, the SRNA stated she was responsible for the care of Resident #2 and was unaware the resident's call light had been on for so long. In an interview, SRNA #49 stated she was responsible for the resident and added she was unsure who was answering the lights while the three SRNAs worked together. At this time one SRNA left the room and SRNA #53 stayed to assist SRNA #49 in providing care for Resident #2. Resident #51, who was the Resident Council President, was interviewed on 12/07/2023 at 1:27 PM and stated one of the issues discussed in Resident Council on a monthly basis was related to SRNAs not answering call lights. Resident #51 stated the SRNAs came into residents' rooms, turned the call light off, said they would be right back, and never returned. Resident #51 stated the facility had enough people to work and there was enough time but the SRNAs just sat at the nurse's station doing nothing. Resident #51 stated they were mostly independent with activities of daily living but stated another resident in Resident Council had concerns about being left for hours without care. Resident #51 stated they were able to smell when their roommate was incontinent and would activate the call bell for help for the roommate. Staff would come in and tell the roommate they would receive care, but then it would be two to three hours before any staff returned. The resident stated they were able to time how long staff took to respond by how many 30-minute television shows had passed. The Housekeeping Supervisor (HS) was interviewed on 12/08/2023 at 8:40 AM. The HS was the Activity Director until Monday, 12/04/2023. The HS stated common concerns discussed at Resident Council meetings included that when residents activated their call lights for incontinence care, the SRNA went into the resident's room and turned the call light off and told the resident they would return. The HS stated she had given the Director of Nursing (DON) the concern about call light response time, but the DON had not addressed the residents with a solution. Resident #50 was interviewed on 12/09/2023 at 11:18 AM. Resident #50 stated that when he/she activated the call light it may take from fifteen (15) minutes to three hours for the call light to be answered. Resident #50 stated he/she had reported the call light concern to the Social Services Director (SSD). The DON was interviewed on 12/11/2023 at 1:25 PM and stated she expected call lights to be answered within eight to ten minutes, and the time it had taken to answer Resident #2's call light, the number of staff that passed the door without answering the resident's call light, and the staff talking in the hall without answering the resident's call light, were unacceptable.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure one (1) of six (6) residents, observed during medication administration, was prohibited from maintaining their albuterol sulfate inhaler in their possession for self-administration, despite a physician's order indicating the resident was not capable of medication self-administration and without evidence of an assessment to determine if the resident was clinically appropriate for medication self-administration (Resident #23). The findings include: Review of the facility's policy titled, Medication/Self-Administration, undated, revealed, 1. An evaluation should be completed annually or with a change in the resident's condition. 2. The evaluation should be reviewed quarterly with a progress note indicating said review. Attached to the policy was a blank Evaluation of Resident's Ability to Safely Self-Administer Medication, which was a check-off list for the resident to demonstrate knowledge and ability related to self-administration of a medication, along with a section for a nurse to document the rationale regarding why a resident was not capable of self-administration. Also attached to the policy was a blank BHP Medication Self-Administration Assessment, which was an assessment available within the facility's electronic health system that captured the same information as the Evaluation of Resident's Ability to Safely Self-Administer Medication. Review of Resident #23's Admission Record revealed the facility admitted the resident on 08/08/2023 with diagnoses that included generalized anxiety disorder, chronic obstructive pulmonary disease (COPD), and acute respiratory failure. Review of a Significant Change Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/14/2023, revealed Resident #23 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. According to the MDS, the resident had no functional limitations in range of motion. Review of Resident #23's comprehensive care plan revealed a Focus area, initiated on 08/08/2023, that indicated the resident had COPD. An intervention dated 08/08/2023 directed nursing staff to administer medications as ordered. Resident #23's comprehensive care plan did not address self-administration of any medications. Review of Resident #23's Order Summary Report, listing active orders as of 12/07/2023, revealed an order dated 08/08/2023 that indicated Resident #23 was not capable of self-administering their medications. The Order Summary Report also reflected an order dated 08/08/2023 for an albuterol sulfate inhaler, ninety (90) micrograms per actuation, two (2) puffs four (4) times a day for COPD. Review of Resident #23's medical record revealed no evidence a BHP Medication Self-Administration Assessment had been conducted to determine if the resident was clinically appropriate to self-administer their albuterol sulfate inhaler. During an observation of medication administration on 12/07/2023 at 8:48 AM, Licensed Practical Nurse (LPN) #6 located an empty box in the medication cart labeled as Resident #23's albuterol sulfate inhaler; however, LPN #6 was not able to locate the resident's inhaler. LPN #6 then prepared and administered the remainder of Resident #23's medications. While in the resident's room, the surveyor observed two (2) unlabeled albuterol sulfate inhalers on the resident's overbed table and pointed them out to LPN #6. LPN #6 stated she did not think the resident could keep the medications at the bedside. Resident #23 stated LPN #6 could not take their inhalers, but if she did, she could only take one of them. Resident #23 stated they kept the inhalers in their pocket because they needed the inhaler when they went outside to smoke. Resident #23 was not able to answer who advised them they could keep their inhaler with them. At 8:55 AM, Registered Nurse (RN) #19, a hospice nurse, entered Resident #23's room and informed LPN #6 the resident would need an order to keep the medication at the bedside. RN #19 advised LPN #6 to contact the physician. Resident #23 refused to give the inhalers to either RN #19 or LPN #6, and the resident said they were supposed to use two (2) puffs four (4) times a day and it was redundant for them to have to retrieve the inhaler (from staff) each time. During an interview on 12/07/2023 at 10:45 AM, LPN #6 stated she called the physician and the physician stated Resident #23 should not have the inhalers at the bedside. During an interview on 12/11/2023 at 9:01 AM, the Director of Nursing (DON) stated a resident was allowed to self-administer medications if the resident had the ability, had been educated, and had the correct assessment completed. During an interview on 12/11/2023 at 1:37 PM, the Administrator stated residents should be assessed to determine if they could safely self-administer medications.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to notify the resident's responsible party when there was a change of condition for one (1) of one (1) sampled residents reviewed for behavioral health when the resident reported suicidal thoughts (Resident #80). The findings include: Review of the facility's policy titled, Resident Suicide Threats, dated 01/10/2003, revealed It is the policy of this facility that a resident suicide threat be taken seriously and immediately reported to the nurse supervisor and/or charge nurse. The policy revealed, 4. The nurse supervisor/charge nurse will notify the resident's responsible party and the Director of Nursing [DON] of the incident. Review of Resident #180's Admission Record revealed the facility admitted the resident on 01/13/2023, with diagnoses that included Alzheimer's disease and anxiety disorder. The Admission Record revealed the resident had a medical history that included diagnoses of depression and hallucinations. Further review of the Admission Record revealed, Power of Attorney (POA) #60 was Resident #180's healthcare POA and POA #61 was the resident's responsible party, financial POA, and healthcare durable POA. Review of Resident #180's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/22/2023, revealed the resident had a Brief Interview for Mental Status (BIMS) score of five (5), which indicated the resident had severe cognitive impairment. Continued review of the MDS revealed the resident had, in the two (2) weeks prior to the assessment, little interest or pleasure in doing things for several days; felt down, depressed, or hopeless for several days; and felt tired or had little energy seven (7) to eleven (11) days. Review of Resident #180's Care Plan, initiated on 01/17/2023, revealed the resident was at risk for psychosocial well-being due to the death of their spouse. Review of Resident #180's Psychotherapy Diagnostic Assessment, dated 05/22/2023, revealed the resident was currently a danger to self/others. The assessment revealed the resident reported thoughts of wanting to end their life. The assessment revealed the resident reported they would use a gun or a knife, but their religious beliefs kept them from following through with harming himself/herself. The assessment revealed the resident agreed to tell a staff member if he/she had intent to harm himself/herself. Further review revealed of the assessment revealed the Social Service Director (SSD) was notified on 05/22/2023 at 9:45 AM. Review of Resident #180's Progress Notes, written by the SSD and dated 05/22/2023 at 1:44 PM, revealed the resident reported to a psychotherapist that they wanted to end their life. The Progress Note indicated the psychotherapist reported this to the SSD. The Progress Note indicated the SSD followed up with the resident who stated they would like for his/her life to be over, and they missed their family, but he/she did not intend to harm himself/herself. The Progress Note revealed the SSD notified a charge nurse and placed Resident #180 on suicide watch. Further review of Resident #180's Progress Notes for the time period 05/22/2023 through 07/15/2023, revealed no documented evidence that indicated the resident's family or POAs were notified of Resident #180's suicidal verbalizations. During an interview on 12/11/2023 at 8:44 AM, Licensed Practical Nurse (LPN) #7 stated if a resident expressed suicidal thoughts, she would immediately notify the Director of Nursing (DON), the Administrator, the resident's POA, and the doctor because it would be considered a change of condition. During an interview on 12/12/2023 at 8:23 AM, POA #60 stated they were not notified the resident had suicidal ideations. POA #60 stated they would have liked to have been notified at the time so the family could discuss it. During an interview on 12/12/2023 at 8:40 AM, POA #61 stated they were not notified of Resident #180's suicidal verbalizations. POA #61 stated they should have been informed, then the family would have come in to visit the resident first, and then decided if they should have an action plan. During an interview on 12/12/2023 at 11:52 AM, the DON stated she expected suicidal verbalizations to be reported to the charge nurse if Resident #180 had intent to harm himself/herself and had a plan. She stated the charge nurse should notify the resident's family and the doctor. The DON stated that the family should have been notified as soon as possible. During an interview on 12/12/2023 at 1:32 PM, the Advanced Practice Registered Nurse (APRN) stated when a resident experienced grief and suicidal thoughts, the charge nurse should notify him, the doctor, and the resident's family. During an interview on 12/12/2023 at 3:29 PM, the Administrator stated she, the resident's family, the DON, and the APRN should have been notified about Resident #180's suicidal verbalizations.

Based on interview and record review, it was determined the facility failed to provide an Advance Beneficiary Notice (ABN) for two (2) of three (3) sampled residents reviewed for Beneficiary Notices (Residents #18 and #31). The findings include: During an interview on 12/10/2023 at 12:37 PM, the Administrator stated the facility did not have a policy for Beneficiary Notices. 1. Review of a Beneficiary Notice-Residents discharged within the Last Six Months worksheet revealed the facility discharged Resident #18 on 10/28/2023 from Medicare covered Part A stay with benefit days remaining. Per the worksheet, the resident remained in the facility to receive further services/care. Review of a Notice of Medicare Non-Coverage (NOMNC) revealed that services for Resident #18 would end on 10/27/2023. Further review revealed Resident #18 was provided the NOMNC notice, which was signed on 10/25/2023. Review of Resident #18's Electronic Medical Record (EMR) revealed no ABN notice was provided to the resident. 2. Review of a Beneficiary Notice- Resident discharged within the Last Six Months worksheet revealed the facility discharged Resident #31 on 09/26/2023 from Medicare covered Part A stay with benefit days remaining. Per the worksheet, the resident remained in the facility to receive further services/care. Review of a Notice of Medicare Non-Coverage (NOMNC) revealed that services for Resident #31 would end on 09/26/2023. Further review revealed Resident #31's representative was provided a NOMNC notice on 09/18/2023. Review of Resident #31's EMR revealed no ABN notice was provided to the resident's representative. During an interview on 12/08/2023 at 3:09 PM, the Social Services Director (SSD) stated she had never provided an ABN notice. She stated that if the resident was long-term care, the resident already knew their patient (resident)liability. She stated if there was a resident who was private pay, then she would need to let the resident know the cost. During an interview on 12/09/2023 at 2:07 PM, the Administrator stated if a resident was losing services and staying in the facility, the resident should have been provided an ABN notice along with the NOMNC.

Based on record review, interviews, and facility policy review, the facility failed to ensure allegations of abuse were investigated to ensure residents were protected from further abuse for three (3) (Residents #184, #34, and #49) of fifteen (15) residents sampled for allegations of abuse. The findings included: Review of a facility policy titled, Resident Protection Plan, dated 09/15/2022, revealed, All reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management. 1. A review of Resident #184's Admission Record revealed the facility admitted the resident on 08/03/2023 with diagnoses that included bipolar disorder, depression, and anxiety. A review of an Admission Minimum Data Set (MDS), with an Assessment Reference Date of 08/06/2023, revealed Resident #184 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident was moderately cognitively impaired. Further review of the MDS revealed the resident had no delirium, psychosis, or behavioral symptoms. A review of Resident #184's care plan revealed a focus statement with an initiation date of 08/17/2023 that indicated the resident had behavioral symptoms that included making false accusations toward staff. Prior to 08/17/2023, behavioral symptoms were not addressed in the resident's care plan. A review of a facility Grievance Form, dated 08/07/2023, revealed the form was completed by the Social Services Director (SSD) for a complaint made by Resident #184. Resident #184 reported that State Registered Nurse Aide (SRNA) #48 made rude statements. The grievance resolution documented on the form and dated 08/10/2023 indicated that SRNA #48 had been terminated from employment. During an interview on 12/07/2023 at 9:47 AM, the Director of Nursing (DON) stated that when she walked past SRNA #48 at approximately midnight on 08/03/2023, the SRNA's speech, demeanor, body language, and tone were unprofessional. The DON stated she verbally educated SRNA #48 on professionalism. The DON stated the next day, 08/04/2023, they received an allegation from another resident about SRNA #48 being rude and stating the resident complained too much. The DON stated after receiving the allegation, I said, well I'm not surprised. The DON stated SRNA #48 was suspended and then terminated from employment on 08/10/2023. During an interview on 12/07/2023 at 2:47 PM, the Administrator stated she signed the grievance form related to Resident #184's complaint on 08/10/2023 but did not think about investigating the grievance because SRNA #48 had already been terminated from employment. During an interview on 12/07/2023 at 3:19 PM, the Administrator stated Resident #184's complaint had to have come from an experience with SRNA #48 that occurred on 08/03/2023 or before, because the SRNA was suspended on 08/04/2023, and did not work after that. During an interview on 12/07/2023 at 4:22 PM, the Social Services Director (SSD) stated she checked on Resident #184 on Monday, 08/07/2023, and the resident complained about an SRNA matching SRNA #48's description. The SSD stated the SRNA was later confirmed to be SRNA #48. She stated she informed the DON and the Administrator about the grievance. She stated it was her responsibility to write out the grievance, but the decision to investigate a grievance as an allegation of abuse came from the DON and the Administrator. The SSD stated she did not know why they decided not to investigate the complaint as verbal abuse, because it was similar to the complaint made by another resident related to SRNA #48. During an interview on 12/12/2023 at 11:43 AM, the DON stated an abuse investigation should have been initiated for Resident #184's complaint because it was the same complaint that another resident made. The DON stated they looked at it from the angle that SRNA #48 was terminated. The DON stated it was a new allegation so they should have started a new investigation. During an interview on 12/12/2023 at 3:29 PM, the Administrator stated the facility should have initiated an abuse investigation for Resident #184's allegation, but they did not. 22445 2. A review of Resident #63's Admission Record revealed the facility admitted the resident on 06/28/2022 with diagnoses that included unspecified mood (affective) disorder, bipolar disorder, intellectual disabilities, and depression. A review of a Quarterly Minimum Data Set (MDS), with an Assessment Reference Date of 08/16/2023, revealed Resident #63 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident was moderately cognitively impaired. The MDS indicated Resident #63 had physical behavioral symptoms directed toward others and rejected care one to three days during the review period. The MDS indicated Resident #63 required extensive assistance with bed mobility, locomotion, and dressing and was totally dependent on staff for transfers, toilet use, and personal hygiene. A review of Resident #63's care plan revealed a focus statement with a revision date of 08/08/2022 that indicated Resident #63 displayed behaviors that included biting, hitting, screaming, shouting, yelling, refusing medications, being disruptive and lashing out during physician's visits, using foul language and racial expletives, and throwing objects from their bedside table. Interventions directed staff to attempt interventions before behavioral symptoms begin, not seat Resident #63 around others who would disturb them, help the resident avoid people or situations that would disturb them, offer the resident diversions they enjoy, refer the resident to a psychologist/psychiatrist as needed, give medications as ordered, and remove the resident from an activity when negative behaviors begin, returning/resuming the activity when the behavior subsides. 3. A review of Resident #34's Admission Record revealed the facility initially admitted the resident on 08/08/2019 and readmitted the resident on 02/03/2020 with diagnoses that included unspecified dementia, major depressive disorder, obsessive-compulsive disorder, and hypertension. A review of a Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/28/2023, revealed Resident #34 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident was severely cognitively impaired. The MDS indicated Resident #34 had no behavioral symptoms. Further review of the MDS indicated Resident #34 required extensive assistance with ambulation and locomotion and used a wheelchair or walker for mobility. A review of the Resident #34's care plan revealed a focus statement, with a revision date of 05/10/2022, that indicated the resident had behavioral symptoms that included attempting to clean the floor, rearranging furniture, cleaning and fixing the bed, and refusing assistance. 4. A review of Resident #49's Admission Record revealed the facility admitted the resident on 10/27/2023 with diagnoses that included severe vascular dementia with anxiety. A review of an admission MDS, with an ARD of 11/08/2023, revealed Resident #49 had a BIMS score of 0, which indicated the resident was severely cognitively impaired. The MDS indicated Resident #49 wandered four to six days during the assessment period and used a walker for mobility. A review of Resident #49's care plan revealed a focus statement, with an initiation date of 10/28/2023, that indicated the resident was at a risk of falls due to dementia with poor safety awareness. A review of Resident #63's acute monitoring Progress Notes, dated 11/29/2023 and written by Licensed Practical Nurse (LPN) #6, indicated Resident #63 was in their wheelchair in front of the nurses' station and was observed kicking and cursing other residents. The note indicated Resident #63 was redirected to not curse and kick other residents. LPN #6 was interviewed on 12/04/2023 at 11:52 AM. The LPN reported she had seen Resident #63 kicking and hitting Resident #34 and Resident #49. LPN #6 stated she tried to explain to Resident #63 that they should not hit other residents and then Resident #63 reached out and scratched her. The LPN stated she had reported her observations to LPN #39 (the unit manager) and the Assistant Director of Nursing (ADON),but was not sure what else had been done about the incident. LPN #6 stated it was considered abuse when one resident hit another but for Resident #63 it was considered a behavior. LPN #6 added that Resident #6 called other residents expletives and used obscene hand gestures toward other residents. She stated after she had observed Resident #63 hitting and kicking the other residents, she returned the resident to their room and told the resident they had to be good. The Director of Nursing (DON) was interviewed on 12/11/2023 at 11:16 AM and stated the initial report to the state agency regarding Resident #63's abuse of Resident #34 and Resident #49 was submitted on 12/06/2023. The DON stated the progress note dated 11/29/2023 at 2:06 PM indicated Resident #34 and Resident #49 had been kicked by Resident #63. The DON stated LPN #6 said she may have told LPN #39 or the Assistant Director of Nursing (ADON) about the incident but when the DON interviewed LPN #39 and the ADON, they reported they were not made aware that physical contact had occurred between the residents. The DON stated by not reporting the incident timely, LPN #6 had not ensured an investigation was initiated and that Resident #49 and Resident #34 were protected from further abuse. The Administrator was interviewed on 12/12/2023 at 9:56 AM. The Administrator stated LPN #6 should have called her immediately for direction after witnessing the incident between Resident #63, Resident #34, and Resident #49. The Administrator stated that since LPN #6 had not reported the incident, there had been no investigation initiated and no interventions had been put in place to protect Resident #49 and Resident #34 from further abuse.

Based on interviews, record review, and facility policy review, it was determined the facility failed to notify the resident and/or the resident's representative in writing of a transfer to the hospital and provide a copy of the written notice to the long-term care ombudsman for one (1) (Resident #16) of one (1) sampled resident reviewed for hospitalization . The findings included: Review of an undated facility policy titled, Notice of a Transfer and/or Discharge, did not reveal evidence to specify what information should be provided to the resident and/or their representative when a resident transferred to the hospital. The Notice of a Transfer and/or Discharge policy also did not reference notification of the long-term care ombudsman when a resident transferred to the hospital. Review of Resident #16's Admission Record revealed the facility admitted the resident on 02/23/2022. Review of Resident #16's Progress Notes dated 11/23/2023 at 9:08 AM, revealed Resident #16 was transferred to the hospital by way of emergency medical services. Review of Resident #16's medical record revealed no evidence to indicate written notice was provided to Resident #16 or the resident's representative of the resident's transfer to the hospital on 11/23/2023. During an interview on 12/06/2023 at 10:23 AM, Resident #16's responsible party (representative) stated the facility did not provide them with written notification when the resident was transferred to the hospital. During an interview on 12/06/2023 at 11:19 AM, the Ombudsman stated the facility did not notify her when a resident transferred or discharged from the facility. During an interview on 12/07/2023 at 2:33 PM, the Social Service Director (SSD) stated when a resident was transferred to the hospital, the resident's representative was notified only by way of telephone. The SSD stated the facility did not provide written notification to the resident's representative regarding the transfer. The SSD stated it was not the facility's policy to notify the Ombudsman when a resident transferred to the hospital. During an interview on 12/11/2023 at 9:01 AM, the Director of Nursing (DON) stated when a resident was transferred to the hospital, the facility notified the resident's family by way of telephone and did not notify the resident's representative in writing. The DON stated it was not the facility's current practice to notify the Ombudsman when a resident transferred to a hospital. During an interview on 12/11/2023 at 1:37 PM, the Administrator stated when a resident was transferred to the hospital, the facility notified the resident's family by way of telephone and did not notify the resident's representative in writing. The Administrator stated the Ombudsman was not notified when a resident transferred to a hospital.

Based on interviews, record review, and facility policy review, it was determined the facility failed to provide written information regarding the facility's bed-hold policy to a resident and/or their representative when the resident transferred to the hospital for one (1) of one (1) sampled resident reviewed for hospitalization (Resident #16). The findings included: Review of an undated facility policy titled, Bed Hold Policy, revealed Our facility shall inform residents upon admission and prior to a transfer for hospitalization or therapeutic leave of our bed-hold policy. The policy specified, 2. When emergency transfers are necessary, the facility will provide the resident or representative (sponsor) with information concerning our bed-hold policy within 24 hours of such transfer. Per the policy, 8. A copy of the resident's bed-hold or release record will be filed in the resident's medical record. Review of Resident #16's Admission Record revealed the facility admitted the resident on 02/23/2022. Review of Resident #16's Progress Notes dated 11/23/2023 at 9:08 AM, revealed Resident #16 was transferred to the hospital by way of emergency medical services. Review of Resident #16's medical record revealed no documented evidence to indicate the resident and/or his/her representative was provided information about the facility's bed-hold policy when the resident transferred to the hospital on 11/23/2023. During an interview on 12/06/2023 at 10:23 AM, Resident #16's responsible party (representative) stated the facility did not provide them with information regarding the facility's bed-hold policy. During an interview on 12/07/2023 at 2:33 PM, the Business Office Manager (BOM) stated the facility's bed-hold policy was provided to the resident with their admission packet. Per the BOM, she called the resident's family to notify the representative of the facility's bed-hold policy when the resident transferred to the hospital. During an interview on 12/11/2023 at 9:01 AM, the Director of Nursing stated she was not aware of the facility's policy regarding bed-hold. During an interview on 12/11/2023 at 1:37 PM, the Administrator stated when a resident was transferred to the hospital, the BOM should discuss with and provide the resident's representative a copy of the facility's bed-hold policy.

Based on interview, record review, and review of the Resident Assessment Instrument (RAI) 3.0, it was determined the facility failed to complete an admission assessment timely for one (1) of twenty-three (23) sampled residents reviewed for Minimum Data Set (MDS) assessments (Resident #234). The findings include: Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.18.11, dated October 2023, revealed, The Admission assessment is a comprehensive assessment for a new resident and, under some circumstances, a returning resident that must be completed by the end of day 14, counting the date of admission to the nursing home as day 1 if: this is the resident's first time in the facility, OR the resident has been admitted to this facility and was discharged return not anticipated, OR the resident has been admitted to this facility and was discharged return anticipated and did not return within 30 days of discharge. Review of Resident #234's Admission Record revealed the facility admitted the resident on 11/10/2023 with diagnoses that included moderate protein-calorie malnutrition, adjustment disorder with mixed anxiety and depressed mood, constipation, dysphagia, history of malignant neoplasm of breast, and Alzheimer's disease. Review of Resident #234's Admission MDS with an Assessment Reference Date (ARD) of 11/22/2023 revealed sections A related to identification information, B related to hearing, speech, and vision, GG related to functional abilities and goals, H related to bowel and bladder, I related to diagnoses, J related to health conditions, L related to oral/dental status, M related to skin conditions, N related to medications, O related to special treatments, procedures, and programs, P related to restraints and alarms, and V related to care area assessment (CAA) summary were not completed. During an interview on 12/09/2023 at 1:01 PM, the Regional MDS Coordinator stated that the MDS for Resident #234 was incomplete. She stated she expected the MDS to be completed. During an interview on 12/09/2023 at 1:51 PM, the Director of Nursing (DON) stated the MDS did not fall under clinical. She stated she did not know the frequency or how often the MDS was to be completed. During an interview on 12/09/2023 at 1:58 PM, the Administrator stated the MDS should be completed timely. The Administrator reviewed Resident #234's MDS and stated the resident's MDS was not completed timely.

Based on observation, interview, record review, review of the facility's policy, and review of the Centers for Medicare and Medicaid Services (CMS), Resident Assessment Instrument (RAI) Manual 3.0, it was determined the facility failed to ensure the Comprehensive Care Plan (CCP) was reviewed and revised by an interdisciplinary team composed of individuals who had knowledge of the resident and his/her needs for two (2) of ten (10) sampled residents (Resident #1 and Resident #2). The facility's failed to closely supervise the residents' exit-seeking behaviors, Resident #1 exited the facility, on 07/10/2021 at approximately 4:40 PM, without staff knowledge. Resident #1 was found by police at an apartment building next door. The resident was short of breath and needed medical treatment. In addition, on 07/10/2021 at approximately 4:30 PM to 4:45 PM, staff, sitting out back on break, found Resident #2 outside of the building, unsupervised walking around the back of the building and holding onto the building and gutters for stability. The facility's failure to have an effective system in place to ensure CCP's were reviewed and revised for each resident, for residents who were assessed at risk for elopement, which led to elopements, has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) was identified on 07/15/2021 and determined to exist on 07/10/2021. The facility provided an acceptable Immediate Jeopardy Removal Plan on 07/27/2021, with the facility alleging removal of the Immediate Jeopardy on 07/23/2021. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on 07/23/2021, prior to exit on 07/29/2021. The facility's remaining non-compliance was at a Scope and Severity of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, revised December 2016, revealed it was the facility's policy to ensure the comprehensive, person-centered care plan included measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs and described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Further review of the policy, revealed the comprehensive, person-centered care plan would aid in preventing or reducing a decline in the resident's functional status and/or functional levels and reflect currently recognized standards of practice for problem areas and conditions. Further review revealed resident assessments were ongoing and care plans were revised as information about the residents and the residents' conditions changed. In addition, the Interdisciplinary Team (IDT) must review and update the care plan when: there had been a significant change in the resident's condition; the desired outcome was not met; the resident had been readmitted to the facility from a hospital stay; and at least quarterly, in conjunction with the required Quarterly Minimum Data Set (MDS) Assessment. Review of the CMS, Resident Assessment Instrument (RAI) Manual 3.0, dated October 2016, revealed the CCP must be reviewed and revised periodically, and the services provided or arranged should be consistent with each resident's written plan of care. Continued review revealed the CCP was driven not only by identified resident issues and/or conditions, but also by a resident's unique characteristics, strengths, and needs. Furthermore, a CCP based on a thorough assessment and effective clinical decision making, was compatible with current standards of clinical practice that provided a strong basis for optimal approaches to quality of care and quality of life needs of individual residents. A well developed and executed assessment and CCP re-evaluated the resident's status at prescribed intervals (quarterly, annually, or if a significant change in status occurred) using the RAI, and then, the individualized CCP was modified as appropriate and necessary. 1. Review of Resident #1's medical record revealed the facility admitted the resident, on 10/20/2020, with multiple diagnoses to include Chronic Obstructive Pulmonary Disease (COPD), Schizophrenia, Cognitive Communication Deficit, and Need for Assistance with Personal Care. Review of Resident #1's Quarterly MDS Assessment, dated 06/13/2021, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of fourteen (14) out of fifteen (15), indicating intact cognition. Additionally, the resident exhibited the behavior of wandering. Further, the resident had an elopement wander alarm. Review of Resident #1's Comprehensive Care Plan (CCP), initiated on 10/19/2020, revealed the resident was at risk for elopement related to wandering. The focus was the resident ambulated frequently throughout the facility and attempted to go outside for a cigarette. The goal was the resident would remain safe during nursing home placement. Further review revealed interventions included to provide the resident with education; involve the resident in decision making regarding daily choices; involve the resident in preferred activities; redirect the resident from doors; take picture of the resident for identification for updating the elopement book; and ensure wander guard bracelet was worn and functioning properly. Review of Resident #1's Physician's Orders, for July 2021, revealed an order for a secure care bracelet due to a possible elopement risk, which was originally dated 11/22/2020. Review of the facility's Long Term Care Facility-Self Reported Incident Form-Five (5) day Follow Up/Final Report, and attached facility's investigation, dated 07/14/2021 and signed by the Administrator, revealed, on 07/10/2021, Resident #1 exited the facility unattended. Per the report, the resident proceeded to leave the property and knocked on an apartment door across the street asking for a cigarette; at this time, he/she became short of breath. The report stated, a lady at the apartment building called 911. Per the report, the resident was taken to the local hospital for further evaluation. Continued review revealed the resident returned from the hospital with no new orders or injury. Review of the report, revealed the time frame the resident left the facility was between 4:45 PM and 4:55 PM. Resident #1 was immediately placed on one-to-one (1:1) supervision. Review of Resident #1's Mental Health Progress Note, signed by the Advanced Practice Registered Nurse, dated 01/12/2021 at 12:07 PM, revealed the resident was a flight risk related to exit-seeking behaviors. Further review revealed, under discussion notes, a recommendation for hourly checks because the resident was a flight risk. However, there was no documented evidence in Resident #1's CCP or Progress Notes that the resident had been placed on hourly checks. Interview with the Director of Nursing (DON), on 07/14/2021 at 1:54 PM, revealed Resident #1 was care planned for behaviors of exit-seeking. However, the CCP did not reflect hourly checks nor, was the DON aware of the recommendation. Per interview, the DON stated, if he had been aware of the recommendation, he would have ensured the CCP was revised with hourly checks for Resident #1. Review of Resident #1's Progress Note, dated 03/09/2021 at 1:20 PM, revealed Resident #1 was standing in the doorway of the front lobby with his/her arms spread blocking anyone from entering or exiting the facility. Per the note, the receptionist attempted to redirect the resident without success. When the nurse asked the resident where he/she was going, the resident responded, To the gas station to buy cigarettes. However, despite this exit-seeking behavior, there was no documented evidence the CCP was updated. Review of Resident #1's Progress Note, dated 05/09/2021 at 11:30 AM, revealed Resident #1 attempted to leave the facility to smoke. Further review revealed when the resident was redirected, the resident became upset and combative. Per the note, Resident #1 hit a staff member on the arm and cursed at the receptionist. However, there was no documented evidence the CCP was revised to reflect the attempt to exit or to address the behaviors related to combativeness. Review of Resident #1's Progress Note, dated 05/31/2021 at 6:08 PM, revealed Resident #1 went outside the back door . this AM and sat at a table. Per the note, the resident was witnessed by two (2) residents, who were alert and oriented, and Resident #1 remained in their sight at all times. Per the note, the resident stated, (He/she) just wanted some sunshine. The DON was made aware; and the family was notified. However, there was no documented evidence the CCP was revised related to exit-seeking behaviors. Review of Resident #1's Progress Note, dated 06/30/2021 at 6:24 PM, revealed staff from A-Wing saw the resident attempt to go outside through the back door twice, unsupervised. Resident #1 was redirected back to his/her unit and was educated about not attempting to go outside alone without staff present. However, there was no documented evidence the CCP was revised to reflect increased supervision or monitoring. Interview with Unit Manager (UM) #1, on 07/13/2021 at 5:45 PM, revealed staff should have increased the level of supervision of Resident #1 when he/she began exhibiting exit-seeking behaviors. In addition, she stated the CCP should have been updated to reflect the increased level of supervision that was needed related to Resident #1 exit-seeking, on 03/09/2021, 05/09/2021, 05/31/2021, and 06/30/2021. UM #1 stated she expected the CCP's to be revised timely and accurately, as per the facility's CCP policy and RAI guidelines. Interview with Licensed Practical Nurse (LPN) #7, on 07/15/2021 at 10:25 AM, revealed Resident #1's CCP should have been revised. Furthermore, LPN #7 stated if Resident #1 had been placed with a staff member on one-to-one (1:1) supervision, this elopement could have been prevented. Further, she stated it was important to have a current, accurately revised CCP to ensure direct care staff would know how to provide care to residents to meet their needs and keep residents safe and secure. Interview with LPN #4, on 07/14/2021 at 9:01 AM, revealed she had worked at the facility for seventeen (17) years. She stated she was assigned to B-Unit. Per the interview, any time the resident attempted to exit the facility, became aggressive with staff, or exhibited exit-seeking behaviors the CCP should be updated. Therefore, Resident #1's CCP should have been updated. 2. Review of Resident #2's electronic medical record revealed the facility admitted the resident, on 02/21/2021, with diagnoses that included Alzheimer's, Unspecified Dementia with Behavioral Disturbance, and Unspecified Psychosis. Resident #2 was independent for mobility. Review of Resident #2's Nursing Admission Assessment Elopement Evaluation Section, dated 02/22/2021 and signed by Unit Manager (UM) #1, revealed the resident was a new admission to the building. Per the Note, upon entering the facility, the resident began looking for exits and voicing the desire to walk out into the snow/ice to go home. Review of Resident #2's Nursing Admission Assessment, dated 02/22/2021, revealed the facility assessed Resident #2 as being a high risk for elopement. Continued review revealed a secure care bracelet was placed on the resident's ankle for safety. Review of Resident #2's Comprehensive Care Plan (CCP), initiated on 02/22/2021, revealed the resident was at risk for elopement related to wandering. The goal was the resident would remain safe during nursing home placement. Further review revealed interventions included to involve the resident in preferred activities; redirect the resident from doors; and a wander guard bracelet was to be worn, with proper functioning ensured. Observation, on 07/13/2021 at 1:35 PM, revealed Resident #2 was wandering aimlessly in the hallways. Resident #2 was observed on the back hall of Unit A by the exit door. Further observation revealed when staff assisted other residents outside for a smoke break, Resident #2 attempted to follow staff out the door. The resident was redirected by staff. Interview with Kentucky Medication Aide (KMA) #1, on 07/13/2021 at 3:42 PM, revealed on 07/10/2021 at approximately 4:30 PM to 4:45 PM staff, she was sitting outside on break when she and another staff member found Resident #2 outside of the building unsupervised. KMA #1 stated they observed the resident walking around the back of the building holding onto the building and gutters. She stated it was not safe for Resident #2 to be outside unsupervised. Further interview revealed she had not been informed to increase supervision or monitoring for Resident #2. However, after the incident, the resident should have been placed on one-to-one (1:1) supervision for the resident's safety. Record review revealed no documented evidence the resident's care plan was revised. Interview with KMA #3, on 07/14/2021 at 4:14 PM, revealed she was not informed to increase supervision or monitoring for Resident #2 after she brought him/her back in the building on 07/10/2021. Further interview revealed staff utilized a KARDEX to know how to care for the residents, and it was not revised with regard to the resident's safety. Telephone Interview with Licensed Practical Nurse (LPN) #3, on 07/13/2021 at 6:17 PM, revealed she was made aware by KMA #3 of Resident #2 being outside unsupervised. However, she did not revise the resident's care plan related to the resident exiting the facility unsupervised, and without staff knowledge. Per the interview, she did not increase supervision or monitoring for the resident. LPN #3 stated she was not directed by the Director of Nursing (DON) or the Administrator to document the incident or revise the care plan. Furthermore, she stated she should have revised the care plan and increased supervision and monitoring to prevent another possible elopement. Continued interview with LPN #4, on 07/14/2021 at 9:01 AM, revealed any staff nurse could make revisions to the CCP. She stated the CCP's should be accurate so that staff was aware of how to care for residents. However, review of the CCP revealed there was no documented evidence the resident's CCP was revised to increase supervision or monitoring after the resident exited the building on 07/10/2021 unsupervised. Continued interview with LPN #7, on 07/15/2021 at 10:25 AM, revealed any nurse could revise the care plan. She stated nurses depended on each other and management to ensure appropriate interventions were in place and person centered for each resident. Per the interview, when any resident was exhibiting exit-seeking behaviors and attempting to exit the door unsupervised, the CCP should be revised to include increased supervision. Interview with the MDS Coordinator, on 07/15/2021 at 1:14 PM, revealed the facility utilized the CMS Resident Assessment Instrument (RAI) Manual 3.0, as a guideline for CCP's. She stated at the morning clinical meetings, staff discussed any new orders or incidents. Per the interview, she was responsible for revisions to the CCP as appropriate. However, she stated any staff nurse had access to revise the care plan. Further, she stated it was important to have a current, accurately revised CCP to ensure direct care staff would know how to provide care to residents to meet their needs. Interview with the DON, on 07/14/2021 at 1:54 PM, revealed he expected the CCP's to be revised accurately, as per the facility's policies. Per the interview, the MDS Coordinator was responsible for revision of the electronic version of the CCP, including any changes related to elopement; but, any licensed nurse could update the CCP on the paper copy. Additionally, he stated the current process in place was, during the facility's Morning Clinical Meeting, held on Monday through Friday, to review the CCP's to ensure revisions were made as necessary and for the Interdisciplinary Team (IDT, the DON, Unit Managers, etc.) to review any incidents and new orders. The DON stated the MDS Coordinator was to check to ensure the CCP's had been revised as necessary with the morning reviews. Continued interview revealed Resident #1's and Resident #2's CCP's should have been revised to include increased supervision and monitoring. In addition, the DON stated the CCP's should be revised as necessary to ensure residents received appropriate services and individualized care. Interview with the Administrator, on 07/15/2021 at 3:18 PM, revealed the facility was to utilize the RAI Manual and facility policies as resources to ensure the CCP was revised as necessary. He stated it was important for the CCP to be revised accurately to reflect a resident's current status and ensure the CCP addressed each resident's individual needs. The facility provided an acceptable Immediate Jeopardy Removal Plan on 07/27/2021 alleging removal of the IJ on 07/23/2021. Review of the IJ Removal Plan revealed the facility implemented the following: 1. On 07/15/2021, the Director of Nursing (DON) assessed Resident #1 and Resident #2 for exit seeking behaviors. 2. On 07/15/2021, the Administrator, DON, and the [NAME] President of Compliance (VPoC) reviewed the Elopement policy. 3. On 07/15/2021, the VPoC, Administrator, DON and the Minimum Data Set (MDS) Coordinator reviewed the Care Plans, Comprehensive Person-Centered policy. 4. On 07/15/2021, the VPoC and the Administrator completed a Root Cause Analysis (RCA) for the Mag Lock system and the Secure Care System. 5. On 07/15/2021, the Maintenance Director changed all three (3) entrance and exit door codes. 6. Beginning on 07/15/2021, any resident or non-staff member would be escorted in and out of the facility's front and two (2) rear doors, by a staff member. 7. The staff are to be notified of the new door codes via Dial My Calls system. 8. On 07/16/2021, the VPoC in-serviced the MDS Coordinator, on the Comprehensive Person-Centered Care Plan policy and the importance of adding interventions timely as needed to prevent elopement. 9. On 07/16/2021, Resident #1's and Resident #2's Care Plans were reviewed and revised, by the MDS Coordinator and/or the DON, to include more person-centered interventions related to wandering/elopement. 10. On 07/16/2021, the VPoC in-serviced the Maintenance Director, on the process of changing door codes weekly for four (4) weeks and then monthly; and, to ensure all exit doors were checked Monday through Friday for properly locking operation. 11. On 07/16/2021, the DON and the VPoC re-assessed all residents for elopement risk. 12. On 07/16/2021, the DON and the Regional Nurse removed the Secure Care bracelet off the residents. Additionally all three (3) exit doors were locked with a code needed to exit and/or enter. 13. On 07/16/2021, the Business Office Manager (BOM) and or the Assistant BOM (ABOM) informed eight-three (83) of ninety (90) employees, via call or in person, not to give out door codes to non-staff members. 14. On 07/16/2021 and 07/21/2021, the Maintenance Director conducted Elopement Drills. The Administrator and VPoC made observations to evaluate staff during the drills. 15. Beginning on 07/16/2021, doors would be checked daily by the Manager on Duty (MOD), on the weekend, and the DON, Maintenance Director or Charge Nurse, during the week, to ensure locks were working properly and required a code to open. 16. On 07/16/2021, eight (8) of nine (9) Managers, who serve as MOD's on weekends were instructed by the Administrator to make sure the doors were checked for proper locking operation on weekends. The remainder of the Managers would be in-serviced prior to their next scheduled MOD weekend. 17. On 07/17/2021, the Administrator sent out a mass text message, to eighty-four (84) of ninety (90) staff, via Dial My Calls system, not to give door codes to any non-staff member and one-to-one (1:1) supervision must be done with exit seeking residents. 18. On 07/19/2021, the Administrator sent out a message, to sixty-eight (68) of sixty-nine (69) families of residents, via Dial My Call system, explaining door codes would only be given to staff members. 19. Beginning on 07/19/2021, the Interdisciplinary Team (IDT), not limited to the Administrator, DON, MDS Coordinator, Director of Clinical Education (DCE), Activities Director, Rehab Director, Charge Nurses, Maintenance Director, Environmental Services Director, BOM, and Admissions Director, met daily until Immediate Jeopardy(s) were abated. The topics discussed were the review of any problems identified with the door functioning; residents who may need added supervision to prevent elopement and/or newly added care plan interventions related to elopement. 20. Beginning on 07/20/2021, the DCE and/or the DON, in-serviced all staff on the Elopement policy, and the importance of one-to-one (1:1) supervision when a resident was actively exit seeking; not giving the door codes to any non-staff member; and escorting visitors in and out of the doors to ensure no resident exited in the process. As of 07/22/2021, sixty-nine (69) of ninety (90) staff had been in-serviced. After 07/22/2021, any staff members not attending the in-service would be in-serviced prior to working their next scheduled shift by the DON or the DCE. 21. Beginning on 07/20/2021, the VPoC or the DCE in-serviced the DON, Charge Nurses, Registered Nurses (RN) and Licensed Practical Nurses (LPN), on the Comprehensive Person Centered Care Plans policy and the importance of adding interventions timely as needed to prevent elopement. Seventeen (17) of the twenty-one (21) above individuals were in-serviced by 07/22/2021. Anyone in the group not in-serviced by 07/22/2021 will be in-serviced by the DCE or DON prior to their next scheduled shift. 22. Competencies of the training were evaluated immediately following the education through staff Question and Answer, to ensure staff understood the information. 23. Until Immediate Jeopardies were removed, the DON, MDS Coordinator, Regional MDS Coordinator, or Charge Nurses will do daily reviews of the care plan of any new resident considered an elopement risk to ensure the care plan reflected person-centered interventions related to elopement risk. 24. The audit findings of the daily checks on all three (3) entrance and exit doors would be reported, by the Administrator, in a Monthly Quality Assurance Performance Improvement (QAPI) meeting for a minimum of three (3) months. 25. On 07/22/2021, the DON, VPoC and/or the MDS Coordinator reviewed the current care plans of all residents with an elopement risk and ensured there were person-centered interventions related to wandering/elopement. Additionally, the MDS Coordinator, DON, Charge Nurse, LPN's and RN's could develop and/or revise the care plan based on the resident's needs by timely adding interventions. 26. All new staff will be in-serviced on Elopement and Care Plans during the orientation process by the VPoC or the DCE; there were no agency staff. 27. Any deficient practice found during the audits will be corrected immediately and education and/or corrective action done by the MDS Coordinator, DCE, DON, or Administrator as appropriate. 28. On 07/15/2021, a QAPI meeting was held with the Administrator, the DON, the Maintenance Director, the MDS Coordinator and the VPoC, to discuss the Immediate Jeopardy's and to collaborate to develop a removal plan. 29. On 07/16/2021, a QAPI meeting was held with the Interdisciplinary Team (IDT) consisting of: the Administrator, DON, MDS Coordinator, Charge Nurses, Admissions Director, Environmental Services Director, BOM, ABOM, Dietary Manager, Admissions Director, DCE, Activities Director, VPoC, and Therapy Director. Discussed at the meeting were the Immediate Jeopardies (IJ) and the IJ Removal Plan. 30. On 07/21/2021, Resident #1's and Resident #2's Care Plans were updated by the MDS Coordinator, VPoC, and/or the DON to reflect person-centered interventions to include increased supervision/monitoring, one-to-one (1:1) supervision, when the resident exhibited exit seeking behaviors, until the behaviors ended. 31. On 07/21/2021, a QAPI meeting was held with the Medical Director, Administrator, DON, MDS Coordinator, Activities Director, BOM, Dietary, Admissions, Medical Records, Therapy Director, and VPoC to discuss needed to the IJ Removal Plan. A training schedule for in-services was needed and a new compliance date. The State Survey Agency validated the implementation of the facility's IJ Removal Plan as follows: 1. Review of the Elopement Risk Assessment, dated 07/15/2021, revealed eleven (11) areas were assessed: cognition, mobility, history of elopement/wandering, hearing, vision, communication, new admits, medications, verbalization of desire to go home, change in medical condition, and poor decision making skills. Review of Resident #1's Elopement Risk Assessment tool, dated 07/16/2021, completed by the DON, revealed he/she was at risk of elopement. Review of Resident #1's Care Plan related to elopement, revealed a revision, dated 07/10/2021, which included person-centered risk interventions for elopement to include one-to-one (1:1) monitoring when the resident exhibited elopement behaviors. Review of Resident #2's Elopement Risk Assessment tool, dated 07/16/2021, completed by the DON, revealed he/she was at risk of elopement. Review of Resident #2's Care Plan related to elopement, revealed a revision, dated 07/15/2021, which included person-centered risk interventions for elopement. When the resident exhibited elopement behaviors, Resident #2 was placed on one-to-one (1:1) supervision until behaviors resolved. Interview with the VPoC, on 07/28/2021 at 4:15 PM, revealed he evaluated the elopement of Residents #1 and Resident #2 with the DON. Additionally, he used the Elopement Risk Assessment tool to assure no item or detail was overlooked. Per the interview, he implemented a process, which was to use the Elopement Risk Assessment tool, to make sure all residents who were at risk for elopement received one-to-one (1:1) supervision if needed. Further, he individualized the interventions to be resident-specific for each resident. 2. Review of the Wandering and Elopement policy, dated 03/2019, revealed the facility would identify residents who were at risk for elopement. The policy included interventions for residents who exhibited wandering behaviors. Interview with the DON, on 07/28/2021 at 2:00 PM, revealed she reviewed the Wandering and Elopement policy with the Administrator and the VPoC on 07/15/2021. Interview with the VPoC, on 07/28/2021 at 4:15 PM, revealed he reviewed the Wandering and Elopement policy with the Administrator and the DON on 07/15/2021. 3. Interview with the DON, on 07/28/2021 at 2:00 PM, and MDS Coordinator, on 07/28/2021 at 3:35 PM, revealed they reviewed the Care Plans, Comprehensive Person-Centered policy, on 07/15/2021, with the VPoC and the Administrator. Interview with the VPoC, on 07/28/2021 at 4:15 PM, and the Administrator, on 07/29/2021 at 9:00 AM, revealed they reviewed the Care Plans, Comprehensive Person-Centered policy, on 07/15/2021, with the DON and the MDS Coordinator. They determined no changes were needed to the policy. 4. Interview with the Administrator, on 07/29/2021 at 9:00 AM, revealed he and the VPoC completed a Root Cause Analysis (RCA) for the Mag Lock system and the Secure Care System, on 07/15/2021, which showed: A. The problem was stated-residents were outside of the building without the knowledge of staff.; B. The residents both had secure care bracelets on; C. Both residents' secure bracelets were in date and were recognized by the door alarm as appropriate; and, D. When those bracelets were checked by the Administrator and the Maintenance Director, even though the bracelets were on and up-to-date, the door locking mechanisms did not work. The bracelets interfered with the ability of the door to lock. The bracelets were removed. Interview with the DON, on 07/28/2021 at 2:00 PM, revealed no secure bracelets would be used on residents. 5. Interview with the Maintenance Director, on 07/28/2021 at 3:50 PM, revealed he changed the door codes on all three (3) entrance and exit doors on 07/15/2021. Per the interview, the codes were changed every Tuesday. Additionally, he notified the Administrator of the new codes, and the Administrator informed the staff. Further, the staff was notified of the code changes by text messages. Interview with LPN #6 and LPN #3, on 07/28/2021 at 3:15 PM, revealed they received text messages about the door codes. 6. Interview with the Maintenance Director, on 07/28/2021 at 3:50 PM, revealed residents could not exit the building by themselves. He stated staff must now accompany all residents and non-staff members out of the facility. Interview with State Registered Nursing Assistant (SRNA) #5 and SRNA #6, on 07/28/2021 at 3:00 PM; and, SRNA #1, SRNA #3, SRNA #4, Kentucky Medication Aide (KMA) #1, KMA #5, and Licensed Practical Nurse (LPN) #5, on 07/28/2021 at 4:00 PM, revealed residents could not go out of the facility by themselves. Further, they stated staff must accompany all residents and non-staff out of the facility. 7. Observation of the Dial My Calls system on the Administrator's computer, on 07/29/2021 at 9:00 AM, revealed texts were sent out as a Reminder for door code security to all staff. Interview with Housekeeper #3, Housekeeper #4, Laundry Worker #1, and the Housekeeping Supervisor, on 07/28/2021 at 2:40 PM, revealed the door locks were changed on 07/15/2021. Further, they stated they received text messages when the codes were changed. In addition, they stated codes were changed every Tuesday. 8. Review of an Employee Education Attendance Record, dated 07/16/2021, revealed the VPoC in-serviced the MDS Coordinator. The in-service was on the Comprehensive Person-Centered Care Plan policy and the importance of adding interventions timely as needed to prevent elopement. Interview with the MDS Coordinator, on 07/28/2021 at 3:35 PM, revealed she was in-serviced by the VPoC on 07/16/2021. The education was related to the Comprehensive Person-Centered Care Plan policy. The education included the importance of adding interventions timely as needed to prevent elopement. 9. Review of Resident #1's Care Plan, related to elopement, revealed a revision, dated 07/10/2021, which included a person-centered risk for elopement intervention of one-to-one (1:1) supervision when the resident exhibited elopement behaviors. Review of Resident #2's Care Plan, related to elopement, revealed a revision, dated 07/15/2021, which included a person-centered risk for elopement intervention of one-to-one (1:1) supervision when the resident exhibited elopement behaviors. Interview with the DON, on 07/28/2021 at 2:00 PM, revealed she reviewed and revised the care plans for Resident #1 and Resident #2 to include person-centered risk for elopement interventions. 10. Review of the in-service sign-in sheet related to education on door locks, dated 07/16/2021, presented by the VPoC revealed the Maintenance Director attended the in-service. Review of daily audits of door locks, dated 07/16/2021 through 07/28/2021, revealed the doors were checked daily for proper locking. Interview with the Maintenance Director, on 07/28/2021 at 3:50 PM, revealed he changed the door codes and informed the Administrator of the new codes. Additionally, the Administrator then notified the staff. Further, he stated the do [TRUNCATED]

Based on observation, interview, record review, review of the facility's policies, review of the facility's investigation, and review of a Local Weather document, it was determined the facility failed to have an effective system in place to ensure each resident received adequate supervision to prevent elopement for two (2) of ten (10) sampled residents (Resident #1 and Resident #2). The facility admitted Resident #1, on 10/20/2020, with diagnoses that included Cognitive Communication Deficit, Chronic Obstructive Pulmonary Disease (COPD), Schizophrenia, and Need for Assistance with Personal Care. Resident #1 was independent with mobility. Interviews and record review revealed the resident exhibited exit-seeking behaviors. On admission, the facility assessed the resident to be an elopement risk and a secure care bracelet was placed on his/her right ankle. Interviews revealed the resident was constantly exit-seeking, attempting to go outside and smoke. Review of Resident #1's notes and care plans revealed Resident #1 exited the building on 02/13/2021, 03/02/2021, and 05/31/2021 and attempted to exit on 03/18/2021, 05/09/2021, 05/22/2021, 05/24/2021, and 06/30/2021. Per record review, around 5:05 PM on 07/10/2021, staff received a call from police dispatch alerting them there was an elderly person next door at the apartment buildings, complaining of shortness of breath and asked if the facility was missing a resident. The elderly person was identified as Resident #1. Interview with Resident #1 revealed he/she went out the front door when no staff was around. The resident stated he/she walked to the apartment buildings next door and started knocking on doors looking for a cigarette; when he/she got short of breath, a family let him/her in their home, offered him/her a glass of water, and called 911. Review of the Emergency Medical Services (EMS) Emergency Run Report for the incident revealed Resident #1 exhibited shortness of breath, pursed lip breathing, had an oxygen saturation level of eighty-seven percent (87%), and his/her lung sounds were diminished bilaterally. The resident was transported to the local hospital for evaluation. The facility admitted Resident #2, on 02/21/2021, with diagnoses that included Alzheimer's, Unspecified Dementia with Behavioral Disturbance, and Unspecified Psychosis. Resident #2 was independent for mobility. Review of Resident #2's Progress Note dated 02/22/2021, revealed the resident was a new admission, and upon entering the facility, the resident began looking for exits and voicing the desire to walk out into the snow/ice to go home. The facility assessed Resident #2 as being a high risk for elopement, and a secure care bracelet was placed on the resident's ankle for safety. Interviews with staff revealed Resident #2 was constantly wandering the halls aimlessly, pushing on exit doors, and attempting to follow others out of the door. On 07/10/2021 at approximately 4:30 PM to 4:45 PM, staff sitting out back on break, found Resident #2 outside of the building, unsupervised. The staff immediately got the resident and escorted him/her back into the building and informed LPN #3. Interview with LPN #3, revealed she not assess the resident or check the secure care bracelet for functioning and did not increase the resident's level of supervision. Further interview revealed she was not directed to fill out an incident report or advised to document the incident by the Director of Nursing (DON) or Administrator. The facility failed to determine how and when the residents exited the facility without staff knowledge. The facility's failure to have an effective system in place to ensure each resident received adequate supervision to prevent elopement has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified on 07/15/2021 and were determined to exist on 07/10/2021. The facility provided an acceptable Immediate Jeopardy Removal Plan on 07/27/2021, with the facility alleging removal of the Immediate Jeopardy on 07/23/2021. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on 07/23/2021, prior to exit on 07/29/2021. The facility's remaining non-compliance was at a Scope and Severity of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's policy titled, Wandering and Elopements, undated, revealed the facility would identify residents who were at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. Further, if identified as a risk for wandering, elopement, or other safety issues, the resident's care plan would include strategies and interventions to maintain the resident's safety. In addition, when the resident returned to the facility after an elopement, the Director of Nursing Services (DON), or charge nurse shall: examine the resident for injuries; contact the Attending Physician and report findings and conditions of the resident; notify the resident's legal representative; notify search teams that the resident had been located; complete and file an incident report; and document relevant information in the resident's medical record. Review of the facility's policy titled, Accidents and Supervision, dated 01/01/2020, revealed the residents' environment was to remain as free of accident hazards as possible; and, each resident received adequate supervision and assistive devices to prevent accidents. Further review revealed this included identifying, evaluating and analyzing hazard(s) and risk(s), implementing interventions to reduce hazard(s) and risk(s), monitoring interventions for effectiveness, and modifying interventions when necessary. 1. Review of Resident #1's medical record revealed the facility admitted the resident on 10/20/2020, with diagnoses that included COPD, Schizophrenia, Cognitive Communication Deficit, and Need for Assistance with Personal Care. Review of Resident #1's Quarterly Minimum Data Set Assessment, dated 06/13/2021, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of fourteen (14) out of fifteen (15), which indicated intact cognition. Additionally, the behavior of wandering was present. Further, the resident had an elopement wander alarm. Review of Resident #1's Comprehensive Care Plan (CCP), initiated on 10/19/2020, revealed the resident was at risk for elopement related to wandering. A focus was the resident ambulated frequently throughout the facility and attempted to go outside for a cigarette. The goal was the resident would remain safe during nursing home placement. Further review revealed interventions included to provide the resident with education; involve the resident in decision making regarding daily choices; involve the resident in preferred activities; redirect the resident from doors; take a picture of the resident for identification for updating the elopement book; and, the wander guard bracelet was to be worn, with proper functioning ensured. Observation, on 07/13/2021 at 1:00 PM, revealed Resident #1 sitting in the back on the B-Wing, on the sun porch with other residents present. Further, there was no staff member present at the time. Interview with Resident #1, on 07/13/2021 at 1:15 PM, revealed he/she exited the front door of the building when no staff was around. Resident #1 stated he/she wanted a cigarette, and he/she saw the opportunity to exit the front door when no staff was present. Resident #1 further stated he/she walked to the apartment buildings next door and started knocking on doors looking for a cigarette. when he/she got short of breath. Resident #1 stated a family let him/her in their home, offered him/her a glass of water, and called 911. Telephone interview with Licensed Practical Nurse (LPN) #4, on 07/14/2021 at 9:01 AM, revealed she was assigned to Resident #1 on 07/10/2021. LPN #4 stated Resident #1 was constantly exit-seeking and required redirection. She stated she last saw Resident #1 around the sun porch, at approximately 4:30 PM on 07/10/2021, just before she started the pre-dinner finger sticks for blood glucose monitoring. LPN #4 stated, a little while later, she received a call from the police asking if the facility was missing a resident, as Resident #1 had been found at the apartment buildings next door to the facility. The LPN stated she went over to the apartments; however, Resident #1 was in the ambulance to be transported to the hospital for complaints of shortness of breath. Review of the EMS (Emergency Medical Services) Emergency Run Report, dated 07/10/2021 at 4:31 PM, revealed Resident #1 exhibited shortness of breath, pursed lip breathing, had an oxygen saturation level of eighty-seven percent (87%, normal was 95 to 100%), and his/her lung sounds were diminished bilaterally. The resident was transported to the local hospital for further evaluation. Review of the local weather conditions, for the facility's geographical area, revealed, on 07/10/2021 between 4:30 PM and 5:08 PM, the temperature was eighty-two (82) degrees Fahrenheit. Review of Resident #1's Progress Note, documented by LPN #4, dated 07/10/2021 at 5:00 PM, revealed the staff nurse received a phone call from dispatch reporting that Resident #1 was at the apartment building next to the facility. Further review revealed, Resident #1 was alert, had been evaluated by EMS, and was being sent to the local emergency room (ER) due to his/her oxygen saturation at eighty-seven (87) percent (%) on room air. Additionally, the Note stated that just prior to the incident, the resident was seen on the sun porch asking staff for a mask. Review of Resident #1's Progress Note, documented by LPN #1, dated 07/10/2021 at 8:00 PM, revealed the resident returned to the facility from the ER with no new orders. Further review, revealed the resident would remain on one-to-one (1:1) supervision with staff; the secure care bracelet would remain in place to the right ankle; and the bracelet would function properly. In addition, a skin assessment was completed, and the resident was educated related to the time for scheduled smoke breaks and the risk of attempting to leave the facility without staff or family. The Note stated Resident #1 replied, I know, I won't do it again. Interview with Kentucky Medication Aide (KMA) #1, on 07/13/2021 at 3:42 PM, revealed she was typically assigned to the B-Wing; however, she did work A-Wing when needed. She stated she was working, on 07/10/2021, as an aide on first shift and then switched to work as a KMA on second shift. She stated that Resident #1 was constantly exit-seeking. Continued interview revealed the resident would become aggressive and would hit staff if he/she did not get his/her way. KMA #1 stated she witnessed Resident #1 ask the nurse for a cigarette, around 4:00 PM on 07/10/2021. In addition, she stated the resident had exited the building several times; however, this was the first time, to her knowledge, that the resident got off of the facility property. Interview with the receptionist, on 07/13/2021 at 5:17 PM, revealed she worked on 07/10/2021. She stated at approximately 4:45 PM, she stepped away from the front lobby to go to the restroom. She stated there was no staff, family members, or residents present when she left. In addition, she stated she returned between 5:05 PM to 5:10 PM. The Receptionist stated the phone was ringing, and when she answered it, police dispatch asked her if they possibly had one (1) of our residents. Per the interview, she stated Resident #1 attempted to elope often. She stated upon her return to her desk there were no alarms sounding. She stated, staff members and some family members had the codes to the doors, and she was unaware of the protocol if family members were permitted to have the code. Observation of the facility's secure care system and interview with the Maintenance Director, on 07/14/2021 at 1:10 PM, revealed when a resident, who was wearing the secure care bracelet, got close to the door, the key pad on the door would flash red and alarm, and a panel at the nurse's station flashed red and alarmed. In addition, the door locked so no one could enter the code to open the door; however, he stated the door would open after pushing on the egress bar for fifteen (15) seconds. He stated the flashing and alarming stopped when the resident wearing the bracelet moved out of the perimeter of the secure care system; therefore, the system did not require manual deactivation of the alarm. Interview with State Registered Nurse Aide (SRNA) #1, on 07/13/2021 at 5:26 PM, revealed he was assigned to Resident #1 on 07/10/2021. He stated, at approximately 4:10 PM, the resident requested a mask from him. Per the interview, he informed the resident he did not have a mask, and the resident could request a mask from the nurse. He stated the resident then walked up the hallway toward the nurse's station. In addition, he stated Resident #1 was constantly exit-seeking and repeatedly would ask to go out and smoke a cigarette. Review of Resident #1's Admission/Readmission Nursing Evaluation, dated 10/19/2020 at 2:05 PM, revealed Resident #1 had a past history of elopement; date of occurrence not available. Resident #1 had a total score of sixteen (16) on the assessment, which indicated the resident was at high risk for elopement. A Wander Guard bracelet was placed on the resident's right ankle. Additional review of Resident #1's Quarterly Nursing Evaluation, dated 03/04/2021 at 11:43 AM, revealed Resident #1 was ambulatory, alert, and had purposeful exit-seeking, with a total elopement score of thirteen (13); a score of ten (10) or higher indicated the resident was at risk for elopement. In addition, under the comment section, it stated the resident had no history of elopement, but had made numerous attempts to exit the facility. Observation of the elopement route, on 07/10/2021, revealed Resident #1 ambulated through the front door, turning left down the sidewalk, exiting through the black lift handle gate, then turning right into the parking lot; at the end of the parking lot, the resident turned left and proceeded down a one (1) lane road; the resident then turned left, up a steep hill to an apartment building. When Resident #1 arrived at the apartment building where he/she was found, it was approximately five-hundred sixty three (563) feet away from the facility. Review of Resident #1's Mental Health Progress Note, signed by the Advanced Practice Registered Nurse (APRN), dated 01/12/2021 at 12:07 PM, revealed the resident had diagnoses to include Schizophrenia; Cognitive Disorder; and Major Depressive Disorder. Further review revealed, under the discussion notes, there was a recommendation for hourly checks for the resident related to being a flight risk. However, there was no documented evidence in the resident's CCP or Physician's Orders of the resident being placed on hourly checks. Interview with the DON, on 07/14/2021 at 1:54 PM, revealed the resident was care planned for behaviors of exit-seeking. Further interview revealed Social Services was responsible for reviewing the Mental Health Progress Notes and recommendations. Per the interview, the facility currently did not have a Social Service employee, and he was unaware of the recommendation for hourly checks, dated 01/12/2021. Further interview revealed the DON was currently responsible for all contractual Progress Notes from outside providers. Interview with the DON, on 07/14/2021 at 5:30 PM, revealed nurses were responsible for updating the working copy of the care plan, and the MDS Coordinator was responsible for ensuring the electronic version of the CCP was updated. However, there was no documented evidence, of the Mental Health Progress Note, dated 01/12/2021 related to hourly checks for Resident #1, having been implemented. Review of Resident #1's Mental Health Progress Note, dated 02/24/2021 at 1:43 PM, signed by the APRN, revealed under behaviors: wandering and elopement risk; resident was found walking out of the building. However, there was no documented evidence on the CCP of increased monitoring or supervision. Review of Resident #1's Progress Note, dated 03/09/2021 at 1:20 PM, revealed the resident was standing in the doorway of the front lobby with arms spread, blocking anyone from entering or exiting the facility. The receptionist attempted to redirect the resident without success. The nurse asked the resident where he/she was going and the resident responded, To the gas station to buy cigarettes. However, there was no documented evidence the CCP was updated. Review of Resident #1's Progress Note, dated 06/30/2021 at 6:24 PM, revealed staff from A-Wing saw the resident attempt to go outside through the back door twice unsupervised. The resident was redirected back to his/her unit and was educated about not attempting to go outside alone without staff present. However, there was no documented evidence on the resident's CCP that increased supervision or monitoring was implemented related to the attempted elopement. Review of Resident #1's Progress Note, dated 07/07/2021 at 4:15 PM, completed by Unit Manager #1, revealed the resident ran past a new employee, exiting the back door and running into the gazebo used for the residents' smoke breaks. Staff was present and witnessed the occurrence. Per the note, the resident became aggressive with staff and refused to go back inside. The resident was educated on smoke breaks and that cigarettes could not be shared. Resident #1's son, the DON, and the Administrator were notified of the incident. Per the Note, the Administrator requested that referrals be sent out to other facilities that could allow the resident more smoking privileges. Interview with B-Wing Unit Manager #1, on 07/13/2021 at 5:45 PM, revealed she had worked at the facility for eight (8) years. She stated Resident #1 had made numerous attempts to elope. She stated the resident was always asking for a cigarette. Unit Manager #1 stated the resident would not be safe outside unsupervised by staff. Review of the facility's Incident Report, dated 07/10/2021 at 5:00 PM, completed by LPN #4, revealed the Police Dispatcher called the facility and reported that the resident was seen out of the facility and went to an apartment asking for a cigarette. When LPN #4 arrived at the apartment, Resident #1 was with EMS being evaluated, and the resident's oxygen saturation level was at eighty-seven percent (87%) on room air. Per the report, EMS placed oxygen on the resident and was transporting him/her to the local hospital for further evaluation. Continued review revealed the resident reported that he/she walked out the front door and was looking for a cigarette. Record review revealed LPN #4 spoke with EMS and the resident in the ambulance prior to being transferred to the hospital. The Administrator was notified of the incident. Per the report, staff initiated checks to verify all residents were in the building. Upon return form the hospital, Resident #1's wander guard bracelet was checked and functioning. The report stated the door alarms were working, and one-to-one (1:1) supervision was initiated for Resident #1. Review of the Long Term Care Facility-Self Report Incident Form, Initial Report, dated 07/10/2021 at 8:10 PM, revealed an incident, missing resident/elopement occurred on 07/10/2021 involving Resident #1. Per the report, Resident #1 exited the facility property and went next door to an apartment. Continued review revealed the police were notified, and the Ambulance transported the resident to a local hospital for evaluation. Per the report, no injuries were noted, and the investigation was started. Per the report, all other residents were accounted for. Continued review revealed the wander guard system was checked for proper functioning. Telephone interview with Resident #1's son was attempted, on 07/15/2021 at 11:28 AM. A voice message was left to return the State Survey Agency (SSA) Surveyor's call, but no call from the son was received. Telephone interview with Resident #1's Physician, on 07/15/2021 at 7:59 AM, revealed he was made aware of the elopement. Per the interview, he stated the resident should not have been outside unsupervised, and it was fortunate he/she did ask for help. Review of Resident #1's CCP, dated 07/10/2021, revealed the resident had exit-seeking behaviors and eloped from the facility; the resident was placed on one-to-one (1:1) supervision, from 07/10/2021 through 07/12/2021; and was then placed on fifteen (15) minute checks between the hours of 2:00 PM and 8:00 PM. Interview with the DON, on 07/14/2021 at 1:54 PM, revealed the root cause analysis for changing the resident from one-to-one (1:1) supervision to fifteen (15) minute checks during the hours of 2:00 PM to 8:00 PM was that this was the particular time the resident needed to be monitored. He stated this was the resident's peak times under his determination. Further interview revealed they were searching for alternative placement at an assisted living facility where the resident would be better suited. Observation of Resident #1, on 07/14/2021 at 09:45 AM revealed the resident was sitting in the back of B-hall in the sunroom unattended. Per the interview, the resident stated he/she was asking for a cigarette. Interview with LPN #7, on 7/15/2021 at 10:25 AM, revealed she worked on the B-Wing where Resident #1 resided. She stated the resident was an elopement risk and had a history of exiting the facility. Per the interview, she was not surprised when she was informed of Resident #1's elopement because the resident had a history of outburst and being impulsive. Further interview revealed when a resident was wearing a wander guard, it was her understanding the door would flash and beep; and, at the nurse's station, the panel would tell the onlooker which door was alarming. She stated the alarm was not supposed to be silenced or reset until the door was checked for a resident. Interview with LPN #4, on 07/15/2021 at 1:10 PM, revealed, on 07/10/2021, when she was assigned to Resident #1, she did not hear any alarms sounding. She stated sometimes it was hard to hear the alarm if she was in another resident's room or down the hallway. Interview with the DON, on 07/15/2021 at 2:37 PM, revealed he was unaware of the silencing button at the nurse's station for the wander guard system. Furthermore, he was not aware, if silenced, it would have to be reset for proper functioning. The DON stated the risk factors would be the resident could exit the facility without staff knowledge. He further stated it was his expectation for staff to ensure the resident's safety at all times. The DON stated if a resident eloped, he would expect for staff to increase his/her supervision and monitoring to ensure his/her safety. Interview with the Administrator, on 07/15/2021 at 3:18 PM, revealed it was his expectation for staff to ensure the residents' safety. He expected staff to manage the situation for the safety of the residents. He further stated he would expect staff to update the care plans of any new intervention for the residents to ensure their safety. He stated the risk factors for an elopement would be the resident could fall and get seriously injured. The Administrator stated staff should not just silence the alarm and should always check to see why the alarm was sounding to ensure each resident's safety. 2. Review of Resident #2's electronic medical record revealed the facility admitted the resident on 02/21/2021, with diagnoses that included Alzheimer's, Unspecified Dementia with Behavioral Disturbance and Unspecified Psychosis. Resident #2 was independent for mobility. Review of the Nursing Admission Assessment, dated, 02/22/2021, signed by UM #1, revealed the facility assessed Resident #2 as being a high risk for elopement and a secure care bracelet was placed on the resident's ankle for safety. Further review of the Nursing Admission Assessment Elopement Evaluation Section revealed a Progress Note that stated the resident was a new admission to the building; and, upon entering the facility, the resident began looking for exits and voicing the desire to walk out into the snow/ice to go home. Review of Resident #2's Comprehensive Care Plan (CCP), initiated on 02/22/2021, revealed the resident was at risk for elopement related to wandering. The goal was the resident would remain safe during nursing home placement. Further review revealed interventions included to involve the resident in preferred activities; redirect the resident from doors; and the wander guard bracelet was to be worn, with proper functioning ensured. Observation, on 07/13/2021 at 1:35 PM, revealed Resident #2 was wandering aimlessly in the hallways. Resident #2 was observed on the back hall of Unit A by the exit door. Continued observation revealed staff taking other residents outside for a smoke break, and Resident #2 was attempting to follow staff out the door. Resident #2 was redirected from the door by staff. Interview with Kentucky Medication Aide (KMA) #1, on 07/13/2021 at 3:42 PM, revealed she was assigned to B-Unit; however, Resident #2 resided on A-Unit. Per the interview, Resident #2 was independent with mobility, was alert, but was not oriented. KMA #1 stated the resident wandered aimlessly up and down the halls, pushing furniture around; went in and out of other residents' rooms; and attempted to follow staff and visitors out the doors. On 07/10/2021 at approximately 4:30 PM to 4:45 PM, she was sitting outside on break when she and another staff member found Resident #2 outside of the building unsupervised, walking around the back of the building holding onto the building and gutters. She stated the other staff member (KMA #3) got the resident, escorted him/her back into the building, and informed LPN #3 of the incident. She stated it was not safe for Resident #2 to be outside unsupervised. Further interview revealed she had not been informed to increase supervision or monitoring for Resident #2. However, after the incident, the resident should have been placed on one-to-one (1:1) supervision for the resident's safety. Interview with KMA #3, on 07/14/2021 at 4:14 PM, revealed she and another coworker were outback on break when she looked up and saw Resident #2 coming from around the building, in the grass, holding onto the building and gutters. She stated she immediately got the resident and escorted him/her back into the building; then, she informed LPN #3 of the incident. Telephone interview with LPN #3, on 07/13/2021 at 6:17 PM, revealed she was made aware, by KMA #3, of Resident #2 being outside unsupervised. She stated she informed the Director of Nursing (DON) and the Administrator of staff finding the resident outside unsupervised. However, she did not assess the resident or check the secure care bracelet for functioning and did not increase the resident's level of supervision. Further interview revealed she was not directed to fill out an incident report or advised to document the incident. Continued interview revealed the resident wandered aimlessly and liked to rearrange furniture in the front lobby. She stated the resident was always on the move and walking. LPN #3 stated she did not recall hearing an alarm sounding, but she was admitting a new resident at the time. Review of Resident #2's Progress Note, from 07/10/2021, revealed there was no documented evidence of the incident of Resident #2 being outside unsupervised. Interview with the Administrator, on 07/13/2021 at 5:45 PM, revealed the facility did not have an incident report related to Resident #2's elopement. Per the interview, it was his understanding the resident was outside with staff, and he was unaware the resident was outside unsupervised. The Administrator stated it would not be safe for the resident to be outside unsupervised, as the resident was at risk for elopement. Interview with the DON, on 07/14/2021 at 8:00 AM, revealed he was unaware of Resident #2 being outside unsupervised on 07/10/2021. Further interview revealed Resident #2 would not be safe outside unsupervised. There was no documented evidence the facility completed a Long Term Care Facility-Self Report Incident Form related to Resident #2's elopement. Review of Resident #2's Quarterly MDS, dated [DATE], revealed the resident was assessed by the facility with a Brief Interview for Mental Status (BIMS) score of three (3) out of fifteen (15), indicating the resident was moderately impaired and not interviewable. Further review revealed the resident exhibited hallucinations and delusions at times. Review of Resident #2's CCP, initiated on 02/22/2021, with focus revealed a focus was at risk for elopement related to wandering behaviors; and, the goal was the resident would remain safe during nursing home placement. Further review of the CCP revealed interventions were to involve the resident in preferred activities; redirect the resident from doors; and the wander guard bracelet was to be worn, with proper functioning ensured. However, there was no documented evidence the CCP was revised, on 07/10/2021, when the resident exited the facility. Interview with UM #1, on 07/13/2021 at 5:45 PM, revealed she was told by staff that Resident #2 had walked out the front door in view of staff, but she was not sure of the staff. She stated she was in a panic related to the incident with Resident #1 and could have misunderstood the incident with Resident #2. Continued interview revealed Resident #2 was not allowed outside unsupervised. Per the interview, she did not think the resident would intentionally exit-seek, but with Resident #2's disease process with Alzheimer's, the resident would not be safe. Interview with the UM of A-Unit, on 07/13/2021 at 5:57 PM, revealed she was out of town, on 07/10/2021, and learned of Resident #1's elopement on Monday, 07/12/2021. However, she was not informed of Resident #2 being outside unsupervised. She stated it was her expectation for staff to inform her of incidents and document these incidents in the electronic health record. Telephone interview with KMA #2, on 07/13/2021 at 6:06 PM, revealed she worked on A-Unit on 07/10/2021. She stated she was helping another aide do rounds, when she witnessed KMA #3 escorting Resident #2 through the back door. She stated she was unsure of the time. Continued interview revealed it would not be safe for the resident to be outside unsupervised. She further stated LPN #3 was made aware of the incident; however, LPN #3 was also working on a new admission. Interview with LPN #4, on 07/14/2021 at 9:01 AM, revealed she was informed from another nurse that Resident #2 had also exited the facility at the same time as Resident #1. Per the interview, Resident #2 wandered to the back of the building, and KMA #1 and KMA #3 saw him/her while they were out on break. She stated the resident was escorted back into the building. LPN #4 stated the resident was not safe to be outside unattended, and she was unaware of any new interventions. Telephone interview with Resident #2's Physician, on 07/14/2021 at 8:00 AM, revealed he was made aware of the incident. He stated the resident should not be out of the building unsupervised because the resident would not be safe. Further interview revealed the Physician expected the staff to have knowledge of the resident's location and not allow the resident to leave the facility unassisted and without staff's knowledge to ensure the resident's safety. Subsequent interview with the DON, on 07/14/2021 at 1:54 PM, revealed he received a call from LPN #3, on Saturday, 07/10/2021, notifying him that Resident #2 went out the front door and around back. Further interview revealed there was no documented evidence of the incident. He stated it was his expectation for th [TRUNCATED]

Based on observation, interview, record review, review of the facility's policies, and review of the facility's investigative report, it was determined the facility failed to have an effective system to maintain an environment free from physical and verbal abuse for ten (10) of twenty-two (22) sampled residents, Residents #1, #2, #3, #4, #6, #7, #8, #9, #10, and #11. On 05/03/2021, Personal Care Attendant (PCA) #6 reported she witnessed Licensed Practical Nurse (LPN) #8 commit physically and verbally abusive acts toward Residents #1, #2, and #3. According to PCA #6, LPN #8 committed the abuse over the past two (2) months, but she could not provide exact dates she witnessed the resident abuse. The PCA stated she was afraid to report LPN #8's actions while the nurse was still working at the facility because she feared the nurse would retaliate against her, and she reported the abuse only after the facility terminated LPN #8, on 05/01/2021. On the weekend of 04/23/2021 to 04/25/2021, PCA #6 reported LPN #8 told her she had given marijuana to Resident #4. Interviews with Resident #4 and his/her family member also confirmed LPN #8 gave him/her marijuana. On 05/04/2021, Resident #7 hit Resident #6 on the arm with a cup after Resident #7 yelled at him/her. Resident #6 then threw the cup at Resident #7, and the cup hit Resident #7 near his/her eye. On 03/05/2021, Resident #10 smacked Resident #11 in the face twice. Further record reviews and interviews with staff revealed Resident #10 was known to have aggressive behaviors directed towards others. On 04/04/2021, Resident #8 smacked Resident #9 on the forehead with an open hand and subsequently Resident #9 hit Resident #8 with an open hand to the facial region. Further interviews with staff revealed Resident #8 was known to have aggressive behaviors directed towards others. The facility's failure to have an effective system in place to maintain an environment free from staff-to-resident physical and verbal abuse has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified on 05/21/2021 and was determined to exist on 04/25/2021. The facility provided an acceptable Immediate Jeopardy Romoval Plan on 05/28/2021, with the facility alleging removal of the Immediate Jeopardy on 05/26/2021. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on 05/26/2021, prior to exit on 06/03/2021, with the remaining non-compliance at a Scope and Severity of a E while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's policy titled, Resident Rights, revised December 2016, revealed residents had certain basic rights that included a dignified existence, to be treated with respect, kindness, and dignity, and to be free from abuse, neglect, misappropriation of property, and exploitation. Review of the facility's policy titled, Abuse Prevention Program, revised December 2016, revealed residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This included but was not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Further review of the policy revealed it stated as part of resident abuse prevention, the administration would protect residents from abuse by anyone including, but not necessarily limited to facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, and any other individual. In addition, per the policy, the facility would implement measures to address factors that could lead to abusive situations by providing staff with opportunities to express challenges related to their job and work environment without fear of retaliation; instructing staff regarding appropriate ways to address interpersonal conflicts; and helping staff understand how cultural, religious and ethnic differences could lead to misunderstanding and conflicts. Further review revealed facility staff would receive training on abuse prevention, identifying and reporting abuse, and handling verbally or physically aggressive resident behavior. Review of the facility's policy titled, Recognizing Signs and Symptoms of Abuse/Neglect, revised January 2011, revealed the facility would not condone any form of resident abuse or neglect. The policy defined neglect as failure to provide goods and services as necessary to avoid physical harm, mental anguish or mental illness. The policy stated among the signs of actual neglect, a caregiver's indifference to a resident's personal care needs was included within the list. Review of the facility's policy titled, Abuse and Neglect-Clinical Protocol, revised March 2018, revealed the facility management and staff would institute measures to address the needs of residents and minimize the possibility of abuse and neglect. Further review revealed that the Physician and staff would address appropriately, causes of problematic resident behavior where possible, such as [CONDITION(S)], [CONDITION(S)], and medication side effects. 1. Review of Resident #1's clinical record revealed the facility admitted the resident, on 04/07/2020, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Annual Minimum Data Set (MDS) Assessment, dated 04/11/2021, revealed the resident scored a fourteen (14) out of a possible fifteen (15) on the Brief Interview for Mental Status (BIMS) score for cognition, indicating the resident was interviewable. Review of Resident #2's clinical record revealed the facility admitted the resident, on 10/19/2020, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly MDS assessment, dated 03/13/2021, revealed Resident #2 had a BIMS score of thirteen (13) out of a possible (fifteen (15), indicating the resident was interviewable. Review of Resident #3's clinical record revealed the facility admitted the resident, on 09/22/2015, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly MDS assessment, dated 04/07/202, revealed Resident #3 scored a fifteen (15) out of a possible fifteen (15) on the BIMS assessment for cognitive function, indicating the resident was interviewable. Review of the facility's Investigation Report, dated 05/07/2021 and signed by the Director of Nursing (DON), revealed on 05/03/2021 PCA #6 reported that former employee, LPN #8, displayed behaviors prior to termination of her employment, which could be classified as abuse. The abusive acts affected Residents #1, #2, and #3. According to the investigation, the DON fired LPN #8 on, 05/01/2021, because of her inappropriate treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Per the report, LPN #2 was the first staff member who reported the abuse allegations to administration, as told to her by PCA #6. LPN #2 contacted the Assistant Director of Nursing (ADON), in the early morning of 05/03/2021, and reported the allegations PCA #6 made against LPN #8. Per the report, the DON conducted interviews, on 05/03/2021, with Residents #1, #2, and #3. Residents #1 and #2 confirmed LPN #8 squirted them with water. Review of the DON's interview with Resident #1, dated 05/03/2021, signed by Resident #1 and the DON, revealed the resident identified LPN #8 as the nurse who squirted him/her with water. Review of the DON's interview with Resident #2, dated 05/03/2021, and signed by Resident #2 and the DON, revealed Resident #2 confirmed he/she was squirted with water, and thought a nurse squirted him/her, but was unable to remember the nurse's name. However, the resident said he/she could recognize the staff person, if he/she saw her. Resident #2 told the DON he/she did not report the incident because he/she did not want to get the nurse fired. An additional interview between the two, on 06/02/2021 at 1:54 PM, revealed the DON showed a photo of LPN #8 to Resident #2, and the resident confirmed the individual in the photo was (LPN #8) who squirted him/her with water. When the DON interviewed Resident #3, on 05/03/2021, he/she could not remember if anyone had squirted him/her with water. Review of PCA #6's written statement, dated 05/06/2021, who at that the time wanted to remain anonymous, revealed PCA #6 wrote that LPN #8's abusive acts occurred on night shift when no other staff member was around except her. She wrote the nurse grabbed some cheese and threw it at Resident #1 aiming at his/her face, and she overheard LPN #8 say Dumb M. F-er, under her breath when she thought Resident #1 could not hear her. She also wrote that in the presence of Resident #1, LPN #8 said, This is the reason cousins don't [OBSCENITY] . PCA #6's statement revealed LPN #8 filled a long syringe with water, hit it real hard, and squirted water on Residents #2 and #3. The statement revealed LPN #8 called it a Mini Baptismal and told PCA #6 she did similar things to residents at another facility when she did not like them. The written statement revealed other staff did not like the way LPN #8 talked to the residents. The DON added to PCA #6's written statement that the PCA lived in very close proximity to LPN #8 and truly felt in danger of retaliation because PCA #6 was the only staff member working with LPN #8 when the abusive acts occurred; therefore, it would be obvious to LPN #8 that PCA #6 had reported the abuse. Interview with the DON, on 05/17/2021 at 7:58 PM, revealed that even though PCA #6 requested to be an Anonymous Witness when he interviewed her on 05/06/2021, her statements were no longer considered anonymous. Observations, on 05/10/2020, 05/11/2020, and 05/13/2020 revealed Resident #1 mostly sat in a chair at the doorway to his/her room, and occasionally walked around in the facility's lobby. Resident #1 often called out loudly to staff telling them to bring him/her some water, a pop, or food. During an attempted interview with Resident #1, on 05/11/2021 at 9:46 AM, the resident did not answer the State Survey Agency (SSA) Surveyor's questions. Instead, Resident #1 would interrupt and ask the SSA Surveyor questions about her own family and would proceed to talk about his/her life. Upon several attempts, the resident did not answer the SSA Surveyor's questions, but continued to digress. Observation, on 05/12/2021 at 9:35 AM, of Resident #2, revealed he/she was sitting in a common area waiting to go outside for a smoke break. Interview with Resident #2, on 05/12/2021 at 9:35 AM, revealed he/she had a bad memory and did not remember anyone squirting him/her with water. However, he/she said staff better stop being mean to him/her, and explained a couple of staff told him/her to shut up, but he/she could not remember who they were. Observation, on 05/11/2021 at 10:00 AM, of Resident #3, revealed he/she lived on the facility's A Hallway. He/she was sitting in a high back wheelchair and was watching television in his/her room. Interview with Resident #3, on 05/18/2021 at 3:50 PM, revealed he/she denied anyone had squirted him/her with water, but he/she did not think LPN #8 was a nice person. Resident #3 stated when he/she lived on B Hallway, after completing a phone call to his/her spouse, he/she self-propelled back to the doorway of his/her room. Resident #3 said he/she needed assistance back to bed and called down the hall for the aides that were with LPN #8. Resident #3 said LPN #8's response to the aides was, Oh, he/she doesn't need help! The resident stated he/she continued to sit by the doorway of his/her room, waiting for assistance. The resident said he/she called out to the aides again, and then stated he/she called LPN #8 a cunt. Resident #3 said he thought LPN #8 had a negative attitude. Interview with LPN #2, on 05/11/2021 at 7:00 PM, revealed during the early morning of 05/03/2021, PCA #6 told her about LPN #8's abuse of Residents #1, #2, and #3. She said PCA #6 told her LPN #8 went into the bathrooms of Residents #1, #2, and #3, filled a gastrostomy (g-tube) syringe with water, opened the bathroom door just enough, and squirted water at the residents while they were sleeping. LPN #2 said LPN #8 did not like Resident #1 because he/she made racial slurs. LPN #2 said PCA #6 told her that LPN #8 made fun of Resident #1. LPN #2 said PCA #6 told her, that in reference to Resident #1, in his/her presence, LPN #8 said, Two of his/her cousins had sex and made him/her, and that was why he/she (Resident #1) was stupid. LPN #2 said she reported the allegations to the Assistant Director of Nursing (ADON), on the morning of 05/03/2021, as soon as PCA #6 reported them to her. She stated PCA #6 did not report the allegations until a day or so after the DON fired LPN #8 because she was afraid of what LPN #8 might do if she knew she reported her. LPN #2 said it did not surprise her that PCA #6 was frightened of LPN #8. She stated since LPN #8's dismissal, things were already much better on night shift. Interview with the ADON, on 05/17/2021 at 7:24 PM, revealed LPN #2 called her on 05/03/2021, very early, as she had not yet gotten out of bed, and reported the allegations of abuse against LPN #8. The ADON said she immediately called the DON and was able to reach him before 9:00 AM, which would have been before the morning staff meeting began at the facility. Interview with LPN #1, on 05/10/2021 at 7:50 PM, revealed a night shift nurse's aide, who she thought was PCA #6, spoke up and reported she witnessed LPN #8 do some not nice things to residents on the B Hallway. She stated she thought PCA #6 did not report the allegations of abuse until 05/03/2021, which was after the DON fired LPN #8. LPN#1 stated she heard LPN #8 squirted water at the residents while they slept, and LPN #8 threw cheese at Resident #1. LPN #1 said she worked nights and that PCA #6 reported the allegations to LPN #2, another night shift nurse who worked on 05/03/2021. Interview with PCA #6, on 05/11/2021 at 7:38 PM, revealed she witnessed LPN #8 throw slices of cheese at Resident #1 from the resident's doorway, and then she slammed his/her door shut. She said immediately after that happened, Resident #1 came to the nurse's station and stated, I'm tired of you girls disrespecting me, and I'm not going to have it. PCA #6 said she did not think the resident knew LPN #8 was the one who threw the cheese at him/her. PCA #6 stated she said nothing but just sat back and watched when Resident #1 complained. PCA #6 said it seemed LPN #8 thought it was funny because LPN #8 did not like Resident #1. She said Resident #1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . PCA #6 stated LPN #8 looked at Resident #1, and then at her (PCA #6) and said, This is why cousins don't [OBSCENITY] . PCA #6 said Resident #1 was present when LPN #8 made that statement, but the PCA said Resident #1 was hard of hearing, and she was not sure he/she heard LPN #8's comment. PCA #6 said she saw LPN #8 squirt water at residents while the LPN hid in their bathrooms. She said the LPN would shoot the water at the residents and toward the ceiling so the water would drip down on the residents. PCA #6 said after LPN #8 squirted the water in Resident #2's room, the resident came to the nurse's station and said he/she felt water on his/her face and thought the ceiling was leaking. PCA #6 stated she also saw LPN #8 squirt water at Resident #3. PCA #6 said she was afraid to report the allegations. She said many other nurse aides had quit their jobs because of LPN #8. She said she feared LPN #8 would retaliate if she reported the abuse while the nurse still worked at the facility. She said the possibility of retaliation was always on her mind. PCA #6 said she reported the abuse, on 05/03/2021, after the DON fired LPN #8. PCA #6 stated LPN #8 would know she was the person who reported her abusive actions, and she lived across the street from LPN #8. She said they would sometimes take breaks together. PCA #6 stated she could not pinpoint the exact day(s) she witnessed the LPN's abusive treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with SRNA #15, on 05/15/2021 at 6:05 PM, revealed LPN #8 was stern and loud when she spoke to staff and residents. She said LPN #8 liked to joke with the residents. SRNA #15 gave an example of LPN #8's practical jokes. She stated one night Resident #3 put on his/her call light and when LPN #8 went to the resident's room, she put a video on her phone with sounds of flatulence (gas sounds) and told the resident she could not help him/her right now because she had diarrhea. SRNA #15 said Resident #3 did not think the prank was funny because he/she needed help, but the SRNA could not remember what the resident needed. SRNA #15 said she did not report this to anyone, and she was unsure if anyone else reported the incident. SRNA #15 stated LPN #8 was very drama-filled and picked on people. She said many nurse aides quit because of LPN #8. SRNA #15 stated she did not know if other staff was afraid of LPN #8, but because of her periodic [NAME], she personally never said anything to challenge the nurse. SRNA #15 stated on another occasion, Resident #1 walked to the nurse's station and asked for ice. SRNA #15 said when the SRNA got up to get ice, LPN #8 told her she better sit down now and would not allow her to get the ice for the resident. Interview with PCA #16, on 05/16/2021 at 5:53 PM, revealed she worked the night shift with LPN #8. She said when Resident #1 would yell for ice, LPN #8 would tell her not to get ice for the resident because the resident could help himself/herself. PCA #16 said working with LPN #8 made her uncomfortable. She said she thought the LPN bullied her as well as other nurse aides. She stated LPN #8 tried to send her home by saying the shift was over-staffed. She stated when she worked with LPN #8, on the weekend of 04/23/2021 to 04/25/2021, the LPN told other staff that she (PCA #16) had an offensive odor, and LPN #8 tried to send her home. PCA #16 said she heard the night shift nurses on A Hallway (LPNs #1 and LPN #3) confronted LPN #8 over that. PCA #16 stated LPN #8's actions upset her because she needed to work. PCA #16 said she thought LPN #8 only wanted certain staff to work with her because she knew which ones would not report her if she did things to residents. Interview with the Administrator, on 05/18/2021 at 4:30 PM, revealed he had just spoken to PCA #6 and found out about the alleged abuse when he learned the DON had fired LPN #8. He said PCA #6 told him when she reported to work, on 05/01/2021 at 3:00 PM, staff members told her the DON had fired LPN #8 that morning. The Administrator said PCA #6 worked through the night, until the morning of 05/02/2021, but did not report the abuse allegations to LPN #2 until the morning of 05/03/2021. Interview, on 05/17/2021 at 3:41 PM, with the A Hallway Unit Manager (UM), revealed she became aware of the allegations against LPN #8 on the morning of 05/03/2021. She said it was unclear if the allegations were isolated events, or if they occurred over a longer period-of-time. She stated she heard there was discussion in the morning staff meeting about whether the allegations should be reported since the DON had already fired LPN #8. However, she said the DON consulted the Company's Vice President of Compliance, and he confirmed the facility must report the abuse allegations. The A Hallway UM said the investigation started on 05/03/2021, and she completed resident skin assessments for the investigation. Interview with the B Hallway UM, on 06/02/2021 at 9:30 AM, revealed she became aware of the allegations against LPN #8, on 05/03/2021. She said prior to that, night shift staff had not reported allegations against LPN #8. Interview with LPN #8, on 05/16/2021 at 4:22 PM, revealed the DON told her she was not a good fit for the facility when he fired her, on 05/01/2021, but he did not tell her there was an allegation of resident abuse against her. LPN #8 denied squirting water at Residents #1, #2, and #3, and denied she had thrown cheese at Resident #1. LPN #8 denied making abusive comments about Resident #1. She stated Resident #1 often made racist statements, and when the resident found out she had bi-racial family members, he/she made racist comments to her almost daily. She said Resident #1's racial slurs bothered her, not only because it was personal for her, but that his/her statements could offend some of the residents, too. LPN #8 said she did not think Resident #3 had any concerns about her. LPN #8 stated some staff did not like her because she had bi-racial family members, and she thought a couple of racist nurses had something to do with her dismissal. LPN #8 said staff and residents probably learned about her bi-racial family by looking at her social media account. Interview with the ADON, on 05/18/2021 at 3:21 PM, revealed some staff members did not like LPN #8, and complained she took too many breaks. She said since January 2021, she and the DON had worked a couple of night shifts each. However, night shift staff had not reported any abuse allegations against LPN #8, until 05/03/2021. The ADON stated she had oversight of all three (3) nursing shifts, was responsible for staffing each shift, and was on call day or night to address all types of staffing issues. The ADON said LPN #8's attempt to send PCA #16 home and reassign who was with her, on the weekend of 04/23/2021 to 04/25/2021, raised red flags and led to the DON's decision to fire the LPN. She stated prior to her report of 05/03/2021, PCA #6 had not reported she felt fearful of LPN #8. Interview with the DON, on 05/11/2021 at 11:00 AM, revealed he fired LPN #8, on 05/01/2021. He stated LPN #8 only worked on weekends, and he called her after the weekend of 04/23/2021 to 04/25/2021, but she denied trying to send PCA #16 home. The DON stated he fired LPN #8 because she had made inappropriate personal comments about PCA #16 and tried to reassign staff without a manager's approval. The DON said he talked with night shift LPN #1, who confirmed that PCA #16 did not have an offensive odor, as reported by LPN #8, and that LPN #8 tried to get SRNA #18 to come to work to replace PCA #16. 2. Additional interview with PCA #6, on 05/14/2021 at 6:50 PM, revealed about a week before the DON fired LPN #8, when working the weekend with LPN #8 (which she confirmed was the weekend of 04/23/2021 to 04/25/2021), LPN #8 gave marijuana (a psychoactive drug used primarily for medical or recreational purposes) to Resident #4. PCA #6 said LPN #8 told her to go smell Resident #4's room. PCA #6 stated the resident was awake and in bed, and she did smell the marijuana odor. PCA #6 said she reported this to LPN #8 and the LPN's response was, It's pretty strong, isn't it? PCA #6 stated LPN #8 told her she gave Resident #4 the marijuana. PCA #6 stated she did not think the LPN gave marijuana to other residents, because they were good friends, and she thought LPN #8 would have told her if she gave marijuana to any other residents. On 05/12/2021 at 5:07 PM, when the SSA Surveyor asked the Administrator if the facility had investigated an allegation that LPN #8 gave marijuana to Resident #4, the Administrator stated he was not aware of the allegation, but he would look into it right away. Review of Resident #4's clinical record revealed the facility admitted the resident, on 03/25/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #4's Admission MDS assessment, dated 04/02/2021, revealed the resident scored a fifteen (15) out of a possible fifteen (15) on the BIMS assessment for cognition, indicating the resident was interviewable. Interview with Resident #4, on 05/11/2021 at 3:50 PM, revealed the resident denied that LPN #8 gave him/her marijuana. Review of the facility's Incident Report, dated 05/12/2021 at 5:40 PM, revealed B Hallway staff discovered Resident #4 in his/her bed, groaning upon physical stimuli, nonresponsive to verbal stimuli, eyes open with pinpoint pupils, and unable to answer questions. The nursing staff notified the Advanced Practice Registered Nurse (APRN) and administered [MEDICATION(S)] (an opioid (narcotic) antagonist used to treat opioid overdoses) 0.4 milligrams (mg) intramuscularly. Per the report, the facility called Emergency Medical Services (EMS) and police to the facility. After receiving the [MEDICATION(S)] injection, per the report, the resident returned to a more normal level of consciousness and reported to staff and police he/she had illicit drugs hidden in the seam of his/her sweatshirt and had snorted [MEDICATION(S)] (on a rock) prior to his/her change in condition. The report stated the resident had been out of the facility on a day trip with his/her sister, on 05/11/2021. Interview with the Administrator, on 05/13/2021 at 8:56 AM, revealed the DON interviewed Resident #4, on 05/12/2021, after the resident received two (2) doses of [MEDICATION(S)] for a change in his/her mental status. The Administrator stated the resident told the DON he/she had ingested [MEDICATION(S)] (a very powerful opioid narcotic used to alleviate pain), on a rock (a method of processing the drug where it is broken into small pieces) that the resident had stored in his/her sweatshirt. The Administrator stated Resident #4 also told the DON that LPN #8 had given him/her marijuana. Additional interview with Resident #4, on 05/13/2021 at 12:07 PM, revealed LPN #8 gave him/her some marijuana wrapped in a chewing gum wrapper. Resident #4 denied using the marijuana. The resident said he/she did not ask LPN #8 for the marijuana and was unsure why she gave it to him/her. Resident #4 denied giving the marijuana to other residents, but stated he/she gave it to some other friends outside the facility. Resident #4 stated the DON and the Administrator questioned him/her, on 05/12/2021, after he/she received [MEDICATION(S)] and regained consciousness. Resident #4 said he/she did not initially tell the SSA Surveyor (on 05/11/2021) that LPN #8 gave him/her the marijuana because he/she did not want to get the nurse in trouble. Telephone interview with Resident #4's sister, on 05/19/2021 at 9:06 AM, revealed she overheard Resident #4 tell the Head Nurse at the facility that a nurse had given him/her marijuana. She said Resident #4 reported this after he/she had received the [MEDICATION(S)] and regained consciousness on 05/12/2021. The resident's sister stated Resident #4 told her this, about two (2) or three (3) weeks ago. She said Resident #4 did not tell her what he/she did with the marijuana, but she did not think the resident used it. She stated Resident #4 might have given it away. Resident #4's sister stated the resident told her the nurse just threw the marijuana in a bag down on him/her while he/she was in bed. The resident's sister said the resident could have mentioned the nurse's name, but she could not remember it. Interview with Resident #4's Physician, on 05/18/2021 at 11:45 AM, revealed he no longer thought Resident #4 was a credible individual based on his/her recent behavior of ingesting [MEDICATION(S)] he had stored in his/her clothing. But the Physician stated, obviously, street drugs were always detrimental to a person's health, so he would be very concerned about the resident's health and well-being if a nurse at the facility had given him/her marijuana. Continued interview with LPN #8, on 05/16/2021 at 4:22 PM, revealed she did not give marijuana to Resident #4, and if she knew a staff person had given an illicit substance to a resident, she would report that to administration. Interview with LPN #1, on 05/10/2021 at 7:50 PM, revealed a night shift Aide, who she thought was PCA #6, reported LPN #8 gave marijuana to Resident #4. She stated she heard that LPN #8 told PCA #6 to go into the hallway and see if she smelled the odor of marijuana. LPN #1 said after PCA #6 confirmed she smelled the odor in Resident #4's room, LPN #8 told the PCA she gave marijuana to Resident #4. LPN #1 said she worked nights, and that PCA #6 reported the allegations to LPN #2, another night shift nurse who worked on 05/03/2021. (LPN #1 was the staff person who made a report to the SSA that included the information about LPN #8 providing marijuana to a resident, Resident #4.) Review, of LPN #8's employee file, revealed the facility had an active, Licensed Practical Nurse (LPN) license on file for the nurse, with an expiration date of 10/31/2021. However, a statement at the top of the copy of his/her licence, read, UNDER INVESTIGATION. Details of the investigation are confidential until final resolution. This nurse may practice without restrictions provided the license expiration date is current and no active discipline. Interview with the Administrator, on 05/18/2021 at 12:32 PM, revealed he became aware of the abuse allegations against LPN #8, on 05/03/2021. He stated the DON fired LPN #8, on 05/01/2021, because of her inappropriate treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . He stated he had not directed the DON, the ADON, or other staff to increase monitoring of LPN #8 prior to her dismissal. He said the former Administrator hired LPN #8, in June 2020, and did not convey concerns about her when he took over as Administrator, in December 2020. The Administrator said it was possible LPN #8 could have committed other abusive acts. He said it was never acceptable for a caregiver to take out his/her personal feelings on residents, even if they disagreed with their beliefs and comments. The Administrator said he previously thought the facility had provided sufficient monitoring of LPN #8. But, he said he now thought the facility should have done more to monitor her work. The Administrator said there was an administrative presence at least weekly on all shifts and that included weekends, too. He stated, prior to 05/03/2021, no one had reported allegations of abuse that involved LPN #8. The Administrator said he became aware LPN #8's license was under investigation in February 2021. He said he questioned LPN #8 about her license, and she told him that while working at another facility, she had been falsely accused of possible drug diversion. He stated he had a long talk with LPN #8 and told her, since her license was under investigation, she should perform her duties professionally and always keep the residents safe. In addition, he stated administrative staff had no idea LPN #8 would go [NAME] because he thought the facility had implemented sufficient monitoring of LPN #8, but more should have been done to monitor her work at the facility. The Administrator stated the facility was ultimately responsible for any staff person employed at the facility. He stated LPN #8 was on the clock when the abusive acts occurred, so the facility would be responsible for her actions. Interview, on 06/02/2021 at 4:05 PM, with the Chief Operating Officer (COO) revealed it was company policy to self-report allegations of resident abuse. He stated it sickened staf [TRUNCATED]

Based on observation, interview, record review, and review of the Administrator's Job Description, it was determined the facility failed to be administered in a manner that enabled effective use of its resources to attain and maintain the highest practicable physical, mental, and psychosocial well-being for four (4) of twenty-two (22) sampled residents (Residents #1, #2, #3, and #4). On 05/03/2021, Patient Care Attendant (PCA) #6 came forward to report abusive treatment committed by night shift nurse, Licensed Practical Nurse (LPN) #8, toward Residents #1, #2, and #3. In addition, PCA #6 told the State Survey Agency (SSA) Surveyor that LPN #8 gave marijuana (a psychoactive drug used for medical or recreational purposes) to Resident #4 during the weekend of 04/23/2021 to 04/25/2021. Prior to the report of LPN #8's abusive resident treatment, the Administrator was aware, in February 2021, that LPN #8's nursing license was under investigation, but he continued to allow LPN #8 to work the night shift without implementing increased supervision of the nurse to assure she was providing safe, appropriate, and non-abusive care of the residents. The facility's failure to be administered in a manner that enabled productive use of its resources to have an effective system in place to ensure a staff member immediately reported observations of staff-to-resident abuse has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) was identified on 05/21/2021 and was determined to exist on 04/25/2021. The facility provided an acceptable Immediate Jeopardy Removal Plan on 05/28/2021, with the facility alleging removal of the Immediate Jeopardy on 05/26/2021. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on 05/26/2021, prior to exit on 06/03/2021, with the remaining non-compliance at a Scope and Severity of an E while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. In addition, the Administrator permitted three (3) of eleven (11) Patient Care Attendants (PCA) to provide resident care, even though they were not at least eighteen (18) years of age, as required by a temporary waiver issued, on 04/14/2020, by the Kentucky's Cabinet for Health and Family Services (CHFS). The findings include: Review of the Administrator's Job Description revealed the primary purpose of the position was to direct the day-to-day functions of the facility in accordance with current federal, state and local standards, guidelines, and regulations that govern nursing facilities to assure the highest degree of quality care could be provided to the residents at all times. Under sub-category, Duties and Responsibilities, one (1) of the administrative functions listed as essential was to assume the administrative authority, responsibility, and accountability for all programs in the facility. 1. Review of the facility's investigation, dated 05/07/2021 and signed by the Director of Nursing (DON), revealed on 05/03/2021, PCA #6 reported she witnessed LPN #8 commit physically and verbally abusive acts toward Residents #1, #2, and #3. According to PCA #6, LPN #8 committed the abuse over the past two (2) months. The PCA reported LPN #8 used a gastrostomy tube (g-tube) syringe and squirted water toward Residents #2 and #3 when they were sleeping. The PCA stated LPN #8 stood outside Resident #1's door and threw cheese at the resident and made critical comments about Resident #1 in his/her presence on more than one (1) occasion. As an example, the PCA reported, while Resident #1 was standing at the nurses' station, LPN #8 looked at Resident #1, and then at PCA #6 and said, This is the reason cousins don't [OBSCENITY] . On 05/12/2021 at 5:07 PM, when the SSA Surveyor asked the Administrator if the facility had investigated an allegation that LPN #8 gave marijuana to Resident #4, the Administrator stated he was not aware of the allegation. Interview with PCA #6, on 05/14/2021 at 6:50 PM, revealed, on the weekend of 04/23/2021 to 04/25/2021, LPN #8 told her she had given marijuana to Resident #4. The PCA said LPN #8 told her to go smell in Resident #4's room, and the PCA said she smelled the marijuana odor in the resident's room. Further, interviews with Resident #4, on 05/13/2021 at 12:07 PM, and with his/her family member, on 05/19/2021 at 9:06 AM, confirmed LPN #8 had given marijuana to Resident #4. Interview with Resident #1, on 05/11/2021 at 9:46 AM, revealed the resident frequently changed the subject and would not answer the SSA Surveyor's questions about the alleged abuse. However, review of the Director of Nursing's (DON) documented interview with Resident #1, dated 05/03/2021, and signed by Resident #1 and the DON, confirmed LPN #8 had squirted water at him/her. Review of the DON's documented interview with Resident #2, dated 05/03/2021, and signed by the DON and Resident #2, revealed the resident said someone did squirt him/her with water. Per the interview, he/she thought it was a nurse, but he/she could not remember the nurse's name. Interview with the DON, on 06/02/2021 at 1:54 PM, revealed he showed Resident #2 a picture of LPN #8, and the resident confirmed the picture was of the nurse who had squirted him/her with water. The DON'S interview with PCA #6 on 05/06/2021, signed by the DON, revealed PCA #6 stated she witnessed LPN #8 squirt water at both Residents #2 and #3, throw cheese at Resident #1, and voice a vulgar description of Resident #1 using curse words to disparage Resident #1 in his/her presence. Interview with the Assistant Director of Nursing (ADON), on 05/13/2021 at 1:45 PM, revealed she had been the ADON since January 2021. She stated she had oversight of all three (3) nursing shifts and was involved with scheduling staff. The ADON said she knew some night shift staff did not like LPN #8, but it was not until 05/03/2021, that she became aware some night shift staff, such as PCA #6, was afraid of LPN #8. The ADON said the Administrator had not directed her to increase supervision/monitoring of LPN #8's work on the night shift. Continued review of the facility's investigation, dated 05/07/2021, revealed PCA #6 told the DON she was afraid to report LPN #8's abusive acts while the nurse was still working at the facility because she feared the LPN would retaliate against her. She said that was why she did not report timely the abusive incidents and waited until 05/03/2021 (several months after the incidents occurred) to report how LPN #8 treated the residents. Interview with the Unit Manager (UM) for the B Wing, where LPN #8 worked, on 06/02/2021 at 9:15 AM, revealed she had to call LPN #8 to come to the facility to complete the assigned resident assessments she had not completed while at work. The UM said, after a few weeks of calling the LPN to the facility to complete the work, she wrote-up the LPN and worked a couple of night shifts when LPN #8 was on duty. She said this became an issue in March 2021. The UM said after discussing the write-ups with the LPN, the nurse refused to sign them and threw them away. The UM stated she told the DON that LPN #8 refused to sign the write-ups at that time. Review of LPN #8's employee file revealed the facility had an active (LPN) license on file for the nurse, with an expiration date of 10/31/2021. A statement at the top of the copy of the nurse's license read, UNDER INVESTIGATION. Details of the investigation are confidential until final resolution. This nurse may practice without restrictions provided the license expiration date is current and no active discipline. Interview with the DON, on 06/02/2021 at 2:15 PM, revealed he was aware LPN #8 refused to sign the write-ups and threw them away. He stated the facility leaders reviewed the LPN's license in February 2021; and, the LPN explained she had been accused of possible drug diversion at a previous facility where she had worked. Therefore, he stated he reviewed the narcotics sign out books, and reorders, but did not identify concerns. He stated he worked a couple of night shifts, after the LPN gave the reason for the status of her license, but that was mainly to monitor for any drug diversion. Interview with the Administrator, on 05/18/2021 at 12:32 PM, revealed he became aware of the abuse allegations against LPN #8, on 05/03/2021. He stated the DON fired LPN #8, on 05/01/2021, because of her inappropriate treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . He stated he had not directed the DON, the ADON, or other staff to increase monitoring of LPN #8 prior to her dismissal. He said the former Administrator hired LPN #8, in June 2020, and did not convey concerns about her when he took over as Administrator, in December 2020. The Administrator stated in February 2021, he became aware that LPN #8's license was under investigation. He stated he did not direct nursing leadership to increase monitoring of LPN #8 after he became of aware on the status of her license. However, he said he asked LPN #8 to explain why her license was under investigation, and she told him individuals at another facility had falsely accused her of possible drug diversion. He stated he had a long talk with LPN #8 and told her, since her license was under investigation, she should perform her duties professionally and work to ensure the residents were always safe. He stated it was possible LPN #8 could have committed additional abusive acts toward other residents not yet revealed. The Administrator stated the facility's leadership had no idea LPN #8 would go [NAME], but now he thought he should have required additional supervision of the nurse during the night shifts. The Administrator stated the facility was ultimately responsible for any staff person employed at the facility. He stated LPN #8 was on the clock when the abusive acts occurred, so the facility would take responsibility for her actions. 2. Review of the temporary waiver issued by the State of Kentucky's Cabinet of Health and Family Services (CHFS), on 04/14/2020, revealed the waiver permitted long-term care facilities to employ trained Personal Care Attendants (PCA) to perform defined resident care procedures that did not require the skill or training of a State Registered Nurse Aide. Further review of the letter revealed candidates for PCA training must be at least eighteen (18) years old. Interview with the Administrator, on 05/17/2021 at 8:35 AM, revealed he became the facility's Interim Administrator in December 2020. He stated, not long after that, he looked at the temporary waiver that permitted the facility to train and certify individuals to serve as PCA's. He stated he knew PCA's were working at the facility providing the direct resident care as permissible by the PCA certification. The Administrator said the employees that were younger than eighteen (18) years of age started out working in the dietary and housekeeping departments and were later certified to work as PCA's. However, he said he did not know three (3) of the PCA's had not met the age requirement. The Administrator said the facility's Human Resources (HR) staff should have reviewed their birth dates, and stipulations in the waiver before those individuals transitioned from housekeeping and dietary to providing resident care. Additionally, he said the Director of Clinical Education (DCE) had access to the waiver and should have ensured the PCA's were old enough to make the transition. The Administrator said the facility should have been abiding by the stipulations within the CHFS' waiver. The Administrator stated he was ultimately responsible for ensuring the facility delivered high quality care and services that supported every resident's health and well-being. The facility provided an acceptable Immediate Jeopardy Removal Plan on 05/28/2021 alleging removal of the IJ on 05/26/2021. Review of the IJ Removal Plan revealed the facility implemented the following: 1. On 05/01/2021, the DON fired Licensed Practical Nurse (LPN) #8. LPN #8 was the nurse responsible for the abusive acts toward Residents #1, #2, #3, and #4. In addition, Patient Care Assistant (PCA) #6, who failed to report timely the abuse to her supervisor was no longer employed by the facility. 2. Interview, on 06/01/2021, with the Administrator, revealed after the State Survey Agency identified Immediate Jeopardy (IJ) on 05/21/2021, PCA #6 was given the option of resigning or having her employment terminated, and the PCA decided to resign on 05/21/2021. 3. The residents directly involved in the deficient practice were assessed, on 05/21/2021, by the Administrator through a one-on-one interview for emotional distress and were all interviewed about any further abuse. 4. On 05/21/2021, 05/22/2021, and 05/23/2021, administrative staff, including the ADON, the SSC, the Director of Clinical Education (DCE), Unit Managers, the Minimum Data Set (MDS) Coordinator, Admissions Coordinator, and the Vice-President (VP) of Compliance, interviewed all residents with Brief Interview for Mental Status (BIMS) scores of eight (8) or greater about possible abuse. 5. The facility's DON and Unit Managers completed Resident Skin Assessments on 05/03/2021. 6. Administrative staff interviewed employees, either by phone or in person, about possible abuse and fear of reporting due to retaliation from co-workers. The Director of Clinical Education (DCE), the DON, the VP of Compliance, the MDS Coordinator, the Admissions Coordinator, and the SSC, completed the interviews by using a questionnaire designed for the interviews. Any employee they could not contact would be required to complete the abuse questionnaire prior to their next scheduled shift. 7. The facility held an AD HOC Quality Assurance Performance Improvement (QAPI) meeting with Management Team members, on 05/21/2021, and the Abuse Prevention and Reporting policy was reviewed for accuracy and appropriateness. The MDS Coordinator, Infection Control (IC) Nurse, ADON, Unit Managers, SSC, Dietary Director, Therapy Director, Business Office Manager (BOM), Admissions, Housekeeping Manager and Medical Records attended the meeting. 8. The maintenance staff installed an anonymous, secure drop box on the wall by the Administrator's door, on 05/23/2021, for private reporting by employees who felt intimidated by staff to voice concerns without fear of retaliation. Any allegations of bullying or intimidation would be investigated by the Administrator. 9. From 05/21/2021 through 05/23/2021, sixty four (64) of eighty-eight (88) staff members attended Face-to-Face Abuse and Abuse reporting training provided by the VP of Compliance. In-services included: The Abuse Prevention Program Policy; Residents Rights Policy; Abuse Investigation and Reporting Policy; and, Abuse and Neglect Clinical Protocol. Staff members took a pre-test and post-test for Abuse and Abuse Reporting. Staff members also signed an affidavit acknowledging the in-service on Abuse and Abuse reporting. Additionally, staff received an in-service on the locked drop box in front of the Administrator's office. Any staff not reporting abuse would receive corrective action, up to termination by the Administrator or DON. All staff unable to attend, including PRN staff and staff members out sick, that had not completed an in-service prior to 05/24/2021, would have to complete the in-service and acknowledgements prior to their next shift. Seventy-nine (79) of eighty-eight (88) staff members had attended training by 05/25/2021. All new hires will be in-serviced on these policies during the orientation process by the Director of Clinical Education (DCE). 10. The SSC and/or Administrator will complete ten (10) resident interviews each day, beginning on 05/24/2021, and would be continued until the Immediate Jeopardy (IJ) was abated. The interviews would revolve around any possible abuse that the residents may have experienced. The Administrator or DON would complete five (5) employee interviews each day, beginning on 05/25/2021, and the process would continue until abatement of the IJ. Employee interviews would center on any witnessed abuse and fear of retaliation for reporting it. At least twenty-five percent (25 %) of interviews would be from night shift workers. Any deficient practice found would be corrected immediately, and additional education or corrective action would be provided by the Administrator. 11. Beginning on 05/24/2021 and continuing until abatement of the IJ, the Administrator or DON would question management staff about abuse concerns, abuse allegations, or any bullying by staff during the morning management meetings. The Executive Director or the DON would investigate any concerns, immediately. The Administrator would be responsible for reporting any abuse allegation timely and per policy. 12. The audit findings would be reported by the Administrator in a Monthly QAPI meeting for a minimum of three (3) months. The State Survey Agency validated the implementation of the facility's IJ Removal Plan as follows: 1. Interview with the Director of Nursing (DON), on 06/01/2021, revealed LPN #8's employment at the facility ended, on 05/01/2021, because of her inappropriate behavior toward a subordinate employee on the weekend of 04/23/2021 to 04/25/2021. He stated at the time of her dismissal, the facility was not aware of the abuse allegations, but they did learn of the abuse on 05/03/2021, when PCA #6 came forward and reported to another night nurse, (LPN) #2, what she had seen LPN #8 do to the residents. 2. Review of an Employee Termination Form, dated 05/21/2021, revealed the reason for the employee's termination was violation of company policies, and that PCA #6 would not be eligible for rehire. The Administrator and PCA #6 both signed the Employee Termination Form, and dated their signatures 05/21/2021. 3. Review of Resident #1's clinical record revealed a progress note, completed on 05/22/2021 (1:16 PM) by the Administrator, validating the Administrator interviewed Resident #1 on 05/21/2021, related to an incident of mistreatment by LPN #8, but the resident denied any emotional distress from the incident. According to the Administrator's note, Resident #1 appeared to have suffered no negative psychosocial impact from the incident. Observation of Resident #1 on 06/01/2021, 06/02/2021 and 06/03/2021, revealed the resident appeared to be in good spirits, with no signs of emotional distress. The resident usually sat just outside his/her room, speaking to staff passing by him/her. Interview, on 06/01/2021 at 8:40 AM, revealed the resident spoke, and said, You girls back again? The resident's breakfast tray was on an over-bed table just outside his/her room door, and the resident was sitting in a chair while eating his/her morning meal. Resident #1 stated that he/she felt safe, and no one had hurt him/her. Review of Resident #2's clinical record revealed a progress note, completed on 05/22/2021 (1:23 PM) by the Administrator, validating the Administrator interviewed Resident #2, on 05/21/2021, related to mistreatment by LPN #8. The Administrator wrote the resident denied any emotional distress and seemed to have forgotten the incident, and the resident appeared to have suffered no negative psychosocial impact from the incident. Observation of Resident #2 on 06/01/2021, at 9:30 AM revealed the resident was ambulating in the hallway, and in no apparent distress. Interview with Resident #2 on 06/01/2021 at 10:00 AM, revealed he/she felt safe at the facility, and did not recall being physically or verbally abused. Review of Resident #3's clinical record revealed a progress note, dated 05/22/2021 at 1:35 PM, validating the Administrator interviewed the resident on 05/21/2021, related to an allegation of mistreatment by LPN #8. The note revealed the resident denied any emotional distress. Observation, on 06/03/2021 at 10:20 AM, revealed Resident #3 was sitting in his/her high back wheelchair, looking at a book. The resident did not appear to have any signs of anxiety. Review of Resident #4's clinical record revealed a progress note, completed on 05/22/2021 (1:38 PM) by the Administrator, validating the Administrator interviewed Resident #2, on 05/21/2021, related to mistreatment by LPN #8. According to the note, Resident #4 denied any emotional distress, and the resident appeared to have suffered no negative psychosocial impact from the incident. Observation, of Resident #4, on 06/03/2021 at 10:15 AM, revealed the resident was dressed, but in his/her room. The resident did not appear to have anxiety. Interview with the B Hallway Unit Manager (UM), where all affected residents lived, on 06/02/2021 at 9:15 AM, revealed staff had not reported that any of the affected residents, Residents #1, #2, #3, or #4 showed signs of emotional distress or anxiety, as result of the abusive acts committed by LPN #8. She stated staff had not reported any concerns about the emotional state of any of the four (4) residents. The UM said staff had additional recent in-service education on types of abuse, and on resident behaviors that might signal abuse, and/or the after effects of mistreatment. She said a resident with withdrawn or fearful behaviors could be signaling they had been victims of verbal or physical abuse. She stated staff must report any indicators of abuse to the Social Services Coordinator (SSC), the ADON, the DON, and/or the Administrator. Interview with the Administrator, on 06/03/2021 at 10:58 AM, revealed he did not identify indicators emotional distress or anxiety during his interviews with Residents #1, #2, #3, and #4. He stated he was frequently on both hallways A and B, and no one had reported any concerns. He said the weekday Clinical Morning Meetings provided another opportunity for staff to report concerns because he asked them daily if anyone had witnessed any abuse, or had any other associated concerns with the residents, but no one had voiced concerns. He stated he went around the room and asked each attendee if they had anything that they needed to report. Interview with the SSC, on 06/03/2021 at 10:30 AM, revealed during the Daily Morning Staff Meetings (Monday through Friday), the Administrator has asked each attendee if they had any new allegations of resident abuse to report, or if they had learned of any associated resident concerns. Interview with the DON, on 06/02/2021 at 2:15 PM, revealed the current Daily Morning Staff Meetings gave attendees an opportunity to report and discuss with the group, any identified resident safety concerns, or allegations of abuse. He said the Administrator would assign follow up investigation tasks, as appropriate. 4. Review of the completed Resident Interview forms revealed the residents were asked four (4) questions: Did staff treat them with dignity and respect; Had anyone on the facility's staff been abusive to them; Had the resident reported any abuse, and if so, to whom did they report it? The interviewers also asked residents if they knew how, and to whom to report abuse? There were no identified concerns with the resident interviews. A resident BIMS Assessment Scoring Report was printed and included with the responses of the residents. The BIMS Scoring report validated the BIMS scores of the residents interviewed were within the acceptable range of eight (8) to fifteen (15). Interview with the SSC, on 06/03/2021 at 10:30 AM, revealed beginning on 05/21/2021, she interviewed residents, as directed by the Administrator. She stated she completed about ten (10) resident interviews on 05/21/2021. Interview, on 06/02/2021 at 9:15 AM with the B Hallway Unit Manager revealed she also interviewed residents on 05/21/2021, asking if they had experienced or witnessed abuse, and to ensure they knew who they could report abuse allegations. Interview, on 06/02/2021 at 11:00 AM with the ADON, revealed she interviewed residents beginning on 05/21/2021 using the four (4) question interview form to determine if they had experienced abusive treatment by staff, and to ensure they knew who they could report any allegations of abuse. Interview DCE, on 06/03/2021at 10:40 AM, revealed she also conducted resident interviews for identification of staff-to-resident abuse, and to determine they were knowledgeable of the staff members they should contact to make an allegation of abuse. Interview, on 06/02/2021 at 11:22 AM, with the Vice President (VP) of Compliance, revealed in addition to facilitating staff abuse prevention training that began on 05/22/2021, he also interviewed some of the residents to determine if they had been abused, and if they knew how and to whom they could report abuse. Review of the interviews within the AOC documents, revealed the staff interviewed forty-six (46) residents, during the course of the structured resident interviews that occurred between 05/21/2021 to 05/23/2021. The following residents were interviewed by State Agency Surveyors, on 06/01/2021 regarding whether leadership staff had interviewed them about whether they had ever been abused and if they knew how and to whom to report if they had been abused or if they witnessed someone else being abused. The following residents were interviewed: A) On 06/01/2021 at 8:42 AM, Resident #4 stated the DON and the Director of Clinical Education interviewed him/her about abuse prevention and to whom he/she could report abuse. B) On 06/01/2021 at 8:49 AM, Resident #22 stated he/she was unsure if anyone has talked with him/her about abuse. C) On 06/01/2021 at 8:55 AM, Resident #16 stated administrative staff had spoken with him/her about abuse and how and to whom she could report abuse. D) On 06/01/2021 at 9:06 AM, Resident #13 said the SSC asked if he/she had been abused and if so, who would he/she tell. E) On 06/01/2021 at 9:12 AM, Resident #5 stated the SSC and the Administrator recently talked with him/her regarding abuse and how and to whom he/she could report abuse. F) On 06/01/2021 at 9:20 AM, Resident #6 said the SSC and the Administrator both interviewed him/her and asked if he/she had been abused, and if he/she knew to whom he/she should report an allegation of abuse. 5. Review of the resident skin assessments completed by the A and B Hallway Unit Managers, and the DON, on 05/03/2021, revealed there were no identified changes/areas of concern. The Unit Manager for the A Hallway resigned from her position, prior to the Validation of the AOC, however, interview with A Hallway UM on 05/17/2021 at 3:41 PM, revealed she and the B Hallway UM completed the skin assessments of all residents on 05/03/2021, and did not identify any suspicious resident injuries. Interview with the DON, on 06/02/2021 at 2:15 PM, revealed after PCA #6 reported the abuse allegations, He asked the Unit Managers for the A and B Hallways to complete skin assessments on all residents, and report any identified concerns. He stated there were no suspicious resident injuries discovered. 6. Employees completed the abuse prevention training signed an affidavit confirming they understood that fear of retaliation was not an acceptable excuse for not reporting abuse. Review of the Sign-In Sheet for Abuse In-service Education revealed the training began on 05/22/2021; the Vice President (VP) of Compliance provided the abuse prevention education. Interview, on 06/02/2021 at 11:22 AM with the Vice President of Compliance, revealed the abuse prevention training started on 05/22/2021, and that he provided most of that training. He stated he emphasized that fear of retaliation from another employee was not an acceptable excuse for not reporting staff-to-resident abuse, or any abusive situation. Review of the Education Sign in Sheet, revealed as of 06/01/2021, seven (7) employees had not completed the training because they were hired as part-time, as needed staff. The VP of Compliance stated the DCE would be responsible for ensuring the remaining seven (7)employees received the abuse training before they worked their next shift at the facility. He said the DCE would also provide the same training to any newly hired staff members. Interview, on 06/03/2021 at 10:40 AM with the DCE, revealed she also provided employee abuse prevention training on 05/22/2021 and 05/23/2021, and that she would be responsible for training any employees not yet trained before they worked their next assigned shift. She said she would also ensure the employees she trained signed the required affidavit that validated their receipt and understanding of the training. The DCE stated staff were trained that fear of retaliation from another staff member should be reported to the Administrator immediately, and that the Black Box by the Administrator's office could be used to privately report any fears of retaliation or intimidation by another staff person. She said part of that training was to ensure staff knew if they felt bullied by other staff members, they were to report that immediately to the Administrator or they could submit that concern in writing, by placing it in the newly installed locked black box, by the Administrator's office door. She said she would be responsible for providing that same abuse training session to any newly hired employees. Direct care staff interviews revealed they received abuse prevention training on the weekend of 05/22/2021-05/23/2021, and that they were required to sign an affidavit confirming they understood the abuse training and that fear of retaliation by another employee was not an excuse for not reporting staff-to-resident abuse. The State Agency Agency Surveyor interviewed the following employees: LPN #6, on 06/02/2021 at 10:05 AM; SRNA #19, on 06/02/2021 at 10:10 AM; SRNA #20, on 06/02/2021 at 10:16 AM; LPN #5, on 06/02/2021 at 10:18 AM; SRNA #11, on 06/02/2021 at 10:22 AM; and SRNA #12, on 06/02/2021 at 10:27 AM. 7. Review of the Ad Hoc QAPI Meeting sign-in sheet, dated 05/21/2021, revealed the following Management Team Members signed that they were in attendance: the Director of Rehabilitation; the DCE; the Medical Records Director; the Director of Housekeeping; the Minimum Data Set (MDS) Coordinator; the Director of Food Services; the ADON; the Business Office Manager; the Admissions Director; the Unit Managers for A and B Hallways; the SSC, and the Administrator. Review of the Miscellaneous Notes at the bottom of the sign-in sheet, attendees were informed the State Survey Agency identified Immediate Jeopardy (IJ), and the process toward abatement must start right away. In addition, the document revealed the Leadership Team Members reviewed the facility's Abuse and Neglect reporting policy at the meeting. The State Survey Agency Surveyors interviewed the following Management Team Members to validate their attendance at the Ad Hoc QAPI meeting held on 05/21/2021: Director of Rehabilitation on 06/03/2021 at 9:35 AM; Director of Food Services, on 06/03/2021 at 9:04 AM ; Director of Housekeeping on 06/03/2021 at 9:20 AM; the ADON, on 06/02/2021 at 10:15 AM; the UM for B Hallway, on 0/02/2021 at 9:15 AM; the SSC, on 06/03/2021 at 10:30 AM; and the Administrator, on 06/02/2021 at 3:33 PM. Interview, on 06/02/2021 at 3:33 PM with the Administrator, revealed the purpose of the Ad Hoc QAPI Meeting on 05/21/2021 was to inform leadership that Immediate Jeopardy (IJ) had been identified and the facility needed to formulate a plan to remove the IJ status. The Administrator stated team members mobilized and began interviewing residents on 05/21/2021. The Administrator stated progress toward AoC approval and abatement of the IJ was reviewed daily at the morning meetings with leadership team members. He said he asked leadership team members to report any issues that could impede progress toward abatement, so that they could be addressed immed [TRUNCATED]

Based on observation, interview, record review, review of the facility's policies, and review of the facility's investigative report, it was determined the facility failed to have an effective system to protect residents from abuse, by not implementing its abuse prevention policies to promptly investigate and report staff-to-resident physical and verbal abuse of four (4) of twenty-two (22) sampled residents (Residents #1, #2, #3, and #4). On 05/03/2021, Personal Care Attendant (PCA) #6 reported she witnessed Licensed Practical Nurse (LPN) #8 abuse Residents #1, #2, #3, and #4, verbally and physically. PCA #6 stated LPN #8's abuse of the residents occurred over the past two (2) months, but she could not provide exact dates when she observed LPN #8 commit the abusive acts. PCA #6 also revealed she delayed reporting because she feared LPN #8 would retaliate against her, while the LPN was still working at the facility. The Director of Nursing (DON) said he fired LPN #8, on 05/01/2021, because she made inappropriate comments about a subordinate employee, and then, PCA #6 came forward to report the allegations on 05/03/2021. The facility's failure to ensure staff reported the abuse immediately, per their policies, and without fear of retaliation, delayed the initiation of the investigation of alleged staff-to-resident abuse until 05/03/2021. The facility's failure to have an effective system to protect residents from abuse, by not implementing its abuse prevention policies to promptly investigate and report abuse has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified on 05/21/2021 and was determined to exist on 04/25/2021. The facility provided an acceptable Immediate Jeopardy Removal Plan on 05/28/2021, with the facility alleging removal of the Immediate Jeopardy on 05/26/2021. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on 05/26/2021, prior to exit on 06/03/2021, with the remaining non-compliance at a Scope and Severity of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's policy titled, Recognizing Signs and Symptoms of Abuse/Neglect, revised January 2011, revealed the facility would not condone any form of resident abuse or neglect. The policy stated, to aid in abuse prevention, all personnel were to report any signs and symptoms of abuse/neglect to their supervisor or to the Director of Nursing immediately. The policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. The policy defined neglect as the failure to provide goods and services as necessary to avoid physical harm, mental anguish, or mental illness. Review of the facility's policy titled, Abuse Prevention Program, revised December 2016, revealed the facility would protect residents from abuse by anyone, including, but not necessarily limited to facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual. Further review of the policy revealed the facility would implement policies to aid the facility in preventing the abuse, neglect, or mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility's Investigation Report, initiated on 05/03/2021 and signed by the Director of Nursing (DON), revealed on 05/03/2021, LPN #2, reported that Personal Care Attendant (PCA) #6 told her LPN #8 had committed abusive acts toward Residents #1, #2, and #3 prior to the DON firing LPN #8 on 05/01/2021. The abuse allegations allegedly committed by LPN #8 included squirting water in the faces of Residents #2 and #3 and throwing food at and verbally abusing Resident #1. According to the investigation, the DON fired LPN #8, on 05/01/2021, because of her inappropriate behavior with a subordinate employee. After receiving the allegations of resident abuse, the report revealed the DON tried to call LPN #8 but was unable to reach her to obtain a statement. LPN #2 contacted the Assistant Director of Nursing (ADON) on the morning of 05/03/2021, and reported the abuse allegations. Review of Resident #1's clinical record revealed the facility admitted the resident, on 04/07/2020, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Annual Minimum Data Set (MDS) Assessment, dated 04/11/2021, revealed the resident scored a fourteen (14) out of a possible fifteen (15) on the Brief Interview for Mental Status (BIMS) score for cognition, indicating the resident was interviewable. Review of Resident #2's clinical record revealed the facility admitted the resident, on 10/19/2020, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly MDS assessment, dated 03/13/2021, revealed Resident #2 had a BIMS score of thirteen (13) out of a possible (fifteen (15), indicating the resident was interviewable. Review of Resident #3's clinical record revealed the facility admitted the resident, on 09/22/2015, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly MDS assessment, dated 04/07/202, revealed Resident #3 scored a fifteen (15) out of a possible fifteen (15) on the BIMS assessment for cognitive function, indicating the resident was interviewable Interview with the ADON, on 05/17/2021 at 7:24 PM, revealed night shift nurse, LPN #2, called her, on 05/03/2021 well before 9:00 AM, and reported the allegations of abuse against LPN #8, which PCA #6 had reported that morning. The ADON stated she called the DON right after LPN #2 reported, because she wanted to make sure the DON was aware of the allegations before the morning staff meeting. The ADON said she had no knowledge of LPN #8's alleged resident abuse before 05/03/2021. Interview with LPN #2, on 05/11/2021 at 7:00 PM, revealed on 05/03/2021, PCA #6 told her about the alleged abuse of Residents #1, #2, and #3 committed by LPN #8. She said the PCA reported the abuse allegations about a day or so after the DON fired LPN #8. She stated the PCA told her she was afraid to report the abuse before the DON fired LPN #8 because she was afraid of what LPN #8 would do if the LPN knew the PCA was the one who reported the acts of resident abuse. LPN #2 said when PCA #6 reported the allegations, she immediately called the ADON and reported what PCA #6 said LPN #8 had allegedly done to the residents. LPN #2 stated it did not surprise her that PCA #6 was frightened of LPN #8. She stated LPN #8 was loud and could be harsh with her comments. She said it seemed several of the younger nurse aides were afraid of LPN #8, and since she was gone, things were much better on night shift. Interview with PCA #6, on 05/11/2021 at 7:38 PM, revealed she witnessed LPN #8 throw slices of cheese at Resident #1 from his/her doorway and then slammed his/her door shut. She said immediately after that happened, Resident #1 came to the nurse's station and stated, I'm tired of you girls disrespecting me, and I'm not going to have it. PCA #6 stated she said nothing but just sat back and watched as Resident #1 complained. PCA #6 said it seemed LPN #8 thought it was funny. She stated LPN #8 did not like Resident #1 because he/she had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . PCA #6 stated LPN #8 looked at Resident #1 and then at her (PCA) #6 and said, This is why cousins don't [OBSCENITY] . PCA #6 said Resident #1 was present when LPN #8 made that statement, but the PCA said she was unsure if the resident heard LPN #8's remark because the resident was hard of hearing. Continued interview with PCA #6, on 05/11/2021 at 7:38 PM, revealed she witnessed LPN #8 squirt water at residents while hiding in their bathrooms. She said LPN #8 would shoot the water at the residents and toward the ceiling so the water would drip down on them. PCA #6 said after LPN #8 squirted the water in Resident #2's room, the resident came to the nurse's station and said he/she felt water on his/her face and thought the ceiling was leaking. PCA #6 stated she also saw LPN #8 squirt water at Resident #3. PCA #6 said she was afraid to report the allegations. She said she feared LPN #8's retaliation if she reported the abuse while the nurse still worked at the facility. She said the possibility of retaliation was always on her mind. PCA #6 stated the DON fired LPN #8, on 05/01/2021, so she reported the abuse on 05/03/2021. Further, PCA #6 stated LPN #8 would know she was the person who reported the abuse; PCA #6 said she lived across the street from LPN #8, and they sometimes took their meal breaks together. In addition, PCA #6 stated she could not pinpoint the exact day(s) she witnessed the LPN's abusive treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with LPN #1, on 05/10/2021 at 7:45 PM, revealed she heard about the abuse allegations against LPN #8, as told by PCA #6 to LPN #2 on 05/03/2021. LPN #1 said the allegations included shooting residents in the face with water (Residents #2 and #3), while hiding in their bathrooms, and throwing cheese at Resident #1. The statement given by PCA #6, dated 05/06/2021, within the facility's Investigation Report gave accounts of LPN #8 squirting Residents #2 and #3 with water and that LPN #8 made abusive statements about Resident #1 in his/her presence. Further review of the facility's Investigation Report, revealed the DON interviewed Residents #1, #2, and #3 on 05/03/2021. Residents #1 and #2 confirmed LPN #8 squirted them with water. Resident #3 denied this occurred. However, interview with Resident #3, on 05/18/2021 at 3:50 PM, revealed he/she did not think LPN #8 was a nice person. Resident #3 stated while living on B Hallway, he/she was sitting in the hallway in his/her wheelchair and needed staff assistance back to bed. Resident #3 said he/she called for help, and LPN #8 told the aides that he/she did not need assistance, so the aides did not respond to him/her. Resident #3 said he/she continued to sit by his/her room door and eventually called again for help, and the LPN #8 again told the aides that he/she did not need help. Resident #3 said that upset him/her so the resident called LPN #8 a cunt. Interview with SRNA #15, on 05/15/2021 at 6:05 PM, revealed LPN #8 spoke sternly and loudly, and she liked to joke with the residents. SRNA #15 offered an example of a practical joke LPN #8 played on Resident #3. She said the resident put on his/her call light and when LPN #8 went to Resident #3's room, she turned on a video with her phone that had sounds of flatulence (gas sounds), and LPN #8 told the resident she could not help him/her right now because she had diarrhea. SRNA #15 said Resident #3 did not think the prank was funny because he/she needed help, but she could not remember exactly what the resident needed. SRNA #15 stated she did not report the nurse's actions, and she was unsure if anyone reported that incident. SRNA #15 said LPN #8 was a very drama-filled person, picked on people, and she thought many nurse aides had quit working at the facility because of the nurse. Interview with Kentucky Medication Aide (KMA) #1, on 05/10/2021 at 3:10 PM, revealed it was known that LPN #8 did not like Resident #1 because he/she made racial slurs. KMA #1 said it seemed some direct care staff, especially the younger nurse aides, were intimidated by LPN #8. She said if they had witnessed LPN #8 doing something like that, they may have been afraid to report it. Continued interview with LPN #1, on 05/10/2021 at 7:45 PM, revealed she also heard that LPN #8 gave marijuana (a psychoactive drug used for medicinal and/or recreational purposes)to Resident #4. LPN #1 said she worked night shifts, but the persons investigating the allegations had not yet interviewed her. Additional interview with PCA #6, on 05/14/2021 at 6:50 PM, revealed about a week before the DON fired LPN #8 (05/01/2021), LPN #8 gave marijuana to Resident #4. PCA #6 said LPN #8 told her to go into Resident #4's room and smell it. PCA #6 said the resident was awake and in bed, and she did smell the marijuana odor. PCA #6 said she reported that to LPN #8 and the LPN's response was, It's pretty strong, isn't it? PCA #6 said LPN #8 told her she gave Resident #4 some marijuana. PCA #6 said she did not think LPN #8 gave marijuana to other residents because they were good friends, and she thought LPN #8 would have told her if she gave the substance to others. The statement given by PCA #6, dated 05/06/2021, within the facility's Investigation Report, revealed she made no mention of LPN #8 providing marijuana to Resident #4. On 05/12/2021 at 5:07 PM, when the SSA Surveyor asked the Administrator if the facility had investigated an allegation that LPN #8 gave marijuana to Resident #4, the Administrator stated he was not aware of that allegation, but he would look into it right away. Review of Resident #4's clinical record revealed the facility admitted the resident, on 03/25/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #4's Admission MDS assessment, dated 04/02/2021, revealed the resident scored a fifteen (15) out of a possible fifteen (15) on the BIMS assessment for cognition, indicating the resident was interviewable. Interview with Resident #4, on 05/11/2021 at 3:50 PM, revealed he/she initially denied LPN #8 gave him/her marijuana. However, in a second interview with Resident #4, on 05/13/2021 at 12:07 PM, the resident confirmed LPN #8 had given him/her marijuana. The resident denied using it or giving it to any residents at the facility, and the resident stated he/she gave it to some friends. Resident #4 stated he/she did not initially tell the SSA Surveyor the truth because he/she did not want to get LPN #8 in trouble. Interview with PCA #16, on 05/16/2021 at 5:53 PM, revealed working with LPN #8 made her uncomfortable because she thought the LPN bullied her as well as other nurse aides. She said there were times when LPN #8 would claim the night shift was over-staffed and would try to send her home. PCA #16 said that was upsetting because she needed to work. PCA #16 said on 04/24/2021, LPN #8 claimed she had an offensive odor and again tried to send her home. PCA #16 said she thought LPN #8 only wanted certain staff to work with her because she knew which staff would not report her if she did things to residents. Interview with the Social Services Coordinator (SSC), on 05/17/2021 at 2:44 PM, revealed she learned of the abuse allegations, on 05/03/2021, when she started work about 7:30 AM or 8:00 AM. She stated the Unit Managers (UM's) for both A and B Hallways told her the DON fired LPN #8, on 05/01/2021, and there were allegations of abuse against her. The SSC stated she went directly to the DON's office to get more information and to find out if she should start interviewing all residents or just some of them. She said the DON said, For what? The SSC said she replied by repeating the allegations made against LPN #8. She said the DON acted frustrated and said that was not why he fired LPN #8. The DON stated LPN #8 was fired because she was rude to a staff member (PCA #16). Interview with the ADON, on 05/18/2021 at 3:21 PM, revealed some staff members did not like LPN #8 and complained that she took too many breaks, but she was not aware certain nurse aides were afraid of her. She said since January 2021, she and the DON had worked a couple of night shifts each, but there were no reported allegations of resident abuse against LPN #8 until 05/03/2021. As the ADON, she stated she was on-call day or night to address all types of staffing issues. The ADON said when she worked the night shift, LPN #8 did not demonstrate behavior that prompted concern about her work. However, LPN #8's attempt to send PCA #16 home and reassign who worked with her, on the weekend of 04/23/2021 to 04/25/2021, raised red flags and led to the DON's decision to fire LPN #8. She stated prior to reporting the allegations on 05/03/2021, PCA #6 had not reported feeling fearful of LPN #8. The ADON said she could somewhat understand the younger aides, such as the PCA's, being too insecure and perhaps fearful to report the licensed nurse, but administrative staff thought they had trained them on the importance of reporting any form of abuse, immediately. She stated the facility had provided many in-service education sessions on abuse; but in this situation, she said the facility had a staff member who failed to follow the abuse policy by not reporting LPN #8's abuse of the residents as soon as it happened. Interview with the DON, on 06/02/2021 at 2:15 PM, revealed the facility's administration became aware in February 2021, that LPN #8's license was under investigation by the Kentucky Board of Nursing (KBN). He said that information came to light when a complaint survey was conducted at the facility in February 2021. He stated the previous Administrator had hired LPN #8. In addition, the Administrator said the B Hallway UM had written LPN #8 up a few times because she had not completed her resident assessments on time. He stated he was aware that LPN #8 refused to sign the write-ups and tore them up. Interview with the Administrator, on 05/18/2021 at 12:32 PM, revealed, in February 2021, he became aware LPN #8's nursing license was under investigation. He stated he questioned LPN #8, but she told him she had been falsely accused of possible drug diversion at another facility. He stated he did not do additional investigation of the nurse's past work history, because the former Administrator did not report any concerns with LPN #8, when he took over as Administrator in December 2020. He stated the facility should have done more to monitor LPN #8 for earlier indicators of improper treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Additional interview with the Administrator, on 06/03/2021 at 10:58 AM, revealed he expected all staff members to follow the facility's policies to keep the residents free from abuse and neglect. He stated if employees did not abide by the abuse prevention policies, for example, the mandate to immediately report abuse, that would delay the facility's ability to address critical resident safety issues, to make the required notifications, and to maintain a safe environment for the residents. The facility provided an acceptable Immediate Jeopardy Removal Plan on 05/28/2021 alleging removal of the IJ on 05/26/2021. Review of the IJ Removal Plan revealed the facility implemented the following: 1. On 05/01/2021, the DON fired Licensed Practical Nurse (LPN) #8. LPN #8 was the nurse responsible for the abusive acts toward Residents #1, #2, #3, and #4. In addition, Patient Care Assistant (PCA) #6, who failed to report timely the abuse to her supervisor was no longer employed by the facility. 2. Interview, on 06/01/2021, with the Administrator, revealed after the State Survey Agency identified Immediate Jeopardy (IJ) on 05/21/2021, PCA #6 was given the option of resigning or having her employment terminated, and the PCA decided to resign on 05/21/2021. 3. The residents directly involved in the deficient practice were assessed, on 05/21/2021, by the Administrator through a one-on-one interview for emotional distress and were all questioned about any further abuse. 4. On 05/21/2021, 05/22/2021, and 05/23/2021, administrative staff, including the ADON, the SSC, The Director of Clinical Education (DCE), Unit Managers, the Minimum Data Set (MDS) Coordinator, Admissions Coordinator, and the Vice-President (VP) of Compliance, interviewed all residents with Brief Interview for Mental Status (BIMS) scores of eight (8) or greater about possible abuse. 5. The facility's DON and Unit Managers completed Resident Skin Assessments on 05/03/2021. 6. Administrative staff interviewed employees, either by phone or in person, about possible abuse and fear of reporting due to retaliation from co-workers. The Director of Clinical Education (DCE), the DON, the VP of Compliance, the MDS Coordinator, the Admissions Coordinator, and the SSC, completed the interviews by using a questionnaire designed for the interviews. Any employee they could not contact would be required to complete the abuse questionnaire prior to their next scheduled shift. 7. The facility held an AD HOC Quality Assurance Performance Improvement (QAPI) meeting with Management Team members, on 05/21/2021, and the Abuse Prevention and Reporting policy was reviewed for accuracy and appropriateness. The MDS Coordinator, Infection Control (IC) Nurse, ADON, Unit Managers, SSC, Dietary Director, Therapy Director, Business Office Manager (BOM), Admissions, Housekeeping Manager and Medical Records attended the meeting. 8. The facility maintenance staff installed an anonymous, secure drop box on the wall by the Administrator's door, on 05/23/2021, for private reporting by employees who felt intimidated by staff to voice concerns without fear of retaliation. Any allegations of bullying or intimidation would be investigated by the Administrator. 9. From 05/21/2021 through 05/23/2021, sixty four (64) of eighty-eight (88) staff members attended Face-to-Face Abuse and Abuse reporting training provided by the VP of Compliance. In-services included The Abuse Prevention Program Policy, Residents Rights Policy, Abuse Investigation and Reporting Policy, and Abuse and Neglect Clinical Protocol. Staff members took a pre-test and post-test for Abuse and Abuse Reporting. Staff members also signed an affidavit acknowledging the in-service on Abuse and Abuse reporting. Additionally, staff received an in-service on the locked drop box in front of the Administrator's office. Any staff not reporting abuse would receive corrective action, up to termination by the Administrator or DON. All staff unable to attend, including PRN staff and staff members out sick, that had not completed an in-service prior to 05/24/2021, would have to complete the in-service and acknowledgements prior to their next shift. Seventy-nine (79) of eighty-eight (88) staff members had attended training by 05/25/2021. All new hires would be in-serviced on these policies during the orientation process by the Director of Clinical Education (DCE). 10. The SSC and/or Administrator would complete ten (10) resident interviews each day, beginning on 05/24/2021, and would be continued until the Immediate Jeopardy (IJ) was abated. The interviews would revolve around any possible abuse that the residents may have experienced. The Administrator or DON would complete five (5) employee interviews each day, beginning on 05/25/2021, and the process would continue until abatement of the IJ. Employee interviews would center on any witnessed abuse and fear of retaliation for reporting it. At least twenty-five percent (25 %) of interviews would be from night shift workers. Any deficient practice found would be corrected immediately, and additional education or corrective action would be provided by the Administrator. 11. Beginning on 05/24/2021 and continuing until abatement of the IJ, the Administrator or DON would question management staff about abuse concerns, abuse allegations, or any bullying by staff during the morning management meetings. The Executive Director or the DON would investigate any concerns, immediately. The Administrator would be responsible for reporting any abuse allegation timely and per policy. 12. The audit findings would be reported by the Administrator in a Monthly QAPI meeting for a minimum of three (3) months. The State Survey Agency validated the implementation of the facility's IJ Removal Plan as follows: 1. Interview with the Director of Nursing (DON), on 06/01/2021, revealed LPN #8's employment at the facility ended, on 05/01/2021, because of her inappropriate behavior toward a subordinate employee on the weekend of 04/23/2021 to 04/25/2021. He stated at the time of her dismissal, the facility was not aware of the abuse allegations, but they did learn of the abuse on 05/03/2021, when PCA #6 came forward and reported to another night nurse, (LPN) #2, what she had seen LPN #8 do to the residents. 2. Review of an Employee Termination Form, dated 05/21/2021, revealed the reason for the employee's termination was violation of company policies, and that PCA #6 would not be eligible for rehire. The Administrator and PCA #6 both signed the Employee Termination Form, and dated their signatures 05/21/2021. 3. Review of Resident #1's clinical record revealed a progress note, completed on 05/22/2021 (1:16 PM) by the Administrator, validating the Administrator interviewed Resident #1 on 05/21/2021, related to an incident of mistreatment by LPN #8, but the resident denied any emotional distress from the incident. According to the Administrator's note, Resident #1 appeared to have suffered no negative psychosocial impact from the incident. Observation of Resident #1 on 06/01/2021, 06/02/2021 and 06/03/2021, revealed the resident appeared to be in good spirits, with no signs of emotional distress. The resident usually sat just outside his/her room, speaking to staff passing by him/her. Interview, on 06/01/2021 at 8:40 AM, revealed the resident spoke to the surveyor, and said, You girls back again? The resident's breakfast tray was on an over-bed table just outside his/her room door, and the resident was sitting in a chair while eating his/her morning meal. Resident #1 told the surveyor he/she felt safe, and no one had hurt him/her. Review of Resident #2's clinical record revealed a progress note, completed on 05/22/2021 (1:23 PM) by the Administrator, validating the Administrator interviewed Resident #2, on 05/21/2021, related to mistreatment by LPN #8. The Administrator wrote the resident denied any emotional distress and seemed to have forgotten the incident, and the Resident appeared to have suffered no negative psychosocial impact from the incident. Observation of Resident #2 on 06/01/2021, at 9:30 AM revealed the resident was ambulating in the hallway, and in no apparent distress. Interview with Resident #2 on 06/01/2021 at 10:00 AM, revealed he/she felt safe at the facility, and did not recall being physically or verbally abused. Review of Resident #3's clinical record revealed a progress note, dated 05/22/2021, 1:35 PM, validating the Administrator interviewed the resident on 05/21/2021, related to an allegation of mistreatment by LPN #8. The note revealed the resident denied any emotional distress, and appeared to have suffered no negative psychosocial impact. Observation, on 06/03/2021 at 10:20 AM, revealed Resident #3 was sitting in his/her high back wheelchair, looking at a book. The resident did not appear to have any signs of anxiety or psychosocial distress. Review of Resident #4's clinical record revealed a progress note, completed on 05/22/2021 (13:38 PM) by the Administrator, validating the Administrator interviewed Resident #2, on 05/21/2021, related to mistreatment by LPN #8. According to the note, Resident #4 denied any emotional distress, and the resident appeared to have suffered no negative psychosocial impact from the incident. Observation, of Resident #4, on 06/03/2021 at 10:15 AM, revealed the resident was dressed, but in his/her room. The resident did not appear to have anxiety or any signs of psychosocial distress. Interview with the B Hallway Unit Manager (UM), where all affected residents lived, on 06/02/2021 at 9:15 AM, revealed staff had not reported that any of the affected residents, Residents #1, #2, #3, or #4 showed signs of emotional distress or anxiety, as result of the abusive acts committed by LPN #8. She stated staff had not reported any concerns about the emotional state of any of the four (4) residents. The UM said staff had additional recent in-service education on types of abuse, and on resident behaviors that might signal abuse, and/or the after effects of mistreatment. She said a resident with withdrawn or fearful behaviors could be signaling they had been victims of verbal or physical abuse. She stated staff must report any indicators of abuse to the Social Services Coordinator (SSC), the ADON, the DON, and/or the Administrator. Interview with the Administrator, on 06/03/2021 at 10:58 AM, revealed he did not identify indicators emotional distress or anxiety during his interviews with Residents #1, #2, #3, and #4. He stated he was frequently on both hallways A and B Hallways, and no one had reported any concerns. He said the weekday Clinical Morning Meetings provided another opportunity for staff to report concerns because he asked them daily if anyone had witnessed any abusive, or had any other associated concerns with the residents, but no one had voiced concerns. He stated he went around the room and asked each attendee if they had anything that they needed to report. Interview with the SSC, on 06/03/2021 at 10:30 AM, revealed during the Daily Morning Staff Meetings (Monday through Friday), the Administrator has asked each attendee if they had any new allegations of resident abuse to report, or if they had learned of any associated resident concerns. Interview with the DON, on 06/02/2021 at 2:15 PM, revealed the current Daily Morning Staff Meetings gave attendees an opportunity to report and discuss with the group, any identified resident safety concerns, or allegations of abuse. He said the Administrator would assign follow up investigation tasks, as appropriate. 4. Review of the completed Resident Interview forms revealed the residents were asked four (4) questions: Did staff treat them with dignity and respect; Had anyone on the facility's staff been abusive to them; Had the resident reported any abuse, and if so, to whom did they report it? The interviewers also asked residents if they knew how, and to whom to report abuse? There were no identified concerns with the resident interviews. A resident BIMS Assessment Scoring Report was printed and included with the responses of the residents. The BIMS Scoring report validated the BIMS scores of the residents interviewed were within the acceptable range of eight (8) to fifteen (15). Interview with the SSC, on 06/03/2021 at 10:30 AM, revealed beginning on 05/21/2021, she interviewed residents, as directed by the Administrator. She stated she completed about ten (10) resident interviews on 05/21/2021. Interview, on 06/02/2021 at 9:15 AM with the B Hallway Unit Manager revealed she also interviewed residents on 05/21/2021, asking if they had experienced or witnessed abuse, and to ensure they knew who they could report abuse allegations. Interview, on 06/02/2021 at 11:00 AM with the ADON, revealed she interviewed residents beginning on 05/21/2021 using the four (4) question interview form to determine if they had experienced abusive treatment by staff, and to ensure they knew who they could report any allegations of abuse. Interview DCE, on 06/03/2021at 10:40 AM, revealed she also conducted resident interviews for identification of staff-to-resident abuse, and to determine they wer [TRUNCATED]

Based on observation, interview, record review, review of the facility's policies, and review of the facility's investigative report, it was determined the facility failed to have an effective system to ensure staff immediately reported known acts of physical and verbal abuse committed by a night shift nurse, Licensed Practical Nurse (LPN) #8, that affected four (4) of twenty-two (22) sampled residents (Residents #1, #2, #3, and #4). On 05/03/2021, Personal Care Attendant (PCA) #6, who worked on night shift with LPN #8, reported she witnessed LPN #8 abuse Residents #1, #2, #3, and #4 verbally and physically. PCA #6 stated the acts of abuse occurred sometime within the past two (2) months, but she did not immediately report the abuse while LPN #8 was an employee of the facility. The PCA stated she feared LPN #8 would retaliate against her if she found out she had been reported. On 05/01/2021, the Director of Nursing (DON) fired LPN #8 because of her unacceptable treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #2 immediately reported PCA #6's statements to the Assistant Director of Nursing (ADON), who in turn reported the allegations of staff-to-resident abuse to the DON. The facility's failure to have an effective system in place to ensure a staff member immediately reported observations of staff-to-resident abuse has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified on 05/21/2021 and were determined to exist on 04/25/2021. The facility provided an acceptable Immediate Jeopardy Removal Plan on 05/28/2021, with the facility alleging removal of the Immediate Jeopardy on 05/26/2021. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on 05/26/2021, prior to exit on 06/03/2021, with the remaining non-compliance at a Scope and Severity of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's policy titled, Recognizing Signs and Symptoms of Abuse/Neglect, revised January 2011, revealed the facility would not condone any form of resident abuse or neglect. Also, the policy stated, to aid in abuse prevention, all personnel were to report any signs and symptoms of abuse/neglect to their supervisor or to the Director of Nursing immediately. Review of the facility's policy titled, Abuse Investigation and Reporting, revised July 2017, revealed all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state, and federal agencies (as defined by the current regulations) and thoroughly investigated by facility management. The policy further revealed an alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source) and misappropriation of property, would be reported immediately, but not later than two (2) hours, if the alleged violation involved abuse or had resulted in serious bodily injury; or within twenty-four (24) hours if the alleged violation did not involve abuse and had not resulted in serious bodily injury. Review of the Five (5) day Facility Investigation Report, submitted to the State Agency by the facility's Director of Nursing (DON), dated 05/07/2021 and signed by the DON, revealed on 05/03/2021, the ADON and DON received a report that a nurse, terminated from employment, on 05/01/2021 (LPN #8), had displayed behaviors that could be classified as staff-to-resident abuse. The informant (PCA #6) reported that LPN #8 had committed abusive acts toward Residents #1, #2, and #3. The report stated PCA #6 alleged LPN #8 squirted water in the faces of Residents #2 and #3, threw food at Resident #1 and verbally abused the resident. According to the report, the DON fired LPN #8 on 05/01/2021, because of her inappropriate behavior with a subordinate employee. The facility received PCA #6's reports of abuse after LPN #8's employment was terminated. The report revealed the DON attempted to contact LPN #8 by phone, but after multiple attempts, he could not reach her. 1. Review of Resident #1's clinical record revealed the facility admitted the resident, on 04/07/2020, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Annual Minimum Data Set (MDS) Assessment, dated 04/11/2021, revealed the resident scored a fourteen (14) out of a possible fifteen (15) on the Brief Interview for Mental Status (BIMS) score for cognition, indicating the resident was interviewable. 2. Review of Resident #2's clinical record revealed the facility admitted the resident, on 10/19/2020, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly MDS assessment, dated 03/13/2021, revealed Resident #2 had a BIMS score of thirteen (13) out of a possible (fifteen (15), indicating the resident was interviewable. Documented statements, dated 05/03/2021, given by Residents #1 and #2, were parts of the facility's investigation. In their statements, both residents confirmed LPN #8 was the staff person who squirted them with water. 3. Review of Resident #3's clinical record revealed the facility admitted the resident, on 09/22/2015, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly MDS assessment, dated 04/07/202, revealed Resident #3 scored a fifteen (15) out of a possible fifteen (15) on the BIMS assessment for cognitive function, indicating the resident was interviewable. Interview with Resident #3, on 05/18/2021 at 3:50 PM, revealed he/she thought LPN #8 had a bad attitude and was not a nice person. Resident #3 stated when he/she lived on B Hallway, he/she needed assistance back to bed, and when he/she called for assistance, LPN #8 told the nurse aides that he/she did not need any help. Resident #3 stated he/she continued to wait for staff assistance, even asked again, but the nurse would not allow the staff to help him/her back to bed. Interview with SRNA #15, on 05/15/2021 at 6:05 PM, revealed LPN #8 liked to joke with the residents. SRNA #15 gave an example of LPN #8's practical jokes. She stated one night Resident #3 put on his/her call light and when LPN #8 went to the resident's room, she put a video on her phone with sounds of flatulence (gas sounds) and told the resident she could not help him/her right now because she had diarrhea. SRNA #15 said Resident #3 did not think the prank was funny because he/she needed help, but the SRNA could not remember what the resident needed. SRNA #15 said she did not report this to anyone, and she was unsure if anyone else reported the incident. SRNA #15 stated LPN #8 was very drama-filled and picked on people. She said many nurse aides quit because of LPN #8. Interview with Kentucky Medication Aide (KMA) #1, on 05/10/2021 at 3:10 PM, revealed she worked with LPN #8 on some evening shifts until about 11:00 PM. She stated Resident #3 complained that LPN #8 was rude to him/her, and he/she thought the nurse was rude to other residents and some staff members. KMA #1 said she was not personally afraid of LPN #8, but some staff acted differently when LPN #8 worked, and she thought some of them were intimidated by LPN #8, especially the younger aides. She said the facility had some young aides who worked as Personal Care Attendants (PCA's), and if they witnessed LPN #8 abuse a resident, they may have been afraid to report her. Interview with PCA #6, on 05/11/2021 at 7:38 PM, revealed she could not provide exact dates when she observed LPN #8 abuse Residents #1, #2 and #3, but the abusive acts had occurred within the previous two (2) months before the DON fired LPN #8. PCA #6 revealed she witnessed LPN #8 throw slices of cheese at Resident #1 from the resident's doorway, and then the LPN slammed the resident's door shut. She said immediately after that happened, Resident #1 came to the nurse's station and stated, I'm tired of you girls disrespecting me, and I'm not going to have it. PCA #6 said she did not think the resident knew LPN #8 was the one that threw the cheese. PCA #6 stated she said nothing but just sat back and watched while Resident #1 complained. PCA #6 said it seemed LPN #8 thought it was funny, and she knew LPN #8 did not like Resident #1. In addition, she said Resident #1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . PCA #6 stated LPN #8 looked at Resident #1, and then at her (PCA #6) and said, This is why cousins don't [OBSCENITY] . PCA #6 said Resident #1 was hard of hearing, and she was unsure if he/she heard LPN #8's comment. PCA #6 said LPN #8 squirted water at Residents #2 and #3 while hiding in their bathrooms. She stated the LPN would also squirt water toward the ceiling so it would drip down on the residents. She said after this happened in Resident #2's room, the resident came to the nurse's station and reported he/she thought the ceiling was leaking because he/she felt water drip on his/her face. PCA #6 said she was afraid to report the way LPN #8 treated the residents. She said many other nurse aides had quit their jobs because of LPN #8. She said she feared LPN #8 would retaliate if she reported the abuse while LPN #8 was still working at the facility. She said the possibility of retaliation was always on her mind. PCA #6 said she reported the abuse, on 05/03/2021, after the DON fired LPN #8. PCA #6 stated LPN #8 would know she was the person who reported the resident abuse, and she lived across the street from LPN #8. She said they would sometimes take breaks together, and they were friends. 4. Review of Resident #4's clinical record revealed the facility admitted the resident, on 03/25/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #4's Admission MDS assessment, dated 04/02/2021, revealed the resident scored a fifteen (15) out of a possible fifteen (15) on the BIMS assessment for cognition, indicating the resident was interviewable. Additional review of the Five (5) day Facility Investigation Report did not include an allegation that LPN #8 provided marijuana (a psychoactive drug used for medical or recreational purposes) to Resident #4. However, an allegation reported to the State Agency by a facility staff person, on 05/05/2021, revealed LPN #8 had also provided marijuana to a resident. Additional interview with PCA #6, on 05/14/2021 at 6:50 PM, revealed about a week before the DON fired LPN #8 (which she said was the weekend of 04/23/2021 to 04/25/2021), LPN #8 gave marijuana to Resident #4. PCA #6 said LPN #8 told her to go smell Resident #4's room. She said the resident was in bed and awake, and she smelled the marijuana odor. PCA #6 stated she reported this to LPN #8, and the LPN's response was, It's pretty strong, isn't it? PCA #6 said LPN #8 told her she gave Resident #4 some marijuana. During an initial interview with Resident #4, on 05/11/2021 at 3:50 PM, the resident denied LPN #8 had given him/her marijuana. On 05/12/2021 at 5:07 PM, when the SSA Surveyor asked the Administrator if the facility had investigated an allegation that LPN #8 gave marijuana to Resident #4, the Administrator stated he was not aware of that allegation, but he would look into it right away. A follow-up interview with Resident #4, on 05/13/2021 at 12:07 PM, revealed LPN #8 did give him/her marijuana. Resident #4 said he/she did not initially tell the SSA Surveyor the truth in the previous interview (05/11/2021) because he/she did not want to get the nurse in trouble. Interview with the DON, on 05/11/2021 at 11:00 AM, revealed he fired LPN #8, on 05/01/2021, because, on 04/23/2021 into 04/24/2021 (night shift), the nurse made inappropriate comments about PCA #16 who was scheduled to work with her. He stated LPN #8 accused PCA #16 of having an offensive body odor and told co-workers that PCA #16 had an offensive odor. In addition, he stated LPN #8 tried to send PCA #16 home and tried to get another SRNA to replace her. He stated he interviewed LPN #1 and SRNA #15, who also worked that night, but they told him PCA #16 did not have an offensive odor. He said the ADON called him to report LPN #8's attempt to rearrange the schedule. The DON stated LPN #8 did not have the authority to send staff home or rearrange the schedule without a manager's approval, and by interviewing PCA #16, he learned LPN #8 had actually sent her home on another occasion without a manager's approval. Interview with the ADON, on 05/18/2021 at 3:21 PM, revealed, in the early morning of 05/03/2021, LPN #2 called her to report PCA #6's allegations against LPN #8, and in turn, she immediately called the DON to report the allegations. She stated she was responsible for most of the staff scheduling and was always on call to address any type of staffing issues. She said prior to 05/03/2021, she was not aware PCA #6 was fearful of LPN #8. She stated she knew that some night shift staff did not like LPN #8 because they complained she took too many breaks, but she had not received reports that the nurse had abused residents. She stated the night shift PCA's nor SRNA's reported they felt fearful or intimidated by LPN #8. The ADON said she had worked maybe two (2) night shifts since the first of the year and came in one night to see if LPN #8 was taking too many breaks and to see if she was completing scheduled resident assessments. She stated LPN #8 demonstrated compliant behavior that night, but she doubted the nurse would have been non-compliant while a nursing leader was on the shift. She said the staff members had many in-services on abuse prevention, and the nurse leaders thought the staff understood they must immediately report any allegations of abuse; but in this situation, she said the facility had a staff member who failed to follow the abuse policy by not reporting LPN #8's abuse of the residents as soon as it happened. Interview with the DON, on 06/02/2021 at 2:15 PM, revealed he expected staff to immediately report any type of abusive treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated he thought the staff knew he would maintain confidentiality as much as possible, if they reported any allegation of staff-to-resident abuse. He stated his own cell phone number was easily accessible and posted in many areas of the facility, so staff could contact him day or night, without alerting other staff members that they had done so. He stated PCA #6 should have known she could call him to make the report against LPN #8, but she failed to do so. The DON said PCA #6 was no longer employed by the facility. Interview with the Administrator, on 06/03/2021 at 10:58 AM, revealed he expected all staff members to follow the facility's policies to keep the residents free from abuse and neglect. He stated staff must immediately report any known abuse to him or other facility leaders such as the DON, the ADON, and the Social Services Coordinator (SSC), who was also the Abuse Coordinator. He stated fear of retaliation was not an excuse for not reporting staff-to-resident abuse, but if a staff person was fearful of another staff member, that must be reported as well. The Administrator said more should have done to monitor LPN #8 because the facility was ultimately responsible for the actions of individuals employed. He stated if employees did not abide by the abuse prevention policies, for example, the mandate to immediately report abuse, that would delay the facility's ability to address critical resident safety issues, to make the required notifications, and to maintain a safe environment for the residents. The facility provided an acceptable Immediate Jeopardy Removal Plan on 05/28/2021 alleging removal of the IJ on 05/26/2021. Review of the IJ Removal Plan revealed the facility implemented the following: 1. On 05/01/2021, the DON fired Licensed Practical Nurse (LPN) #8. LPN #8 was the nurse responsible for the abusive acts toward Residents #1, #2, #3, and #4. In addition, Patient Care Assistant (PCA) #6, who failed to report timely the abuse to her supervisor was no longer employed by the facility. 2. Interview, on 06/01/2021, with the Administrator, revealed after the State Survey Agency identified Immediate Jeopardy (IJ) on 05/21/2021, PCA #6 was given the option of resigning or having her employment terminated, and the PCA decided to resign on 05/21/2021. 3. The residents directly involved in the deficient practice were assessed, on 05/21/2021, by the Administrator through a one-on-one interview for emotional distress and were all questioned about any further abuse. 4. On 05/21/2021, 05/22/2021, and 05/23/2021, administrative staff, including the ADON, the SSC, The Director of Clinical Education (DCE), Unit Managers, the Minimum Data Set (MDS) Coordinator, Admissions Coordinator, and the Vice-President (VP) of Compliance, interviewed all residents with Brief Interview for Mental Status (BIMS) scores of eight (8) or greater about possible abuse. 5. The facility's DON and Unit Managers completed Resident Skin Assessments on 05/03/2021. 6. Administrative staff interviewed employees, either by phone or in person, about possible abuse and fear of reporting due to retaliation from co-workers. The Director of Clinical Education (DCE), the DON, the VP of Compliance, the MDS Coordinator, the Admissions Coordinator, and the SSC, completed the interviews by using a questionnaire designed for the interviews. Any employee they could not contact would be required to complete the abuse questionnaire prior to their next scheduled shift. 7. The facility held an AD HOC Quality Assurance Performance Improvement (QAPI) meeting with Management Team members, on 05/21/2021, and the Abuse Prevention and Reporting policy was reviewed for accuracy and appropriateness. The MDS Coordinator, Infection Control (IC) Nurse, ADON, Unit Managers, SSC, Dietary Director, Therapy Director, Business Office Manager (BOM), Admissions, Housekeeping Manager and Medical Records attended the meeting. 8. The facility maintenance staff installed an anonymous, secure drop box on the wall by the Administrator's door, on 05/23/2021, for private reporting by employees who felt intimidated by staff to voice concerns without fear of retaliation. Any allegations of bullying or intimidation would be investigated by the Administrator. 9. From 05/21/2021 through 05/23/2021, sixty four (64) of eighty-eight (88) staff members attended Face-to-Face Abuse and Abuse reporting training provided by the VP of Compliance. In-services included The Abuse Prevention Program Policy, Residents Rights Policy, Abuse Investigation and Reporting Policy, and Abuse and Neglect Clinical Protocol. Staff members took a pre-test and post-test for Abuse and Abuse Reporting. Staff members also signed an affidavit acknowledging the in-service on Abuse and Abuse reporting. Additionally, staff received an in-service on the locked drop box in front of the Administrator's office. Any staff not reporting abuse would receive corrective action, up to termination by the Administrator or DON. All staff unable to attend, including PRN staff and staff members out sick, that had not completed an in-service prior to 05/24/2021, would have to complete the in-service and acknowledgements prior to their next shift. Seventy-nine (79) of eighty-eight (88) staff members had attended training by 05/25/2021. All new hires would be in-serviced on these policies during the orientation process by the Director of Clinical Education (DCE). 10. The SSC and/or Administrator would complete ten (10) resident interviews each day, beginning on 05/24/2021, and would be continued until the Immediate Jeopardy (IJ) was abated. The interviews would revolve around any possible abuse that the residents may have experienced. The Administrator or DON would complete five (5) employee interviews each day, beginning on 05/25/2021, and the process would continue until abatement of the IJ. Employee interviews would center on any witnessed abuse and fear of retaliation for reporting it. At least twenty-five percent (25 %) of interviews would be from night shift workers. Any deficient practice found would be corrected immediately, and additional education or corrective action would be provided by the Administrator. 11. Beginning on 05/24/2021 and continuing until abatement of the IJ, the Administrator or DON would question management staff about abuse concerns, abuse allegations, or any bullying by staff during the morning management meetings. The Executive Director or the DON would investigate any concerns, immediately. The Administrator would be responsible for reporting any abuse allegation timely and per policy. 12. The audit findings would be reported by the Administrator in a Monthly QAPI meeting for a minimum of three (3) months. The State Survey Agency validated the implementation of the facility's IJ Removal Plan as follows: 1. Interview with the Director of Nursing (DON), on 06/01/2021, revealed LPN #8's employment at the facility ended, on 05/01/2021, because of her inappropriate behavior toward a subordinate employee on the weekend of 04/23/2021 to 04/25/2021. He stated at the time of her dismissal, the facility was not aware of the abuse allegations, but they did learn of the abuse on 05/03/2021, when PCA #6 came forward and reported to another night nurse, (LPN) #2, what she had seen LPN #8 do to the residents. 2. Review of an Employee Termination Form, dated 05/21/2021, revealed the reason for the employee's termination was violation of company policies, and that PCA #6 would not be eligible for rehire. The Administrator and PCA #6 both signed the Employee Termination Form, and dated their signatures 05/21/2021. 3. Review of Resident #1's clinical record revealed a progress note, completed on 05/22/2021 (1:16 PM) by the Administrator, validating the Administrator interviewed Resident #1 on 05/21/2021, related to an incident of mistreatment by LPN #8, but the resident denied any emotional distress from the incident. According to the Administrator's note, Resident #1 appeared to have suffered no negative psychosocial impact from the incident. Observation of Resident #1 on 06/01/2021, 06/02/2021 and 06/03/2021, revealed the resident appeared to be in good spirits, with no signs of emotional distress. The resident usually sat just outside his/her room, speaking to staff passing by him/her. Interview, on 06/01/2021 at 8:40 AM, revealed the resident spoke to the surveyor, and said, You girls back again? The resident's breakfast tray was on an over-bed table just outside his/her room door, and the resident was sitting in a chair while eating his/her morning meal. Resident #1 told the surveyor he/she felt safe, and no one had hurt him/her. Review of Resident #2's clinical record revealed a progress note, completed on 05/22/2021 (1:23 PM) by the Administrator, validating the Administrator interviewed Resident #2, on 05/21/2021, related to mistreatment by LPN #8. The Administrator wrote the resident denied any emotional distress and seemed to have forgotten the incident, and the Resident appeared to have suffered no negative psychosocial impact from the incident. Observation of Resident #2 on 06/01/2021, at 9:30 AM revealed the resident was ambulating in the hallway, and in no apparent distress. Interview with Resident #2 on 06/01/2021 at 10:00 AM, revealed he/she felt safe at the facility, and did not recall being physically or verbally abused. Review of Resident #3's clinical record revealed a progress note, dated 05/22/2021, 1:35 PM, validating the Administrator interviewed the resident on 05/21/2021, related to an allegation of mistreatment by LPN #8. The note revealed the resident denied any emotional distress, and appeared to have suffered no negative psychosocial impact. Observation, on 06/03/2021 at 10:20 AM, revealed Resident #3 was sitting in his/her high back wheelchair, looking at a book. The resident did not appear to have any signs of anxiety or psychosocial distress. Review of Resident #4's clinical record revealed a progress note, completed on 05/22/2021 (13:38 PM) by the Administrator, validating the Administrator interviewed Resident #2, on 05/21/2021, related to mistreatment by LPN #8. According to the note, Resident #4 denied any emotional distress, and the resident appeared to have suffered no negative psychosocial impact from the incident. Observation, of Resident #4, on 06/03/2021 at 10:15 AM, revealed the resident was dressed, but in his/her room. The resident did not appear to have anxiety or any signs of psychosocial distress. Interview with the B Hallway Unit Manager (UM), where all affected residents lived, on 06/02/2021 at 9:15 AM, revealed staff had not reported that any of the affected residents, Residents #1, #2, #3, or #4 showed signs of emotional distress or anxiety, as result of the abusive acts committed by LPN #8. She stated staff had not reported any concerns about the emotional state of any of the four (4) residents. The UM said staff had additional recent in-service education on types of abuse, and on resident behaviors that might signal abuse, and/or the after effects of mistreatment. She said a resident with withdrawn or fearful behaviors could be signaling they had been victims of verbal or physical abuse. She stated staff must report any indicators of abuse to the Social Services Coordinator (SSC), the ADON, the DON, and/or the Administrator. Interview with the Administrator, on 06/03/2021 at 10:58 AM, revealed he did not identify indicators emotional distress or anxiety during his interviews with Residents #1, #2, #3, and #4. He stated he was frequently on both hallways A and B Hallways, and no one had reported any concerns. He said the weekday Clinical Morning Meetings provided another opportunity for staff to report concerns because he asked them daily if anyone had witnessed any abusive, or had any other associated concerns with the residents, but no one had voiced concerns. He stated he went around the room and asked each attendee if they had anything that they needed to report. Interview with the SSC, on 06/03/2021 at 10:30 AM, revealed during the Daily Morning Staff Meetings (Monday through Friday), the Administrator has asked each attendee if they had any new allegations of resident abuse to report, or if they had learned of any associated resident concerns. Interview with the DON, on 06/02/2021 at 2:15 PM, revealed the current Daily Morning Staff Meetings gave attendees an opportunity to report and discuss with the group, any identified resident safety concerns, or allegations of abuse. He said the Administrator would assign follow up investigation tasks, as appropriate. 4. Review of the completed Resident Interview forms revealed the residents were asked four (4) questions: Did staff treat them with dignity and respect; Had anyone on the facility's staff been abusive to them; Had the resident reported any abuse, and if so, to whom did they report it? The interviewers also asked residents if they knew how, and to whom to report abuse? There were no identified concerns with the resident interviews. A resident BIMS Assessment Scoring Report was printed and included with the responses of the residents. The BIMS Scoring report validated the BIMS scores of the residents interviewed were within the acceptable range of eight (8) to fifteen (15). Interview with the SSC, on 06/03/2021 at 10:30 AM, revealed beginning on 05/21/2021, she interviewed residents, as directed by the Administrator. She stated she completed about ten (10) resident interviews on 05/21/2021. Interview, on 06/02/2021 at 9:15 AM with the B Hallway Unit Manager revealed she also interviewed residents on 05/21/2021, asking if they had experienced or witnessed abuse, and to ensure they knew who they could report abuse allegations. Interview, on 06/02/2021 at 11:00 AM with the ADON, revealed she interviewed residents beginning on 05/21/2021 using the four (4) question interview form to determine if they had experienced abusive treatment by staff, and to ensure they knew who they could report any allegations of abuse. Interview DCE, on 06/03/2021at 10:40 AM, revealed she also conducted resident interviews for identification of staff-to-resident abuse, and to determine they were knowledgeable of the staff members they should contact to make an allegation of abuse. Interview, on 06/02/2021 at 11:22 AM, with the Vice President (VP) of Compliance, revealed in addition to facilitating staff abuse prevention training that began on 05/22/201, he also interviewed some of the residents to determine if they had been abused, and if they knew how and to whom they could report abuse. Review of the interviews within the AOC documents, revealed the staff interviewed forty-six (46) residents, during the course of the structured resident interviews that occurred between 05/21/2021 to 05/23/2021. The following residents were interviewed by State Agency Surveyors, on 06/01/2021 regarding whether leadership staff had interviewed them about whether they had ever been abused and if they knew how and to whom to report if they had been abused or if they witnessed someone else being abused. The following residents were interviewed: A) On 06/01/2021 at 8:42 AM, Resident #4 stated the DON and the Director of Clinical Education interviewed him/her about abuse prevention and to whom he/she could report abuse. B) On 06/01/2021 at 8:49 AM, Resident #22 stated he/she was unsure if anyone has talked with him/her about abuse. C) On 06/01/2021 at 8:55 AM, Resident #16 stated administrative staff had spoken with him/her about abuse and how and to whom she could report abuse. D) On 06/01/2021 at 9:06 AM, Resident #13 said the SSC asked if he/she had been abused and if so, who would he/she tell. E) On 06/01/2021 at 9:12 AM, Resident #5 stated the SSC and the Administrator recently talked with him/her regarding abuse and how and to whom he/she could report abuse. F) On 06/01/2021 at 9:20 AM, Resident #6 said the SSC and the Administrator both interviewed him/her and asked if he/she had been abused, and if he/she knew to whom he/she should report an allegation of abuse. 5. Review of the resident skin assessments completed by the A and B Hallway Unit Managers, and the DON, on 05/03/2021, revealed there were no identified changes/areas of concern. The Unit Manager for the A Hallway UM resigned from her position, prior to the Validation of the AOC, however, interview with A Hallway UM on 05/17/2021 at 3:41 PM, revealed she and the B Hallway UM completed the skin assessments of all residents on 05/03/2021, and did not identify any suspicious resident injuries. Interview with the DON, on 06/02/2021 at 2:15 PM, revealed after the PCA #6 reported the abuse allegations, He asked the Unit Managers for the A and B Hallways to complete skin assessments on all residents, and report any identified concerns. He stated there were no suspicious resident injuries discovered. 6. Employees completed the abuse prevention training signed an affidavit confirmi [TRUNCATED]

Based on observation, interview, record review, review of the facility's policy, and review of the Centers for Medicare and Medicaid Services (CMS), Resident Assessment Instrument (RAI) Manual 3.0, it was determined the facility failed to implement a person centered Comprehensive Care Plan (CCP) for each resident to meet the resident's medical, and nursing needs identified in the comprehensive assessment for fourteen (14) of thirty (30) sampled residents (Residents #5/2, #4, #7, #13, #4/20, #7/23, #26, #3/31, #32, #34, #11/37, #39, #16/42, and #44). Review of Resident #5/2's Incident Forms, dated 09/27/2020 and 09/28/2020, and observations on 09/28/2020 through 09/29/2020, revealed the resident required bolsters to the bilateral sides of the bed and the bed in the low position for fall prevention measures; however, the CCP was not developed to include these interventions. (Refer to F689) The CCP for Resident #7 was not developed related to utilizing a catheter dignity bag. (Refer to F550) The CCP for Resident for #26 was not implemented related to completing weekly skin assessments. (Refer to F686) The CCP for Resident #11/37 was not implemented related to non-pharmaceutical interventions to decrease target behaviors related to anxiety and depression. (Refer to F758) The CCP's for Resident #4/20, Resident #7/23, Resident #3/31, Resident #34, and Resident #11/37 were not implemented to monitor intake after each meal. (Refer to F692) The CCP's for Resident #4, Resident #7, Resident #13, Resident #11/37, Resident #39, Resident #16/42, and Resident #44 were not developed to include Restorative Care with interventions, services, or treatment to maintain current functional status or prevent a decrease in function for residents. (Refer to F688) There was no documented evidence Resident #32's CCP was developed after a new [DIAGNOSES REDACTED]. The findings include: Review of the facility's policy, Care Plans, Comprehensive Person-Centered, dated December 2016, revealed it was the facility's policy to ensure the comprehensive, person-centered care plan included measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, developed and implemented the comprehensive, person-centered care plan. The care plan interventions were derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The IDT included: the Attending Physician; a Registered Nurse who had responsibility for the resident; a nurse aide who had responsibility for the resident; a member of the food and nutrition services staff; the resident and the resident's legal representative (to the extent practicable); and other appropriate staff or professionals as determined by the resident's needs or as requested by the resident. Further review of the policy, revealed the comprehensive, person-centered care plan would include the resident's stated goals upon admission and desired outcomes; incorporate identified problem areas; incorporate risk factors associated with identified problems; build on the resident's strength; reflect the resident's expressed wishes regarding care and treatment goals; reflect treatment goals, timetables, and objectives in measurable outcomes; aid in preventing or reducing a decline in the resident's functional status and/or functional levels; enhance the optimal functioning of the resident by focusing on a rehabilitative program; and reflect currently recognized standards of practice for problem areas and conditions. Care plan interventions were chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision-making. Review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, dated October 2016, revealed the Comprehensive Care Plan was an interdisciplinary communication tool and must include measurable objectives and time frames and must describe the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Further review revealed the services provided or arranged must be consistent with each resident's written Plan of Care. 1. Review of Resident #5/2's medical record revealed the facility admitted the resident on 09/11/2019, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 09/07/2020, revealed the facility assessed Resident #5/2 as usually makes himself/herself understood and understands others. Additional review revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of fourteen (14) out of fifteen (15) indicating intact cognition response. Continued review of the Assessment revealed the resident had no behaviors present and required the total assistance of two (2) staff with bed mobility, transfers, dressing, toilet use, and personal hygiene. Per Assessment, the resident did not ambulate and had impaired balance during transitions between surfaces and could only stabilize with staff assistance. Further review revealed the resident had falls since the prior assessment: one (1) non-injury and two (2) with minor injuries such as skin tears, abrasions, lacerations, superficial bruises, hematoma or sprains, or any fall related injury that caused the resident to complain of pain. Review of Resident #5/2's CCP, dated 09/11/2019, revealed the resident was at risk for falls related to balance problems, incontinence, psychoactive drug use, vision problems, weakness, [MEDICAL CONDITION], paresthesia, and a history of falls; 09/01/2020 fall from bed; 09/06/2020 fall; 09/07/2020 fall from bed; 09/08/2020 fall from wheelchair. The goal was the resident would not sustain serious injury. Interventions included schedule visits with family; Occupational Therapy screening related to appropriate seating; anticipate and meet resident's needs; call light within reach; and a wheelchair for locomotion off the unit. A) Review of Resident #5/2's Incident Report Form, dated 09/28/2020, revealed, on 09/27/20 at 2:45 PM, the resident had a fall occurrence in his/her room from the bed to floor. Further, the resident had bolsters to the bed and the bed was in the low position. (Refer to F-689) B) Additional review of Resident #5/2's Incident Report Form, dated 09/28/2020, revealed on 09/27/20 at 6:40 PM, the resident had a fall occurrence in his/her room from the bed to floor. Additionally, the resident had bolsters to the bed and the bed was in the low position. Further, corrective interventions implemented were to change the bed out for a bed that went closer to the floor. (Refer to F-689) C) Review of Resident #5/2's Incident Report Form, dated 09/28/2020 at 2:00 AM, revealed the resident had a fall occurrence in his/her room from the bed to floor. Per the report, the resident had bolsters to the bed and the bed was in the low position. (Refer to F-689) However, review of Resident #5/2's CCP, dated 09/11/2019, revealed no documented evidence the CCP was developed to include the bolsters to bilateral sides of the mattress or the bed in the low position. Observation of Resident #5/2, on 09/28/2020 at 2:30 AM, revealed the resident in bed with his/her eyes closed. Additional observation revealed the bed was in the lowest position and bilateral bolsters were noted on the mattress, under the sheet. Continued observations of Resident #5/2, on 09/28/2020 at 4:00 AM, 6:00 AM, and 10:00 AM, revealed the resident in bed. The bed was in the lowest position and bilateral bolsters were noted on the mattress, under the sheet. Additional observation of Resident #5/2, on 09/29/2020 at 9:00 AM, revealed the resident in bed with his/her eyes closed. The bed was raised to an above the knee height and bilateral bolsters were noted on each side of the mattress under the sheet. This was the first observation of bilateral mattresses on the floor beside the bed, which was the immediate intervention status [REDACTED]. (Refer to F-657) Further observation of Resident #5/2, on 09/29/2020 at 10:30 AM, revealed the resident remained in the bed with bilateral bolsters on each side of the mattress under the sheet. Further, the bed remained raised to an above the knee height. Additional review of Resident #5/2's CCP for falls, dated 09/11/2019, revealed a revision date of 09/29/2020, for the focus, which included: fall with skin tear to left elbow, root cause-decreased safety awareness related to Dementia and decreased motor function, dated 09/27/2020; fall with no injury, root cause-decreased safety awareness and bed did not go low enough, dated 09/27/2020; and fall with skin tear to right arm and hand, root cause-decreased safety awareness related to Dementia, dated 09/28/2020. Further, revisions to the interventions included, offer ice water with neuro checks and routine rounding, dated 09/29/2020; bed changed, low position closer to floor, dated 09/29/2020; and bilateral mattresses to bedside, dated 10/01/2020. Interview with State Registered Nurse Aide (SRNA) #22, on 09/30/2020 at 3:30 PM, revealed she had worked at the facility for fifteen (15) years and was familiar with Resident #5/2. Per interview, she stated she always reviewed Resident #5/2's Kardex (Care Plan) before providing care, and was aware the resident required the assist of two (2) staff for mobility, and was a fall's risk. Additional interview revealed she was aware Resident #5/2 had poor safety awareness and had a history of [REDACTED]. She stated a resident who required assistance with mobility and was a fall risk should not be left alone with the bed not in the low position. Further, she stated it was the responsibility of the staff to ensure residents were provided a safe environment and interventions were care planned to keep the resident safe and to meet their needs. Interview with Licensed Practical Nurse (LPN) #7, on 10/02/2020 at 10:11 AM, revealed she had worked in the facility for six (6) months. Per interview, Resident #5/2 had poor safety awareness, was at high risk for falls, and had a history of [REDACTED]. Additionally, she expected nursing staff to ensure the resident's safety measures were care-planned with interventions to ensure continuity of care and to provide a safe environment for residents. Further interview revealed Resident #5/2's bolsters and bed in the low position should be care planned as fall prevention interventions. She stated a resident who was a high risk for falls should never have the bed height raised above low, unless staff were providing direct care. Further, she stated she expected nursing staff to communicate needed changes to the care plan to her or the Minimum Data Set (MDS) Nurse immediately when they identified the care plan was inaccurate related to the care being provided and needed for the resident. Further, as the Unit Manager, she stated she rounded often and provided direct care to residents to ensure their care plans were an accurate reflection of the resident's care needs. However, she stated she did not identify that Resident #5/2's CCP had not been developed to include the low bed or bolsters. Interview with the Minimum Data Set (MDS) Nurse, on 10/02/2020 at 1:33 PM, revealed she had worked at the facility for sixteen (16) years and had worked as the facility's MDS Nurse for eight (8) years. Per interview, she stated the Corporate MDS Registered Nurse (RN) oversaw her work. Continued interview revealed Monday through Friday she met daily and participated with the Morning Clinical Meeting group to review fall events. Additionally, she stated she would ensure the CCP was accurate to meet the resident's needs based on the fall documentation and meeting discussions. Further interview revealed nursing staff verbally communicated to her necessary changes to the CCP. However, she stated she had not identified there was a failure to ensure appropriate fall interventions were care planned for Resident #5/2. Interview with the Director of Nursing (DON), on 10/02/2020 at 10:45 AM, revealed he expected nurses and Unit Managers to document needed fall interventions on a MDS Communication form, which was kept at the nurse's station. He stated the MDS Nurse reviewed the forms frequently and made appropriate changes to the CCP. Additional interview with the DON, on 10/02/2020 at 5:04 PM, revealed he was not aware Resident #5/2's CCP had not been developed to include low bed positioning or bolsters. Additionally, the facility did not have a CCP audit process in place to identify if a resident's CCP was accurately developed to meet the resident's needs. The DON stated Resident #5/2's CCP should have been developed to include the bilateral bolsters to the mattress and the low bed position. Further, he stated ensuring the CCP was developed to meet the needs of individual residents was important to provide quality care and maintain safety for all residents. Interview with the Administrator, on 10/02/2020 at 5:58 PM, revealed Resident #5/2's CCP should have been developed to include bolsters and a low bed position. Further, the Administrator stated it was important for the CCP to document all care residents received based on their care needs. 2. Review of Resident #7's medical record revealed the facility admitted the resident on 01/21/2020, with [DIAGNOSES REDACTED]. A) Interview and observation with Resident #7, on 09/28/2020 at 9:32 AM, revealed the resident's right hand was closed at rest, and the fingers were folded into the palm. Further, the resident stated he/she did not wear a brace or device and did not have an exercise program to move his/her hand. However, Resident #7 stated he/she had adapted to not using the right hand to complete Activities of Daily Living (ADL) tasks. Review of Resident #7's Quarterly MDS Assessment, dated 07/01/2020, revealed the facility assessed the resident as having a BIMS score of three (3) out of fifteen (15) indicating severe cognitive impairment. Additionally, the facility assessed the resident as requiring total assistance of two (2) staff for locomotion, transfers, personal hygiene, toileting, dressing, and bed mobility. Per the assessment, the resident had functional limitation in range of motion (ROM) to one (1) upper extremity. Further review of the MDS Assessment, revealed the resident did not receive therapy or services from a Restorative Nursing Program (RNP). Review of Resident #7's CCP, dated 03/25/2020 with a revision date of 10/01/2020, revealed the resident had potential/actual impairment to skin integrity related to decreased mobility; wounds; and the [DIAGNOSES REDACTED]. The goal was the resident would maintain or develop clean and intact skin. Interventions included weekly skin assessments, dated 03/25/2020, and palm pillow or rolled wash cloth to the right hand as tolerated to maintain skin integrity, revised 06/15/2020. However, there was no documented evidence the facility developed or implemented Restorative Care with interventions, services, or treatment to maintain current functional status or to prevent a decrease in function. (Refer to F-688) B) Review of physician's orders [REDACTED]. Review of Resident #7's Comprehensive Care Plan (CCP) revealed a focus, initiated on 03/25/2020 revised on 03/30/2020, of the resident had an alteration in elimination of bowel/bladder related to a supra-pubic catheter. The goal was the resident would have no complications from the use of the indwelling catheter such as pain, infection, or obstruction; and would maintain or develop clean and intact skin. Further review revealed interventions included: change catheter as ordered; change catheter bag as ordered; check catheter tubing for proper drainage and positioning; keep catheter drainage bag below the level of the bladder and off the floor; monitor and report signs and symptoms of a urinary tract infection [MEDICAL CONDITION] which were changes in color, odor, or consistency of urine, dysuria, frequency, fever, and/or pain; and supra-pubic catheter care every shift and as needed. However, the CCP was not developed to include the use of a dignity bag. (Refer to F-656) Review of Resident #7's Quarterly MDS Assessment, dated 07/01/2020, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of three (3) out of fifteen (15) indicating severe cognitive impairment. Additionally, the facility assessed the resident as requiring total assistance of two (2) staff for locomotion, transfers, personal hygiene, toileting, dressing, and bed mobility. Further, per the MDS Assessment, the resident had a [DIAGNOSES REDACTED]. Observation, on 09/29/20 at 9:00 AM, revealed the resident was lying in bed, and the indwelling catheter tubing and catheter bag were hanging on the bed frame; dark urine was noted in the tubing and bag; and the catheter was visible from the hallway. Additionally, there was no dignity bag covering the bag. Further observation, on 10/01/2020 at 9:00 AM, revealed the resident was lying in bed and the catheter tubing and catheter bag were hanging on the bed frame; dark urine was noted in the tubing and bag; and the catheter was visible from the hallway because there was no dignity bag covering the bag. Interview with SRNA #22, on 09/30/2020 at 3:30 PM, revealed she had worked at the facility for fifteen (15) years and was familiar with Resident #7. Per interview, she stated she used the Care Plan as a guide for providing care to residents. Additionally, the CCP should be developed to each resident's needs and should include the use of dignity bags for catheters. SRNA #22 stated catheter bags should always be placed in a dignity bag to ensure residents' privacy. Further, she stated the Kardex (Care Plan) did not specify the use of dignity bags. Interview with LPN #7, on 10/02/2020 at 10:11 AM, revealed she had worked in the facility for six (6) months. Per interview, the CCP should be developed with interventions to ensure each resident's dignity. Additionally, she stated the CCP should have been developed to include individualized interventions such as a dignity bag for Resident #7. Further, she stated she expected nursing staff to ensure the resident's catheter bag was covered and not visible to other residents or guests in the facility to ensure the resident's privacy and dignity. Interview with the Minimum Data Set (MDS) Nurse, on 10/02/2020 at 1:33 PM, revealed she had worked at the facility for sixteen (16) years and had worked as the facility's MDS Nurse for eight (8) years. Per interview, the Corporate MDS Registered Nurse (RN) oversaw her work. She stated the CCP should be developed to include the use of dignity bags for residents with catheters. Further, it was important for the Care Plan to be developed and implemented to include appropriate interventions to maintain a resident's dignity and privacy. Interview with Director of Nursing (DON), on 10/02/2020 at 5:04 PM, revealed he had worked in the facility for one (1) month. Per interview, he expected the CCP to be developed to include dignity bags for catheters. Additionally, he stated dignity bags on catheters ensured a resident's privacy was maintained and prevented any negative cogitation. Interview with the Administrator, on 10/02/2020 at 5:58 PM, revealed he expected residents who had catheters to have a CCP developed to include interventions which had the use of dignity bags. Additionally, he stated he expected residents with catheters to always have the catheter enclosed in a dignity bag. Further, he stated it was important to use dignity bags to maintain a resident's dignity and ensure quality care. 3. Review of Resident #39's medical record revealed the facility admitted the resident, on 07/22/2020, with [DIAGNOSES REDACTED]. Observation of Resident #39, on 10/02/2020 at 4:30 PM, with Licensed Practical Nurse (LPN) #7, revealed the resident was resting in bed on his/her right side, the right hand was out of the covers and at rest; the right hand was grossly [MEDICAL CONDITION] at the knuckles, closed in a fist, and had no device in it. Further observation revealed LPN #7 was not able to perform ROM because the resident's right hand middle digit was folded down on the right hand palm and could not be lifted/raised from the resting position. LPN #7 was able to place her finger underneath the resident's right middle digit. Additional observations revealed right hand digits #4 and #5 had limited ROM, however, they could be lifted/raised off the resident's palm and extended. Further observation revealed the resident stated ouch and guarded his/her right hand by pulling away from LPN #7. Review of Resident #39's Admission MDS Assessment, dated 07/29/2020, revealed the facility assessed the resident as having severely impaired cognitive skills for daily decision-making; short and long-term memory problems. Additionally, the facility assessed the resident as requiring extensive assistance of two (2) staff for bed mobility, transfer, locomotion, dressing, toileting, and personal hygiene. Continued review revealed eating required extensive assistance of one (1) staff. Per the MDS Assessment, ambulation did not occur. Further, the resident had no functional limitation in ROM to the upper or lower extremities. Per the MDS assessment, the resident received five (5) days of therapy for at least fifteen (15) minutes per session in the last seven (7) days. Review of Resident #39's Quarterly MDS Assessment, dated 08/30/2020, revealed the facility assessed the resident as having severely impaired cognitive skills for daily decision-making; short and long-term memory problems. Additionally, the facility assessed the resident as requiring total assistance of two (2) staff for bed mobility, transfer, locomotion, dressing, toileting, eating and personal hygiene. Per the MDS Assessment, ambulation did not occur. Further, the resident had no functional limitation in ROM to the upper or lower extremities. Per the MDS Assessment, therapy ended, on 08/07/2020, and the resident did not receive RNP. Review of Resident #39's CCP, dated 07/23/2020, revealed the resident had an ADL self-care deficit related to needing assistance with ADL's. The goal was the resident would remain free of body odor and appropriately dressed and groomed by staff. Interventions included nursing staff to ensure daily needs were met; turn and reposition, shift weight to enhance circulation, during care rounds; and total dependence on one (1) staff for eating. However, there was no documented evidence the facility developed or implemented a Restorative Care Plan with interventions, services, or treatment to maintain current functional status or prevent a decrease in function. (Refer to F-688) 4. Review of Resident #44's medical record revealed the facility admitted the resident, on 06/15/2020, with [DIAGNOSES REDACTED]. Observation and interview with Resident #44, on 09/28/2020 at 8:00 AM, revealed the resident's bilateral arms were bent/contracted at the elbow, and while at rest his/her hands rested on the collarbone. Additionally, the resident's bilateral hands were closed at rest; the right and left hand fingers were curled and closed in a fist, and the resident was not wearing any devices on his/her hands or arms. Per interview, the resident stated he/she had been at the facility for three (3) months and had contractures to hands and arms prior to admission to the facility. Continued interview revealed the resident currently did not consistently use any special devices or braces for the contractures. Resident #44 stated he/she was too far-gone and a burden to staff. Further, the resident stated he/she had historically worked with therapy but since therapy ended, had not been involved in any type of RNP. Review of Resident #44's Quarterly MDS Assessment, dated 08/29/2020, revealed the facility assessed the resident as having a BIMS score of fifteen (15) out of fifteen (15) indicating intact cognition. Additionally, the facility assessed the resident as requiring total assistance of two (2) staff for eating, personal hygiene, dressing, and bed mobility. Continued review revealed transfers and toileting only occurred once or twice but required two (2) staff, and locomotion required one (1) staff. Further, the resident had functional limitation in ROM to two (2) upper extremities. Per the MDS assessment, the resident did not receive therapy or services from the Restorative Nursing Program (RNP). Review of Resident #44's CCP, revealed the resident had an alteration in musculoskeletal status related to bilateral hand contractures. The goal was the resident would remain free of injury or complications related to contractures. Further review revealed interventions included to anticipate and meet needs; ensure call light was within reach and responded to promptly; monitor for skin breakdown; and Occupational Therapy to evaluate and treat as indicated. However, there was no documented evidence the facility developed or implemented a Restorative Care plan with interventions, services, or treatment to maintain current functional status or to prevent a decrease in function. (Refer to F-688) Interview with SRNA #22, on 09/30/2020 at 3:30 PM, revealed she had worked at the facility for fifteen (15) years. Per interview, she used the Care Plan as a guide for providing care to residents. Additionally, she stated the CCP should be developed based on each resident's needs and should include interventions to prevent a decline in functional ROM. Further, not all residents received ROM; only residents who were in therapy. Per interview, ROM was important to reduce the risk for worsening contractures or development of new contractures. Interview with SRNA #4, on 10/01/2020 at 3:45 PM, revealed she used the Kardex (Care Plan) to know how to provide care to residents. Additionally, the CCP should be individualized for each resident to include how to provide care to prevent a decline in functional ROM. Further, ROM and devices were not always specified on the Care Plan; however, ROM and devices were important to ensure the resident did not decline. Interview with SRNA #21, on 10/10/2020, at 1:20 PM, revealed she had worked at the facility for one (1) year. Additionally, she used the Care Plan on the Electronic Health Record to know how to provide care to each resident. Per interview, she stated ROM was only provided to residents who were in therapy. Further, it was important to provide ROM and devices to residents so they would not get stiff, not have pain with moving, and not develop skin issues. Interview with the Occupational Therapist (OT), on 10/01/2020 at 2:18 PM, revealed the Care Plan was a communication tool for the Interdisciplinary Team to ensure resident specific care was consistently provided to meet each resident's needs. Additionally, the Care Plan should include specific functional limitations for each resident and include ROM and devices as necessary. Continued interview revealed she expected therapy recommendations to be followed up by nursing staff post discharge to ensure the resident's best wellbeing and to refer residents back to therapy when a change in the resident's functioning occurred. Further, she stated the therapy department communicated therapy discharge recommendations during the Morning Clinical Meeting, Monday through Friday, as well as verbally communicated each individual resident's discharge recommendations to the MDS nurse the week of discharge. Interview with LPN #7, on 10/02/2020 at 10:11 AM, revealed she had worked in the facility for six (6) months. Per interview, the CCP should be developed with interventions to ensure each resident's safety and to prevent a decline in ROM. Additionally, the CCP should have been developed to include individualized interventions to maintain the resident's current functional status and to prevent worsening or a decline in ROM. Further, it was important for a CCP to be developed to meet ROM and device needs of all residents to ensure staff provided the necessary care, and the resident's needs were met. Interview with the MDS Nurse, on 10/02/2020 at 1:33 PM, revealed she had worked at the facility for sixteen (16) years. Continued interview revealed she met daily with the therapy department to discuss residents being discharged from therapy and ensured the Care Plan was accurate to meet the resident's needs. However, she did not review therapy discharge summaries and relied on physician's orders [REDACTED]. Additionally, the Care Plan would not be developed to include ROM, because ROM was provided by SRNAs during morning care. Further, it was important for the Care Plan to be developed and implemented to include appropriate services, equipment, and assistance to maintain or improve mobility with independence to ensure each resident's care needs were met and a decline in functionality was avoided. Interview with the Director of Nursing (DON), on 10/02/2020 at 5:04 PM, revealed he expected the RAI Manual Guidelines and the facility's policy to be followed related to development of the CCP for functional limitations in ROM. Additionally, if a resident had a functional limitation in ROM, the CCP should be developed to include interventions, services, or treatment to maintain current functional status or to prevent a decrease in function of ROM. Further, he stated it was important for the CCP to be developed to ensure the Interdisciplinary Team provided necessary care to residents to prevent complications and maintain quality of care. Continued interview with the Administrator, on 10/02/2020 at 5:58 PM, revealed he expected the interventions developed on the CCP to be implemented per RAI guidelines and the facility's policy. Additionally, he expected residents who had functional limitations in ROM, to have a CCP developed to include interventions, services, or treatment to maintain current functional status or to prevent a decrease in function of ROM. Further, he stated it was important for residents to receive treatment (TRUNCATED)

Based on observation, interview, record review, review of the facility's policy, and review of the Centers for Medicare and Medicaid Services (CMS), Resident Assessment Instrument (RAI) Manual 3.0, it was determined the facility failed to have an effective system in place to review and revise the Comprehensive Care Plans for six (6) of thirty (30) sampled residents (Residents #5/2, #4/20, #7/23, #3/31, #34, and #11/37). There was no documented evidence Comprehensive Care Plans (CCP) were reviewed and revised timely, after residents were identified with severe weight loss, to include measurable objectives and individualized interventions to meet the residents' nutrition/hydration needs resulting in significant or severe weight loss and/or dehydration. This failure affected Residents #4/20, #7/23, #3/31, #34, and #11/37. There was no documented evidence Resident #5/2's Comprehensive Care Plan (CCP) was reviewed and revised timely to include measurable objectives and individualized interventions to meet the resident's need for fall interventions implemented after the resident's falls on 09/27/2020 and 09/28/2020. The findings include: Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, revised December 2016, revealed it was the facility's policy to ensure the comprehensive, person-centered care plan included measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs and described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Further review of the policy, revealed the comprehensive, person-centered care plan would aid in preventing or reducing a decline in the resident's functional status and/or functional levels and reflect currently recognized standards of practice for problem areas and conditions. Further review revealed resident assessments were ongoing and care plans were revised as information about the residents and the residents' conditions changed. In addition, the Interdisciplinary Team must review and update the care plan when: there had been a significant change in the resident's condition; the desired outcome was not met; the resident had been readmitted to the facility from a hospital stay; and at least quarterly, in conjunction with the required Quarterly MDS Assessment. Review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, dated October 2016, revealed the care plan must be reviewed and revised periodically, and the services provided or arranged should be consistent with each resident's written plan of care. Continued review of the Manual, revealed the care plan was driven not only by identified resident issues and/or conditions, but also by a resident's unique characteristics, strengths, and needs. Furthermore, a care plan based on a thorough assessment and effective clinical decision making, was compatible with current standards of clinical practice that provided a strong basis for optimal approaches to quality of care and quality of life needs of individual residents. The Manual stated, a well developed and executed assessment and care plan: re-evaluated the resident's status at prescribed intervals (quarterly, annually, or if a significant change in status occurred) using the RAI and then modified the individualized care plan as appropriate and necessary. 1. Review of Resident #3/31's medical record revealed the facility admitted the resident, on 05/28/2019 and re-admitted on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #3/31's Order Summary Report, revealed an order, with a start date of 12/10/2019, for a regular diet with mechanical soft texture, regular consistency; weekly weights until weight stabilized, starting 06/06/2020; and weigh the resident per facility protocol, started on 12/10/2019. Review of Resident #3/31's Comprehensive Care Plan (CCP), initiated on 03/23/2020, revealed a focus of at risk for alteration in nutritional status related to Depression and a disordered eating pattern due to: the resident received a mechanically altered diet; low protein levels; refused meals; inattentive and restless; fluctuating oral intake; and, noted weight loss. The goal, with a target date of 12/19/2020, stated the resident would have no significant unplanned weight change by the next review. Interventions, initiated on 03/23/2020 included: continue to monitor food and fluids for appropriate texture and consistency; diet as ordered; educate family on bringing in foods not allowed on diet; obtain and monitor labs as ordered; and reassess as needed to help ensure adequate nutritional needs were being met daily. Further review revealed additional interventions included: administer appetite stimulant as ordered, initiated on 06/05/2020; weigh as per order, initiated on 06/06/2020; include peanut butter milkshakes six (6) ounces as scheduled, initiated on 06/07/2020; resident required total assistance with meals, initiated on 06/10/2020; refer to Speech Therapy for evaluation and treatment if indicated, initiated on 09/09/2020; and offer Ensure (a supplement) or equivalent twice a day as per order, initiated on 09/18/2020. However, the facility failed to ensure implementation of the CCP related to monitoring of the resident's meal intakes. Review of Resident #3/31's Meal Intake Report, dated August 2020, revealed the resident refused a total of three (3) meals; consumed 0-25% of thirteen (13) meals; consumed 26-50% of twenty (20) meals; consumed 51-75% of two (2) meals; consumed 76-100% of sixteen (16) meals; and thirty-one (31) occurrences where the intake amount was left blank/not documented. Per the CCP the staff will monitor resident's meal intake; however, there was thirty-one (31) occurnaces when the meal intake was not recorded. Review of Resident #3/31's Weight Summary revealed the resident weighed 143.0 pounds on 07/01/2020 and 125.0 pounds on 08/26/2020. This was a weight loss of eighteen (18) pounds within fifty-seven (57) days, indicating a 12.5% weight loss. However, there was no documented evidence the facility reviewed or revised the CCP to address the resident's weight loss. Review of the Weight Exception Report, from 04/21/2020 to 09/21/2020, revealed the electronic health record (EHR) alerted a warning stating the resident had a ten (10) percent weight change, on 08/26/2020, compared to the weight obtained on 07/01/2020. However, there was no documented evidence of immediate intervention once the facility became aware of the resident's weight loss. 2. Review of Resident #4/20's clinical record revealed the facility admitted the resident on 03/02/2020, with [DIAGNOSES REDACTED]. Review of Resident #4/20's CCP, initiated on 05/28/2020, revealed a focus of the resident had unplanned/unexpected weight loss related to poor intake; ate approximately 50-75 percent of meals; received supplements to provide extra calories and the resident reported he/she was not a big breakfast or lunch person, but preferred dinner. The goal, with a target date of 12/12/2020, revealed the resident would have no significant weight change by the next review. Interventions, initiated 05/28/2020 and 05/29/2020 included: monitor intake after each meal and record; monitor for significant weight changes; offer substitutes as requested or indicated, and provide fortified foods with all meals. Another intervention was offer peanut butter milkshakes between breakfast and lunch, initiated 06/07/2020. Per the CCP, other interventions, initiated on 09/01/2020 included: medications reviewed and changes made as per order; weigh as per order; and the resident required total assistance with meals. Another intervention, initiated on 10/01/2020, was Glucerna (low sugar supplemement) twice a day, offer chocolate if available. Review of Resident #4/20's Weight Summary revealed the resident weighed 143.5 pounds on 07/03/2020 and 134.0 pounds on 08/21/2020. This was a weight loss of 9.5 pounds within forty-nine (49) days; indicating a 6.6 percent weight loss. Review of the Weight Exception Report, from 04/21/2020 to 09/21/2020, revealed the EHR alerted with a warning stating Resident #20 had a ten (10) percent weight change on 08/21/2020 compared to the weight obtained on 03/02/2020. However, there was no documented evidence the faciliy reviewed or revised the CCP once the facility became aware of the resident's weight loss. 3. Review of Resident #11/37's medical record revealed the facility admitted the resident on 07/27/2016, with [DIAGNOSES REDACTED]. Review of Resident #11/37's CCP, initiated 02/29/2020, revealed a focus of risk for alteration in nutritional status related to Depression, [MEDICAL CONDITION], Obese with Body Mass Index (BMI) and Dysphagia; the resident had weight loss noted, had a fair appetite, and required staff assistance at times with meals. Further review revealed on 07/02/2020, the resident's weights had stabilized. The goal stated the resident would have no significant unplanned weight change by the next review date with a target date of 10/27/2020. Interventions initiated on 02/29/2020 included: continue to monitor food and fluids for appropriate texture and consistency; diet as ordered; educate family on bringing in foods not allowed on diet; monitor/record intake after each meal and obtain and monitor labs as ordered; reassess as needed to help ensure nutritional needs were being met daily; and use a divided plate with all meals. Further review revealed other interventions included to provide supplements as per order, initiated on 04/30/2020; administer medications as ordered, initiated on 06/05/2020; Ensure as ordered secondary to weight loss and fortified oatmeal with breakfast, initiated on 06/06/2020; may see dietician related to weight loss, initiated on 06/09/2020; and required set-up assistance with meals, initiated on 06/10/2020. Review of Resident #11/37's Meal Intake Report, dated August 2020, revealed the resident refused one (1) meal; consumed 0-25% of seventeen (17) meals; consumed 26-50% of ten (10) meals; consumed 51-75% of sixteen (16) meals; consumed 76-100% of ten (10) meals; and twenty-nine (29) occurrences where the intake amount was left blank/not documented. Per the CCP the staff will monitor resident's meal intake, however there was twenty-nine (29) occurnaces when the meal intake was not recorded. Review of Resident #11/37's Weight Summary revealed the resident weighed 179.6 pounds on 07/02/2020 and 167.0 pounds on 08/23/2020. This was a severe weight loss of 12.6 pounds within fifty-two (52) days, indicating a 7.02 percent weight loss. Review of the Weight Exception Report, from 04/21/2020 to 09/21/2020, revealed the EHR alerted with a warning stating Resident #37 had a 7.5 percent weight change on 08/23/2020 compared to the weight obtained on 06/25/2020. However, there was no documented evidence of immediate intervention once the facility became aware of the resident's weight loss. The facility failed to review and revise the CCP to provide timely interventions related to Resident #37's weight loss. 4. Review of Resident #7/23's medical record revealed Resident #23 was admitted to the facility, on 01/04/2011, with [DIAGNOSES REDACTED]. Review of Resident #7/23's CCP revealed a focus for unplanned/unexpected weight loss. The goal, initiated on 05/28/2020 and revised on 07/08/2020, was for Resident #23 to consume 50-75 percent for two (2) of three (3) meals per day. Review of Resident #7/23's weights revealed the resident was weighed on 07/07/2020 at 165.4 pounds and was not weighed again until 08/21/2020, forty-five (45) days later, at 144 pounds. This was a loss of 21.4 pounds, or 12.94 percent, which was considered a severe weight loss. Review of the Weight Exception Report, from 04/21/2020 to 09/21/2020, revealed the EHR alerted with a warning stating Resident #7/23 had a 7.5 percent weight change, on 08/21/2020, compared to the weight obtained on 06/03/2020. However, there was no documented evidence the facility reviewed or revised the CCP with immediate intervention once the facility became aware of the resident's weight loss. Although not available in review of the EHR or paper medical record, documentation was provided indicating the Registered Dietician was notified, on 08/22/2020, regarding Resident #23 experiencing a 21 pound weight loss in one (1) month. This weight loss was not identified on the care plan, with no interventions added to the unplanned/unexpected weight loss care plan interventions, until 09/02/2020, for a magic cup as ordered, and also, on 09/02/2020, to administer medication as ordered. 5. Review of Resident #34's medical record revealed the resident was admitted to the facility, on 09/22/15, with [DIAGNOSES REDACTED]. Review of Resident #34's CCP revealed a focus on nutrition toward weight loss, with an intervention to monitor and record meal intake. Review of Resident #34's weights revealed the resident was weighed on 07/03/2020 at 220.3 pounds and was not weighed again until 08/23/2020, fifty-one (51) days later, at 204 pounds. This was a loss of 16.3 pounds, or 7.39 percent, which was considered a severe weight loss. Review of the Weight Exception Report, from 04/21/2020 to 09/21/2020, revealed the EHR alerted with a warning stating Resident #34 had a 7.5 percent weight change on 08/24/2020 compared to the weight obtained on 06/19/2020. However, there was no documented evidence the facility reviewed/revised the resident's care plan. Nor was there an immediate intervention once the facility became aware of the resident's weight loss. Although not available in review of the EHR or paper medical record, documentation was provided indicating the RD was notified, on 08/23/20, regarding Resident #34 experiencing a 16 pound weight loss in one (1) month. This weight loss was not identified on the care plan, with no interventions added to the nutrition care plan until a new intervention for house supplement was added, on 09/18/20, to go along with a Physician order [REDACTED].> 6. Review of Resident #5/2's medical record revealed the facility admitted the resident on 09/11/2019, with [DIAGNOSES REDACTED]. Review of Resident #5/2's Quarterly Minimum Data Set (MDS) Assessment, dated 09/07/2020, revealed the facility assessed Resident #2 as usually makes himself/herself understood and understands others. Additional review revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of fourteen (14) out of fifteen (15) indicating intact cognition response. Further review revealed the resident had falls since the prior assessment, one (1) non-injury and two (2) with minor injures. Review of Resident #5/2's CCP, dated 09/11/2019, revealed a focus of the resident was at risk for falls related to balance problems, incontinence, psychoactive drug use, vision problems, weakness, [MEDICAL CONDITION], paresthesia, and a history of falls; 09/01/2020 fall from bed; 09/06/2020 fall; 09/07/2020 fall from bed; 09/08/2020 fall from wheelchair. The goal was the resident would not sustain serious injury. Interventions included to schedule visits with family; Occupational Therapy screening related to appropriate seating; anticipate and meet the resident's needs; call light within reach; and wheelchair for locomotion off the unit. Review of Resident #5/2's medical record revealed the resident had falls on 09/27/2020 at 2:45 PM, on 09/27/2020 at 6:40 PM, and on 09/28/2020 at 2:00 AM. Additionally, the facility investigated each fall event and determined the Root Cause of the falls and implemented interventions accordingly. Further, the fall invesitgations noted devices in use at the time of each fall, which included bolsters to the mattress. Observations of Resident #5/2, on 09/28/2020 at 2:30 AM, and on 09/28/2020 at 4:00 AM, 6:00 AM, and 10:00 AM, revealed the resident in bed. There were bolsters on the mattress, the bed was in the lowest position and bilateral fall mats were on the floor at the bedside. Further observations of Resident #5/2, on 09/29/2020 at 9:00 AM until 10:20 AM, revealed the resident in the bed. The bed was raised to an above the knee height, and bilateral bolsters were noted on the bed. Additional review of Resident #5/2's CCP for falls, dated 09/11/2019, revealed a revision date of 09/29/2020 for the focus, which included: fall with skin tear to left elbow, root cause-decreased safety awareness related to Dementia and decreased motor function, dated 09/27/2020; fall with no injury, root cause-decreased safety awareness and bed did not go low enough, dated 09/27/2020; and fall with skin tear to right arm and hand, root cause-decreased safety awareness related to Dementia, dated 09/28/2020. Further, revisions to the interventions included, offer ice water with neuro checks and routine rounding, dated 09/29/2020; bed changed, low position closer to floor, dated 09/29/2020; and bilateral mattresses to bedside, dated 10/01/2020. However, there was no documented evidence the CCP was revised to include the bolsters in use. Further, the CCP was not revised to include provide ice water with neurological checks and routine rounding, or change bed, low position closer to the floor, until 09/29/2020, two (2) days after the fall occurrences, on 09/27/2020 at 2:45 PM and 6:40 PM. Further, the CCP was not revised to include bilateral mattresses to the bedside, until 10/01/2020, three (3) days after the fall occurrences, on 09/28/2020 at 2:00 AM. Review of the Random Audits of five (5) resident's charts, for review of Incident Reports to ensure appropriate interventions had been put into place timely to reduce the risk of resident falls/accidents and that care plans had been updated to reflect the intervention, revealed no documented evidence of who completed the audit or the date the audits were completed. Additionally, the audit, with dates ranging from 09/27/2020 through 10/02/2020, revealed on 09/27/2020, Resident #2 was reviewed and noted, Incident report reviewed and completed; offer ice water with neuro checks completed; Care plan updated. However, there was no documented evidence the CCP was revised with offer ice water with neurological checks, until 09/29/2020, two (2) days after the fall. Further review of the Audit revealed Resident #2's fall, on 09/27/2020 at 6:40 PM, and fall, on 09/28/2020 at 2:00 AM, were not included in the audit, which included dates of 09/27/2020 through 10/02/2020. (Refer to F-689, F-835, F-837, and F-865) Interview with SRNA #22, on 09/30/2020 at 3:30 PM, revealed she had worked at the facility for fifteen (15) years. Per interview, she used the CCP as a guide for providing care to residents. Additionally, she stated the CCP should be revised to meet each resident's needs and should include interventions to prevent falls. Further, she stated it was important for the CCP to be revised timely to reduce the risk of the resident falling again. Interview with Licensed Practical Nurse (LPN) #7, on 10/02/2020 at 10:11 AM, revealed she had worked in the facility for six (6) months. Per interview, the CCP should be revised with interventions to ensure each resident's safety and to prevent falls. Additionally, she stated the CCP should have been revised status [REDACTED]. Continued interview, revealed a resident who was a high risk for falls should never have the bed height raised above low, unless staff were providing direct care. Further, she stated direct care nurses were responsible to determine the Root Cause of fall events and to implement an immediate intervention based on the Root Cause of the fall to ensure residents received the best care and their individual care needs were met. However, she stated when a resident sustained [REDACTED]. Per interview, during the Monday through Friday Morning Clinical Meeting, participants reviewed the fall occurrences and revised the CCP to include the most appropriate intervention. Further, Resident #2's CCP was not revised timely after his/her two (2) falls, on 09/27/2020, and the fall on 09/28/2020. LPN #7 stated it was not acceptable to delay revision for two (2) or three (3) days after a fall because staff needed to know how to keep the resident safe during that time. Interview with the Minimum Data Set (MDS) Nurse, on 10/02/2020 at 1:33 PM, revealed she had worked at the facility for sixteen (16) years and had worked as the facility's MDS nurse for eight (8) years. Per interview, the Corporate MDS Registered Nurse (RN) oversaw her work. Further, she stated, Monday through Friday, she met and participated daily with the Morning Clinical Meeting which reviewed fall events. Additionally, during the meeting, she stated she would ensure the CCP was accurately revised to meet the resident's needs based on the fall documentation and meeting discussions. Further interview revealed she had not identified there was a failure to ensure fall interventions were revised in the CCP appropriately and timely. She stated Resident #2's CCP should have been revised to include interventions based on the fall's Root Causes, on 09/28/2020, related to the resident's falls on 09/27/2020, and revised, no later than 09/29/2020, for the resident's fall on 09/28/2020. Interview with the Director of Nursing (DON), on 10/02/2020 at 10:45 AM, revealed he expected the RAI Manual Guidelines and the facility's policies to be followed related to revision of the CCP. Per interview, he stated, for status [REDACTED]. Additionally, he stated falls were investigated by the participants of the Monday through Friday Morning Clinical Meeting. The DON stated falls, from the previous day, were reviewed to ensure action was taken status [REDACTED]. Further interview revealed the CCP was also revised with an appropriate intervention during the Morning Clinical Meeting after the fall occurrence was reviewed. Per interview, the DON stated he also maintained a Line List of resident falls, which included the resident's name, date and time of the fall, cause of the fall, location of the fall, and intervention. The sections, Date and Time of Fall and Interventions, had a note to update the care plan. However, review of the Line List, on 10/02/2020 at 10:45 AM with the DON, revealed the last fall occurrence reviewed was on 09/19/2020. Continued interview with the DON revealed, because State Survey Agency Inspectors were in the facility, the Morning Clinical Meeting participants had not reviewed falls that occurred over the 09/27/2020 weekend forward, and the Line List had not been updated. Additional interview revealed there had been an impromptu discussion for one (1) of Resident #2's falls; however, the facility did not work through the Plan of Correction process with two (2) of the three (3) falls that occurred, on 09/28/2020 at 6:40 PM, and 09/29/2020 at 2:00 AM. Continued review revealed, on 09/27/2020, Resident #2 was noted on the audit, which stated Incident report reviewed and completed; offer ice water with neuro checks completed; Care plan updated; however, there was no documented evidence the CCP was revised with offer ice water with neurological checks, until 09/29/2020. Further interview with the DON revealed on Monday through Friday the previous days incident reports would be reviewed in the Morning Clinical Meeting to ensure appropriate interventions were implemented and a revision to the care plan was completed, per the Plan of Correction, with a compliance date of 09/25/2020. Additionally, he stated Resident #2's falls, on Sunday 09/27/2020, should have been reviewed, on Monday 09/28/2020, and Resident #2's fall, on Monday 09/28/2020, should have been reviewed, on Tuesday 09/29/2020, and the CCP revisions made. Further, the reviews of fall events and revisions to the CCP, for Resident #2, should have been completed more timely, per the Plan of Correction. (Refer to F-689, F-835, F-837, and F-865) Interview with the Administrator, on 10/02/2020 at 5:58 PM, revealed he expected the facility policy and RAI Guidelines to be followed related to revisions of the CCP. Additionally, he stated fall events were reviewed during the Monday through Friday Morning Clinical Meeting. Per interview, he expected fall interventions to be revised timely to ensure each resident's care needs were met. The Administrator stated the DON was responsible for the Plan of Correction Audits related to accident/falls, as of 09/01/2020. Per interview, the Administrator stated the DON was responsible to review fall Incident Reports, to ensure there were appropriate interventions implemented, and to ensure the CCP was revised timely to reduce the risk for falls. Further interview revealed he expected, when non-compliance was identified, that education was provided to the staff involved, and the error was corrected. Continued interview with the Administrator revealed, it was his understanding the audit for accidents/falls, for the week, was current and accurate. Review of the audit revealed Resident #2's fall occurrence, on 09/27/2020 at 2:45 PM, was included in the Audit. However, the audit noted the Incident Report was reviewed and completed, and the CCP was updated. Further, he stated it was not acceptable for Resident #2's CCP to be revised with interventions for the 09/27/2020 falls, on 09/29/2020, two (2) days after the fall occurrences; or, for the resident's fall, on 09/28/2020, the CCP revision to be completed, on 10/01/2020, three (3) days after the fall occurrence. The Administrator stated Resident #2's fall reviews and CCP revisions should have been completed more timely, and the audit process should have identified the noncompliance. Interview with the Administrator and Regional Liaison, on 10/06/2020 at 4:54 PM, revealed on 10/04/2020, the facility identified CCP's were not being revised timely, to include fall interventions, per State Inspector's findings related to Resident #2's falls, on 09/27/2020 and 09/28/2020. Additional interview revealed, on 10/04/2020, the facility implemented a process to ensure immediate fall interventions were communicated to staff. Per interview, both stated a communication binder was placed at each nurse's station, and immediate fall interventions would be written on a paper communication form and used until interventions could be added in the EHR CCP. During the interview, both stated, once fall occurrences were reviewed in the Monday through Friday Morning Clinical Meeting, appropriate interventions should be updated on the CCP in the EHR that day. (Refer to F-689, F-835, F-837, and F-865)

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure a resident who entered the facility without limited range of motion (ROM) did not experience a reduction in range of motion. The facility failed to ensure a resident with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence, unless a reduction in mobility was demonstrably unavoidable for seven (7) of thirty (30) sampled residents with limited ROM (Residents #4, #7, #13, #11/37, #39, #16/42 and #44). Resident #4's Admission Minimum Data Set (MDS) Assessment, dated 03/26/2019, revealed the resident had no functional limitations in ROM for upper and lower bilateral extremities. Review of the most current Quarterly MDS, dated [DATE], Section G revealed the resident had functional limitations in ROM for lower bilateral extremities. Observation, on 10/02/2020, revealed Resident #4 had contractures of the lower bilateral extremities. Resident #7's most current Quarterly MDS Assessment, dated 07/01/2020, Section G, revealed the resident had functional limitations in ROM to bilateral upper extremities. Resident #13's most current Quarterly MDS Assessment, dated 07/01/2020, Section G, revealed the resident had functional limitations in ROM to bilateral lower extremities. Resident #11/37's most current Quarterly MDS Assessment, dated 08/04/2020, Section G, revealed the resident had functional limitations in ROM to one (1) upper extremity and one (1)lower extremity. Resident #39's Admission MDS Assessment, dated 07/29/2020, and most current Quarterly MDS Assessment, dated 08/30/2020, Section G, revealed the resident had no functional limitations in ROM. However, observations and interview with nursing and therapy staff revealed the resident had functional limitations in ROM to his/her right hand since admission to the facility. Resident #16/42's most current Quarterly MDS Assessment, dated 06/30/2020, Section G, revealed the resident had functional limitations in ROM to bilateral lower extremities. Resident #44's most current Quarterly MDS Assessment, dated 08/29/2020, Section G, revealed the resident had functional limitations in ROM to bilateral upper extremities. Substandard Quality of Care (SQC) was identified related to the facility's systemic failure to provide the nursing care needed to prevent a decline in functional status. The findings include: Review of the facility's policy titled, Restorative Nursing Services, dated July 2017, revealed residents would receive restorative nursing care as needed to help promote optimal safety and independence. Additionally, restorative nursing care consisted of nursing interventions that could or could not be accompanied by formalized rehabilitative services. Continued review revealed a restorative program could be started upon admission, during the course of the stay, or when discharged from rehabilitative care. Per policy, restorative goals and objectives were individualized, resident-centered, and outlined in the resident's Care Plan. Further, restorative goals could include, but were not limited to supporting and assisting the resident in: adjusting or adapting to changing abilities; developing, maintaining or strengthening physiological and psychological resources; maintaining dignity, independence and self-esteem; and participating in the development and implementation of the Care Plan. 1. Review of Resident #4's medical record revealed the facility admitted the resident, on 03/18/2019, with [DIAGNOSES REDACTED]. Review of Resident #4's Admission MDS Assessment, dated 03/26/2019, Section G, revealed the facility assessed the resident with no upper or lower extremity limited range in motion impairment for both sides. Review of Resident #4's Quarterly MDS Assessment, dated 12/22/2019, Section G, revealed the facility assessed the resident with no upper extremity limitation in range of motion; however, the facility identified an impairment for limitation in ROM in bilateral lower extremities including hip, knee, ankle and foot. Review of Resident #4's Annual MDS Assessment, dated 03/23/2020, Section G, revealed the facility assessed the resident with no upper extremity limitation in ROM; however, the facility identified an impairment for limitation in ROM in bilateral lower extremities, including hip, knee, ankle and foot. Review of Resident #4's Quarterly MDS Assessment, dated 06/18/2020, Section G, revealed the facility assessed the resident with no upper extremity limitation in ROM; however, the facility identified an impairment for limitation in ROM in bilateral lower extremities, including hip, knee, ankle and foot. Further review revealed the facility assessed the resident as having a Brief Interview of Mental Status (BIMS) score of three (3) out of fifteen (15) for cognitively impaired. Review of the facility's form titled, Nursing Assessment: Contracture Assessment, dated 03/18/2019, revealed Resident #4 was assessed upon admission with moderate ROM for hips, knees, and ankles. Review of Resident #4's Physician order [REDACTED]. Further review revealed there were no directions specified for the order. An additional Physical Therapy (PT) clarification order, dated 08/19/2020, stated do an evaluation only because the resident was not appropriate for skilled PT services and was to transition to a Hoyer (mechincal) lift for safe transfers. An additional order, dated 09/15/2020, stated PT and Occupational Therapy to evaluate and treat if indicated because of decreased mobility; and, PT clarification orders, dated 09/16/2020, stated the resident was to receive skilled PT services to address contractures utilizing total extension (TE) and total abduction (TA), neurological re-education, wheelchair management and orthotic training three (3) times per week for thirty (30) days. Further review revealed an order, dated 09/22/2020, for Occupational Therapy to evaluate and treat for eight (8) visits for thirty (30) days for wheelchair positioning. Review of Resident #4's CCP revealed a focus of the resident had limited physical mobility related to Dementia and decreased mobility to lower extremities, initiated 03/18/2019 with a revision date of 04/03/2019. The goal, with a target date of, 12/13/2020, was for the resident to remain free of complications related to immobility, including contractures, thrombus formation, skin-breakdown, and fall related injury through the next review date. Further review revealed the intervention, initiated 03/18/2019, was to provide gentle ROM as tolerated with daily care. Review of Resident #4's nurse aide care plan (Kardex), dated 09/30/2020, revealed resident care provided gentle ROM as tolerated with daily care. Review of Resident #4's Occupational Therapy Progress and Discharge Summary, dated 07/22/2020, revealed dates of service were 06/21/2020 to 07/22/2020. It stated the end goal status, as of 07/22/2020, not met due to joint misalignment which caused the resident to lean to the side, lying in bed. Further review revealed the resident had poor sitting balance in bed with increased right-side lean and bilateral knee contractures; these conditions required use of positioning devices in order to properly position the resident in bed. Per summary, the resident required these positioning devices to increase independence with self-feeding, and the resident required a maximum assist of two (2) for proper positioning. Review of Resident #4's Nurse's Note, dated 09/25/2020 at 12:09 PM, revealed staff was turning the resident and noticed he/she was not able to straighten his/her legs out in the bed, and they were contracted. The note stated staff would make family and therapy aware, and continue to monitor Resident #4. Observation of Resident #4, on 09/28/2020 at 8:30 AM, revealed the resident lying in bed with covers over the abdomen and the lower extremities. Additional observation, on 09/29/2020 at 8:30 AM and 12:00 PM, revealed Resident #4 lying with covers over the abdomen and the lower extremities. Interview with the Occupational Therapist/Director of Therapy, on 09/30/2020 at 2:53 PM, revealed Resident #4 did not receive ROM, and there was no restorative program at this time. However, she stated SRNA's could complete ROM during regular ADL care. Per interview, the resident was referred to therapy for PT and approval for one (1) session of Occupational Therapy due to insurance carrier approval. The OT stated residents were seen for assessment when referrals were made but re-visits for follow-up were not done after discharge from therapy services. Interview with SRNA #4, on 10/01/2020 at 1:05 PM, revealed she provided ROM care to Resident #4. However, she stated not all residents received ROM care. She stated Resident #4 moved from A Wing with leg contractures. SRNA #4 stated she tried to perform ROM with daily care for residents. Interview with SRNA #21, on 10/01/2020 at 1:28 PM , revealed she worked day shift on B Wing and performed ROM on all residents as part of daily care in the AM. She stated the Therapy Department had provided ROM training in the past as well as having a restorative program. She stated it was important to provide ROM to residents so they did not become stiff, feel pain, and become contracted. SRNA #21 stated ROM promoted strong muscles and prevented skin breakdown. Per interview, SRNA #21 stated, for Resident #4, she tried to provide daily ROM while dressing, getting in the wheelchair, and for leg contractures. Interview with Occupational Therapist (OT) #1, COTA #1, and the Physical Therapy Assistant (PTA) Rehabilitation Manager, on 10/01/2020 at 2:28 PM, revealed upon referral, Resident #4's insurance would not cover therapy. However, the insurance company wanted therapists to train staff to use ROM for four (4) visits only. They stated Resident #4's family did not want to cover the cost of therapy, and in July 2020, the facility received approval from the corporate office for therapy to treat Resident #4 without insurance payment. They stated, in September 2020, Resident #4 was referred to therapy, and the insurance would pay for PT and approval was pending for Occupational Therapy; Occupational Therapy did receive emergency permission for one (1) visit for positioning in the wheelchair. They stated therapy goals were to prevent further contractures, maintain skin integrity, and permit the resident to sit in a wheelchair and enjoy activities. Additional observation, on 10/02/2020 at 3:50 PM, of Resident #4 with the Certified Occupational Therapy Assistant (COTA) #1 and Occupational Therapist (OT) Director of Therapy revealed the resident was resting in bed, under the bed covers, lying on the right side, with knees bent into a fetal position. The COTA explained to the resident the need to examine the contractures and the resident was in agreement. Further observation revealed the resident was uncovered, and there were no lower extremity devices. The resident's knees were touching tightly together with feet resting side by side, and the resident was assisted to his/her back but could not maintain control and rolled back to the right hip; the COTA had to stabilize the resident on his/her back. Further observation revealed Resident #4 held tightly onto the OT Director's hand, displayed facial grimacing, began to sing hymns, and said repetitively I'm ready to go. Further observation revealed both knees were very large with [MEDICAL CONDITION] and warm to the touch, per COTA #1. The COTA began gently to relax the resident and try to extend the right leg; however, the resident stated it could not be extended; the left leg had less extension than the right leg. COTA #1 rocked Resident #4's hips and was able to place both her hands in between the resident's knees, placing a small cloth between the resident's knees. COTA and OT stated, during this obsrvation, the resident was severely contracted in his/her bilateral lower extremities. Interview with SRNA #3, on B wing, on 10/02/2020 at 10:00 AM, revealed she worked with Resident #4 on his/her contractures while providing daily care. She stated she tried to get Resident #4 up, provide ROM, and to get pressure off the legs. Interview with Registered Nurse (RN) #1 B Wing, on 10/02/2020 at 10:10 AM, revealed range of motion (ROM) was done by the aides, during the resident's daily care. RN #1 stated ROM should be on the resident's care plan. Interview on 10/02/2020 at 5:15 PM with State Registered Nurse Assistants (SRNA) #26 and #27; and, Kentucky Medication Aide (KMA) #10 Unit A, revealed Resident #4 had history of [MEDICAL CONDITION] and favors one side over the other. Further interview revealed Resident #4 had pain in his/her knees. However, he/she would not express feeling knee pain. They stated the resident did not walk by himself/herself however, he/she tried to strengthen out his/her legs. 2. Review of Resident 39's medical record revealed the facility admitted the resident, on 07/22/2020, with [DIAGNOSES REDACTED]. Additional review revealed the resident changed rooms, from Wing B to Wing A, on 08/02/2020, related to no longer requiring isolation. Review of Resident #39's Admission Nursing Assessment, dated 07/22/2020, revealed the resident had no contractures. Review of Resident #39's Occupational Therapy Plan of Care, dated 07/23/2020 through 08/07/2020, revealed therapy was needed because the resident required increased assistance with self-care tasks and increased assistance with transfers and ambulation. The plan stated, without therapy, the resident was at risk for increased assistance with self-care tasks. Additional review revealed the resident required maximum assistance with self-feeding, hygiene, dressing, grooming, bathing, toileting, and transfers. Continued review revealed the long-term goal was for the resident to intermittently require supervision or touch assistance to complete activities. Review of Resident #39's Provider Progress Note, dated 07/28/2020, revealed the resident moved all extremities. Review of Resident #39's OT Progress Note and Discharge Summary, dated 08/09/2020, revealed the anticipated goals were not met related to severe cognitive deficits requiring increased verbal and tactile cues with all self-care tasks. Additional review revealed caregiver education was provided on the need for verbal instructions with all activities due to the resident's severe dementia and increased fear of falling. Further, discharge plans and instructions were to discharge the resident to nursing staff; and the resident required twenty-four (24) hour maximum to dependent care. Review of Occupational Therapy notes from 07/23/2020 and 08/09/2020 revealed no documented evidence Resident #39 had functional limitation in ROM to the right upper extremity. Review of Resident #39's Comprehensive Care Plan (CCP), dated 07/23/2020, revealed the resident had an ADL self-care deficit related to needing assistance with them. The goal was the resident would remain free of body odor and appropriately dressed and groomed by staff. Interventions included nursing staff to ensure daily needs were met; turn and reposition, shift weight to enhance circulation, during care rounds; and total dependence on one (1) staff for eating. However, there was no documented evidence the facility implemented a Restorative Care regimen with interventions, services, or treatment to maintain current functional status or to prevent a decrease in function. (Refer to F-656) Review of Resident #39's Admission MDS Assessment, dated 07/29/2020, revealed the facility assessed the resident as having severely impaired cognitive skills for daily decision-making; and short and long term memory problems. Additionally, the facility assessed the resident as requiring extensive assistance of two (2) staff for bed mobility, transfer, locomotion, dressing, toileting, and personal hygiene. Continued review revealed eating required extensive assistance of one (1) staff. Per the MDS Assessment, ambulation did not occur. Further, the resident had no Functional Limitation in Range of Motion (ROM) to upper or lower extremities. Per the MDS Assessment, the resident received five (5) days of therapy for at least fifteen (15) minutes in the last seven (7) days. Review of Resident #39's Quarterly MDS Assessment, dated 08/30/2020, revealed the facility assessed the resident as having severely impaired cognitive skills for daily decision-making; and short and long term memory problems. Additionally, the facility assessed the resident as requiring total assistance of two (2) staff for bed mobility, transfer, locomotion, dressing, toileting, eating, and personal hygiene. Per the MDS Assessment, ambulation did not occur. Further, the resident had no functional limitation ROM to upper or lower extremities. Per the MDS Assessment, therapy ended on 08/07/2020, and the resident did not receive RNP. Review of Resident #39's Progress Notes, dated 08/01/2020 through 10/02/2020, revealed no documented evidence of Restorative Care interventions. Review of Resident #39's Treatment Administration Record (TAR), dated 08/01/2020 through 08/31/2020 and 09/01/2020 through 09/30/2020, revealed no documented evidence of treatment to the resident's right upper extremity. However, observations of Resident #39, on 09/28/2020 at 8:00 AM, revealed the resident's right hand was grossly [MEDICAL CONDITION] and while at rest his/her right hand fingers were folded down onto the palm. Resident #39 was not wearing any devices on his/her right hand. Additional observations of Resident #39, on 09/29/2020 at 1:30 PM, revealed the right hand was [MEDICAL CONDITION] and closed in a fist, with a wash cloth folded in half in the resident's right hand. Continued observations of Resident #39, on 09/30/2020 at 3:30 PM, revealed State Registered Nursing Assistant (SRNA) #22 placed a folded wash cloth into Resident #39's right hand. The resident's right hand was closed in a fist at rest, with the resident's right hand fingers folded down onto the palm. Interview with SRNA #22, on 09/30/2020 at 3:30 PM, revealed she had worked at the facility for fifteen (15) years and did not provide ROM to any resident, especially to residents with contractures. However, she would remove the wash cloth from Resident #39's right hand and move the resident's fingers off of the palm. Observations at this time revealed the right hand middle digit #3's ROM was severely limited and digit #3 could be raised off the palm enough to allow for a washcloth to be wiggled out, and digits #4 (ring finger) and #5 (pinky) also had limited ROM but could be extended off the palm and were not as severe as digit #3. Resident #39 grimaced and stated ouch, and pulled his/her hand away when SRNA #22 was moving the right hand and digits. Continued interview with SRNA #22 revealed she did not provide ROM to residents because it was painful for them and therapy provided it. Further, she stated she worked on A Wing, and when Resident #39 transferred from B Wing in August, he/she had the contracture to his/her right middle finger. Interview with SRNA #4, on 10/01/2020 at 3:45 PM, revealed she had worked on A Wing and recalled when Resident #39 resided on A Wing in July and August 2020. Additionally, she stated, on A Wing, Resident #39 did not have pain in the right hand or limited ROM to the right hand middle finger. Per interview, she recalled, on A Wing, Resident #39 was able to move all fingers without no concern, and the resident did not have a contracted right hand middle finger. Further, she did not recall the resident requiring a device or washcloth for the right hand. Observation of Resident #39, on 10/02/2020 at 4:30 PM, with Licensed Practical Nurse (LPN) #7, revealed the resident was resting in bed on his/her right side, the right hand was out of the covers and at rest; it was grossly [MEDICAL CONDITION] at the knuckles, closed in a fist, and had no device in it. Further observation and interview revealed LPN #7 was not able to perform ROM because the resident's right hand middle digit was folded down on the right hand palm and could not be lifted/raised from the resting position. LPN #7 was able to place her finger underneath the resident's right middle digit. LPN #7, stated the resident's right middle finger was contracted. Additional observations revealed the right hand digits, #4 and #5, had limited ROM. However, they could be lifted/raised off the resident's palm and extended. Further observation revealed the resident stated ouch and guarded his/her right hand by pulling away from LPN #7. Review of Resident #39's Monthly October 2020 physician's orders [REDACTED]. Further review revealed no active therapy orders or RNP related to functional limitations in ROM to the right upper extremity. Interview with the OT, on 10/01/2020 at 2:18 PM, revealed Resident #39 was previously seen when he/she was first admitted to the facility because of the overall need for assistance with self-care. Additionally, Resident #39 had severe Dementia and would scream out and cry because he/she was afraid to fall. Per interview, the resident was discharged from therapy to nursing care because the resident would not participate in therapy due to Dementia; however, when the resident was seen by OT, he/she had no limitations in ROM and no contractures. Continued interview revealed since the resident had been discharged from therapy, he/she was rarely out of bed, at most one (1) time a week. Further interview revealed she expected staff to assist Resident #39 with ROM to decrease the risk for decreased mobility and contractures, skin integrity concerns, and pain. Continued interview revealed Resident #39 should have been referred back to therapy because the resident had a decline in mobility and/or contractures. Per interview, she was not aware the resident's right hand was [MEDICAL CONDITION] and had limited ROM in the digits, with the middle finger folded down on the palm at rest. 3. Review of Resident #11/37's medical record revealed the facility admitted the resident, on 07/23/2015, with [DIAGNOSES REDACTED]. Review of Resident #11/37's Contracture Assessment, dated 07/23/2015, revealed the resident was assessed to have full ROM in both left and right wrists. This was the only documented contracture assessment provided by the facility. Review of Resident #11/37's CCP revealed a focus, with an initiation date of 11/02/2016, of resident had potential for pain and complications related to [MEDICAL CONDITION] to hand, history of septic arthritis, s/p surgery to right knee, and muscle spasms. On 07/29/2020, the resident was noted to have a right hand contracture. The goal stated the resident would be/remain free of complications related to arthritis (contractures, joint stiffness, swelling, or decline in mobility), with a target date of 10/27/2020. Interventions included: right knee immobilizer as needed for support while up to wheelchair or recliner, initiated on 05/30/2019; appointments with physician as scheduled, initiated 11/02/2016; give [MEDICATION NAME] as ordered by the physician, monitor and document for side effects, initiated on 11/02/2016; monitor healed surgical site daily on right knee, initiated on 01/31/2017; monitor/document/report to physician as needed signs and symptoms related to arthritis, joint pain, joint stiffness, usually worse on wakening, swelling, decline in mobility, decline in self care ability, contracture formation/joint shape changes, crepitus (creaking or clicking with joint movement), pain after exercise, or weight bearing, initiated on 11/02/2016; no range of motion to right lower extremity, initiated on 02/07/2016; and notify physician if swelling to right knee worsens, pain worsens or drainage occurs, initiated on 11/12/2016. However, there was no documented evidence the facility developed or implemented Restorative Care with interventions, services, or treatment to maintain the resident's current functional status or to prevent a decrease in function. Review of the Quarterly (MDS) Assessment, dated 08/04/2020, revealed the facility assessed the resident to have a BIMS score of four (4) out of fifteen (15) indicating severe cognitive impairment. Additionally, the facility assessed the resident as requiring total assistance of two (2) staff for bed mobility, transfers, and toilet use. Per the assessment, the resident had functional limitation in ROM to one (1) upper extremity and one (1) lower extremity. Continued review of the assessment, revealed the resident received five (5) days of Occupational Therapy at least fifteen (15) minutes a day within the last seven (7) days of the assessment. Review of Resident #11/37's Occupational Therapy Plan of Care, dated 07/29/2020 through 08/18/2020, revealed the resident was referred to OT services following increased pain, redness, and decreased movement noted to the right ring and the right little finger. The resident was noted to have increased redness to the right knuckles and top of hand. Per the plan of care, therapy was needed for decreased pain, decreased risk for further finger contractures, and increased ROM to the right digits; without therapy, the resident was at risk for increased severe pain and further noted contractures, with increased risk of skin integrity concerns. Per the plan of care, short-term goals were for the resident to increase fine motor coordination with contact guard assist in order to complete care tasks; to have decreased pain in right hand in order to perform object manipulation; to demonstrate donning/doffing of right resting hand splint improving the resident's minimal assistance in order to increase the resident's ability to manipulate objects; and, to improve the right little and ring finger to 0-90 degrees movement without pain. Further review revealed the long-term goal was for the caregiver to be able to assist the resident to complete the exercise program for right digit motion with contact guard assist and respond to tactile and verbal instructions/cues to properly apply the hand brace to decrease contractures. Review of Resident #11/37's Occupational Therapy Daily Treatment Note, dated 08/07/2020, revealed the resident was able to tolerate the use of the gel filled palm protector in order to decrease the risk of skin integrity concerns and increase ROM to the right hand. Continued review revealed therapy monitored the resident's right hand during the day and noted no skin irritation and redness to the hand with use of the palm protector. Review of Resident #11/37's Occupational Therapy Discharge Summary, dated 08/18/2020, revealed the resident's short-term goals were met; the resident demonstrated poor fine motor coordination of right hand with maximum assistance; moderate pain in the right hand; demonstrated donning/doffing of right hand gel palm protector with assistance; the long-term goal revealed the caregiver would be able to assist the resident to complete the exercise program for right digit (ROM) with contact guard assistance and tactile and verbal instructions/cues to decrease contractures and properly apply the hand brace. Per summary, skilled service provided at the start of care included slow passive range of motion, donn/doff of the gel palm protector, and staff education on the use of the gel palm protector. The resident was discharged to the care of nursing on 08/18/2020. Review of Resident #11/37's Order Summary Report of active orders for October 2020, revealed the resident had no active order for a gel palm protector device. Additional review revealed an order dated 08/18/2020 for resident to be discharged from Occupational Therapy Services on this date, for the palm protector program. Review of Resident #11/37's Progress Notes, dated 08/01/2020 through 09/30/2020, revealed no documented evidence of Restorative Care interventions being implemented. Observation of Resident #11/37, on 09/29/2020 at 10:32 AM, revealed the resident up in his/her wheelchair with his/her right hand closed with the fingers folded into his/her palm at rest on the wheelchair arm. Further observation of the resident's room revealed no gel palm protector device in the room. Interview and observation with Resident #11/37, on 10/02/2020 at 4:10 PM, revealed Occupational Therapy was providing ROM to the resident's right hand. The resident was seated in a wheelchair with no device noted to the right hand. The device was observed on the night stand to the far right side of bed; the resident was unable to get his/her wheelchair between the bed and the wall to access the device. Further observation revealed the resident's right hand was at rest on the right wheelchair arm with the ring and pinky fingers bent at rest and more abducted than the middle finger, and the resident could not straighten or extend the fingers for full ROM. The resident stated it hurt when the OT picked up his/her fingers, and he/she could not open these fingers; however, the resident was able to make a full fist with the right hand. The resident stated at times the right hand hurt and felt as though the nails were digging and cutting into his/her skin. OT acknowledged, during the observation, the resident's nails and finger had pressed on the palm, causing redness. OT stated the palm protector when worn, would also prevent skin impairment. Further observation revealed in the mid-palm of the resident's right hand, a red non-blanchable circular area the size of a pencil eraser with peeling edges throughout. Resident #11/37 stated he/she could not stand for the fingers to be pulled out and liked to wear the palm protector because it felt good and kept the nails from cutting his/her skin. The resident's palm protector was then applied by the OT. Interview with the OT, on 10/01/2020 at 2:25 PM, revealed Resident #11/37 was seen by Occupational Therapy about a month ago related to his/her right hand contracture. She stated she did not remember the resident having this contracture when she started as they just started seeing him/her related to the contracture at the end of July. Per interview, she stated therapy provided education to all nursing staff on application and removal of the palm protector device for the resident's right hand, stating there was instructional pictures provided on how to appropriately apply and remove the device placed at the nurse's station. She stated staff should be utilizing this for Resident #11/37 as he/she tolerated the device. Per interview, the OT stated she was not aware the resident had not been wearing the right hand palm protector per therapy's recommendations. Interview with SRNA #3, on 10/01/2020 at 3:24 PM, revealed she cared for Resident #11/37 frequently, and to her knowledge, Resident #11/37 had never had a palm protector for his/her hand. She stated she had noticed the resident's right hand balled up in a fist more frequently and thought nursing was aware of this. SRNA #3 stated there was no mention of a device on Resident #11/37's Kardex or instructions for device application. 4. Review of Resi (TRUNCATED)

Based on interview, record review, review of the facility's policies, and review of the Plan of Correction (POC) related to the deficiencies identified on 06/04/2020, it was determined the facility failed to ensure a resident maintained acceptable parameters of nutritional status, such as usual body weight or a desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrated this was not possible, or the resident's preferences indicated otherwise for five (5) of thirty (30) sampled residents (Residents #4/20, #7/23, #3/31, #34, and #11/37). Resident #4/20 went forty-nine (49) days without having a weight obtained and had a loss of 9.5 pounds, which was a severe weight loss of six (6) percent. Resident #7/23 went forty-five (45) days without having a weight obtained and had a loss of 21.4 pounds, which was a severe weight loss of thirteen (13) percent. Resident #3/31 went fifty-seven (57) days without having a weight obtained and had a loss of 18 pounds, which was a severe weight loss of twelve (12) percent. Resident #34 went fifty-one (51) days without having a weight obtained and had a loss of 16 pounds, which was a severe weight loss of seven (7) percent. Resident #11/37 went fifty-two (52) days without having a weight obtained and had a loss of 12.6 pounds, which was a severe weight loss of seven (7) percent. Substandard Quality of Care (SQC) was identified related to the facility's systemic failure to provide the nursing care needed for residents to maintain acceptable parameters of nutritional status, such as body weight. The findings include: Review of the facility's policy titled, Nutrition (Impaired)/Unplanned Weight Loss - Clinical Protocol, revised September 2017, revealed staff would monitor and document the weight and dietary intake of residents in a format which permitted comparisons over time. Continued review revealed staff would report to the Physician significant weight gains or losses or any abrupt or persistence change from baseline appetite or food intake. The Physician would review for medical causes of weight gains or losses before ordering interventions. Per policy, for individuals with rapid weight gains or losses, staff would review for possible fluid and electrolyte imbalance as a cause, and the Physician would identify medical conditions and medications that could be causing weight gain or loss. Staff and the Physician would identify pertinent interventions based on identified causes and the overall condition, prognosis, and wishes of the resident. Per policy, staff and the Physician would review and consider existing dietary restrictions and modified consistency diets. Further review revealed staff and the Physician would monitor nutritional status and the resident's response to interventions. Review of the facility's policy titled, Nutritional Assessment, revised October 2017, revealed as part of the comprehensive assessment, a nutritional assessment, including current nutritional status and risk factors for impaired nutrition would be conducted for each resident. Review of the facility's policy, Weight Assessment and Intervention, revised December 2019, revealed the multidisciplinary team would strive to prevent, monitor, and intervene for undesirable weight loss for residents. Continued review of the Section, Implementation of Weight Assessment, revealed nursing staff would measure the resident's weight upon admission, the next day, and weekly for four (4) weeks thereafter; if no weight concerns were noted after that point, weights would be measured monthly thereafter. In addition, any weight change of five percent (5%) or more since the last weight assessment would be retaken the next day for confirmation, and if the weight were verified, nursing would notify the Dietician. Per policy, the Dietician would review the Weight Record by the fifteenth of the month to follow individual weight trends over time, and negative trends would be evaluated by the treatment team whether or not the criteria for significant weight change had been met. Review of the State Operations Manual (SOM), Appendix PP, Guidance to Surveyors for Long Term Care Facilities §483.25(g) for F692 revealed current professional standards recommended weighing residents weekly on admission for the first four (4) weeks and at least monthly thereafter. Although a month was not strictly defined in the SOM, the interpretive guidelines discussed parameters for evaluating significance of weight loss, which included a loss of five (5) percent in one (1) month being significant, and with anything over five (5) percent in one (1) month considered severe. As there were twelve (12) months in a year and three hundred sixty-five (365) days in a year, each month would average, with rounding, to thirty (30) days. Review of Merriam-Webster's Dictionary definition of a month was a measure of time amounting to approximately four (4) weeks, thirty (30) days, or one-twelfth (1/12) of a year. 1. Review of Resident #3/31's medical record revealed the facility admitted the resident on 05/28/2019, and readmitted him/her, on 12/10/2019, with [DIAGNOSES REDACTED]. Review of Resident #3/31's Order Summary Report, revealed an order with a start date of 12/10/2019 for a regular diet with mechanical soft texture, regular consistency; weekly weights until weight stabilized, starting 06/06/2020; and weigh the resident per facility protocol, started on 12/10/2019. Review of Resident #3/31's Annual Minimum Data Set (MDS) Assessment, dated 08/12/2020, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of zero (00) indicating severe cognitive impairment. Review of Resident #3/31's Comprehensive Care Plan (CCP), initiated 03/23/2020, revealed a focus of at risk for alteration in nutritional status related to Depression, and disordered eating pattern; received a mechanically altered diet; low protein levels; refused meals; inattention and restlessness; oral intake fluctuated, and noted weight loss. The goal, with a target date of 12/19/2020, stated the resident would have no significant unplanned weight change by next review. Interventions, initiated on 03/23/2020 included: continue to monitor food and fluids for appropriate texture and consistency; diet as ordered; educate family on bringing in foods not allowed on diet; obtain and monitor labs as ordered; and reassess as needed to help ensure adequate nutritional needs were being met daily. Further review revealed additional interventions: administer appetite stimulant as ordered, initiated on 06/05/2020; weigh as per ordered, initiated on 06/06/2020; include peanut butter milkshakes six (6) ounces as scheduled, initiated on 06/07/2020; resident required total assistance with meals, initiated on 06/10/2020; refer to Speech Therapy for evaluation and treatment if indicated, initiated on 09/09/2020; and offer Ensure (a supplement) or equivalent twice a day as per order, initiated on 09/18/2020. However, there was no evidence the CCP was developed related to monitoring the resident's meal intake. Review of Resident #3/31's Weight Summary revealed the resident weighed 130.3 pounds on 06/09/2020 and 135.8 pounds on 06/18/2020. Additional review of Resident #3/31's Weight Summary revealed the resident weighed 136.0 pounds on 06/24/2020 and 143.0 pounds on 07/01/2020. This was a gain of seven (7) pounds, which was a 5.14% increase in weight, and a 9.75% increase compared to the resident's weight of 130.3 pounds on 06/09/2020. Per the facility's policy, since this was a weight change of 5% or more, it should have been confirmed for accuracy. However, there was no evidence staff re-weighed the resident to ensure an accurate weight, nor did staff report the weight increase to the Registered Dietician for his review as per the facility's policy. Continued review of Resident #3/31's Weight Summary revealed the resident weighed 125.0 pounds on 08/26/2020. This was a weight loss of eighteen (18) pounds within fifty-seven (57) days (07/01/2020 to 08/26/2020), indicating a 12.6 percent weight loss. Continued review revealed the resident weighed 112.0 pounds on 09/01/2020. This was a severe weight loss of thirteen (13) pounds within seven (7) days, indicating a 10.4 percent weight loss. However, there was no evidence the facility provided any immediate interventions related to the resident's weight loss. Review of the Weight Exception Report, from 04/21/2020 to 09/21/2020, revealed the electronic health record (EHR) alerted with a warning stating Resident #3/31 had a ten (10) percent weight change on 08/26/2020 compared to the weight obtained on 07/01/2020. However, there was no evidence of immediate intervention once the facility became aware of the resident's weight loss. Review of Resident #3/31's Meal Intake Report, dated August 2020, revealed the resident refused a total of three (3) meals; consumed 0-25% of thirteen (13) meals; consumed 26-50% of twenty (20) meals; consumed 51-75% of two (2) meals; consumed 76-100% of sixteen (16) meals; and thirty-one (31) occurrences where the intake amount was left blank/not documented. Review of the facility's Nutritionally at Risk/Person at Risk (NAR/PAR) meeting notes revealed Resident #3/31's weight loss, on 09/01/2020 was identified. However, there was no evidence the facility provided immediate intervention related to the resident's identified severe weight loss on 08/26/2020. Review of Resident #3/31's Nutrition Note, dated 09/02/2020 at 4:02 PM, revealed a referral nutrition note for a weight decrease of eighteen (18) pounds from 07/01/2020 to 08/26/2020. The Nutrition Note stated the resident was tested to be COVID-19 positive, on 08/05/2020, which could have contributed to a drop in caloric intake. However, there were no interventions implemented related to the resident's identified severe weight loss. Review of Resident #3/31's Nurse's Notes, dated 09/02/2020 at 11:54 PM, revealed the Nurse Practitioner (NP) was notified of a change in weight and gave new orders for a Speech Therapy evaluation. The notes stated the Registered Dietician's recommendations were approved by the NP. This was the first documented intervention since the resident's severe weight loss was identified on 08/26/2020, seven (7) days later. Review of Resident #3/31's Speech Therapy Plan of Care, revealed his/her start of care began on 09/09/2020 related to decreased oral intake and weight loss. Interview with the Regional Liaison, on 10/06/2020 at 4:54 PM, revealed Resident #3/31 was weighed appropriately, even though the resident went fifty-seven (57) days without a weight obtained. She stated they noted the resident's severe weight loss, on 08/26/2020, and interventions were implemented, on 09/02/2020, to refer the resident to Speech Therapy for an evaluation; seven (7) days after the weight loss was identified. 2. Review of Resident #11/37's medical record revealed the facility admitted the resident on 07/27/2016, with [DIAGNOSES REDACTED]. Review of Resident #11/37's Order Summary Report, revealed orders, with a start date of 11/17/2019, for mechanical soft texture, regular consistency, fortified oatmeal with breakfast, and the resident to be fed or supervised by staff at meals. Continued review of the report revealed no active order related to the resident's weights as the resident's order for weekly weights for four (4) weeks related to weight loss was discontinued on 09/22/2020. Review of Resident #11/37's CCP, initiated 02/29/2020, revealed a focus of risk for alteration in nutritional status related to Depression, [MEDICAL CONDITION], Obese with Body Mass Index (BMI) and Dysphagia; the resident had weight loss noted, had a fair appetite, and required staff assistance at times with meals. Further review revealed on 07/02/2020, the resident's weights had stabilized. The goal stated the resident would have no significant unplanned weight change by the next review date with a target date of 10/27/2020. Interventions initiated on 02/29/2020 included: continue to monitor food and fluids for appropriate texture and consistency; diet as ordered; educate family on bringing in foods not allowed on diet; monitor/record intake after each meal and obtain and monitor labs as ordered; reassess as needed to help ensure nutritional needs were being met daily; and use a divided plate with all meals. Further review revealed other interventions included to provide supplements as per order, initiated on 04/30/2020; administer medications as ordered, initiated on 06/05/2020; Ensure as ordered secondary to weight loss and fortified oatmeal with breakfast, initiated on 06/06/2020; may see dietician related to weight loss, initiated on 06/09/2020; and required set-up assistance with meals, initiated on 06/10/2020. However, there was no evidence this CCP was implemented related to monitoring of intakes after each meal and recording the meal intake. Review of Resident #11/37's Weight Summary revealed the resident weighed 179.6 pounds on 07/02/2020 and 167.0 pounds on 08/23/2020. This was a severe weight loss of 12.6 pounds within fifty-two (52) days, indicating a 7.02 percent weight loss. Review of the Weight Exception Report, from 04/21/2020 to 09/21/2020, revealed the EHR alerted with a warning stating Resident #11/37 had a 7.5% weight change on 08/23/2020, compared to the weight obtained on 06/25/2020. However, there was no evidence of immediate intervention once the facility became aware of the resident's weight loss. Review of Resident #11/37's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident as having a Brief Interview of Mental Status (BIMS) score of four (4) out of fifteen (15), indicating severe cognitive impairment. Continued review revealed the facility assessed the resident to need a mechanically altered diet. Review of Resident #11/37's Meal Intake Report, dated August 2020, revealed the resident refused one (1) meal; consumed 0-25% of seventeen (17) meals; consumed 26-50% of ten (10) meals; consumed 51-75% of sixteen (16) meals; consumed 76-100% of ten (10) meals; and twenty-nine (29) occurrences where the intake amount was left blank/not documented. Review of Resident #11/37's Nutrition Note, dated 08/29/2020 at 3:04 PM, revealed the resident had a 7.5% weight loss; the current weight was 167.0 pounds and the resident's weight on 06/25/2020 was 181.3 pounds. The Nutrition Note stated the resident continued to receive Ensure, a Multivitamin, Vitamin C, and Zinc; staff continued to encourage oral intake; and awaiting the Registered Dietician's recommendations. Continued review of Resident #11/37's Nutrition Notes, dated 09/02/2020 at 4:26 PM, revealed the Registered Dietician received a referral related to the resident's thirteen (13) pound weight loss from 07/02/2020 to 08/24/2020. The note stated the resident tested positive for the COVID-19 virus on 08/24/2020, appetite had decreased on 08/23/2020, and was still poor. Per the note, the resident was to take Ensure twice a day, Mighty Shake at each meal before the tray was offered, and the Registered Dietician was available weekly. Review of Resident #11/37's Speech/Language Therapy Screening Form revealed, on 08/29/2020, the resident was screened by Speech Therapy, and it was determined Speech Therapy was not recommended for the resident. Review of the Change in Weight Form, dated 09/01/2020, revealed the facility noted Resident #11/37's severe weight loss of 12.0 pounds in a month, and the resident was already provided Ensure supplements twice a day. Further review revealed the resident was referred to the Registered Dietician. Review of the facility's Nutritionally at Risk/Person at Risk (NAR/PAR) weekly meeting notes, revealed Resident #11/37's severe weight loss was not identified. As stated in the facility's POC, residents with significant/severe weight loss would be reviewed in the weekly NAR/PAR meeting. Interview with the Regional Liaison, on 10/06/2020 at 4:54 PM, revealed Resident #11/37 was weighed appropriately, even though the resident went fifty-two (52) days without a weight obtained. She stated to her knowledge the resident did not have any interventions implemented once the severe weight loss was identified on 08/23/2020. However, she thought the resident was previously seen by Speech Therapy. 3. Review of Resident #4/20's medical record revealed the facility admitted the resident on 03/02/2020, with [DIAGNOSES REDACTED]. Review of Resident #4/20's Quarterly MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS assessment of one (1) out of fifteen (15) indicating severe cognitive impairment. Review of Resident #4/20's Order Summary Report revealed orders, with a start date of 03/02/2020, for a No Added Salt Diet with regular texture and regular consistency. Review of Resident #4/20's CCP, initiated on 05/28/2020, revealed a focus of resident had unplanned/unexpected weight loss related to poor intake; ate approximately 50-75 percent of meals; received supplements to provide extra calories and the resident reported he/she was not a big breakfast or lunch person, but preferred dinner. The goal, with a target date of 12/12/2020, revealed the resident would have no significant weight change by the next review. Interventions, initiated 05/28/2020 and 05/29/2020 included: monitor intake after each meal and record; monitor for significant weight changes; offer substitutes as requested or indicated, and provide fortified foods with all meals. Another intervention was offer peanut butter milkshake between breakfast and lunch, initiated 06/07/2020. Per the CCP, other interventions, initiated on 09/01/2020 included: medications reviewed and changes made as per order; weigh as per order and the resident required total assistance with meals. Another intervention, initiated on 10/01/2020, was Glucerna twice a day, offer chocolate if available. However, the facility failed to ensure implementation of the CCP related to monitoring of the resident's meal intakes. Review of Resident #4/20's Weight Summary revealed the resident weighed 143.5 pounds on 07/03/2020 and 134.0 pounds on 08/21/2020. This was a weight loss of 9.5 pounds within forty-nine (49) days, indicating a 6.6 percent weight loss. Review of the Weight Exception Report, from 04/21/2020 to 09/21/2020, revealed the EHR alerted with a warning stating Resident #4/20 had a ten (10) percent weight change on 08/21/2020 compared to the weight obtained on 03/02/2020. However, there was no evidence of immediate intervention once the facility became aware of the resident's weight loss. Review of the facility's Nutritionally at Risk/Person at Risk (NAR/PAR) weekly meeting notes, revealed Resident #4/20's severe weight loss was not identified. As stated in the facility's POC, residents with significant/severe weight loss would be reviewed in the weekly NAR/PAR meeting. Interview with the Regional Liaison, on 10/06/2020 at 4:54 PM, revealed Resident #4/20 was weighed appropriately, even though the resident went forty-nine (49) days without a weight obtained. She stated they noted the resident had severe weight loss, on 08/21/2020; however, interventions were put into place on 09/02/2020, twelve (12) days after the weight loss was identified. 4. Review of Resident #7/23's medical record revealed the facility admitted the resident, on 01/04/2011, with [DIAGNOSES REDACTED]. Continued review of Resident #7/23's medical record revealed the resident had been prescribed [MEDICATION NAME] (a diuretic/water pill) forty (40) milligrams (mg) twice a day for [MEDICAL CONDITION] since 02/24/2020. Resident #7/23 was diagnosed with [REDACTED]. Review of Resident #7/23's Comprehensive Care Plan (CCP) revealed a focus, with an initiation date of 05/28/2020, of the resident had unexpected/unplanned weight loss related to acute illness and fluctuations in [MEDICAL CONDITION]; selective appetite and oral intake fluctuations; refusal of supplements; and low protein levels. The goal, with a target date of 12/22/2020, stated the resident would consume 50-75 percent for two (2) of three (3) meals a day. Further review revealed interventions, initiated on 05/28/2020, included: if weight decline persisted, contact the Physician and the Registered Dietician (RD) immediately; labs as ordered, report to the Physician and ensure the RD was aware; monitor and record food intake at each meal; offer substitutes as requested or indicated; monitor and evaluate any weight loss, determine percentage lost, and follow facility policy for weight loss; and, to give the resident supplements as ordered and alert the nurse/RD if the resident was not consuming on a routine basis. Per the CCP, continued interventions, initiated on 06/07/2020 and 07/20/2020, included: refer to the RD related to low [MEDICATION NAME]; continue supplements as ordered; and resident was independent with meals and required set up assistance. Additional interventions included: give magic cup as ordered, initiated on 09/02/2020; refer to dietician, initiated on 09/17/2020; and give frozen nutritional supplement, as per order, initiated on 09/22/2020. However, the facility failed to ensure implementation of the CCP related to monitoring of the resident's meal intakes. Review of Resident #7/23's Quarterly Minimum Data Set (MDS), revealed the facility assessed the resident with a BIMS of fifteen (15) out of fifteen (15), and was cognitively intact. The MDS also assessed the resident as independent with meals requiring set up assistance only. Review of Resident #7/23's weights revealed the resident was weighed on 07/07/2020 at 165.4 pounds and was not weighed again until 08/21/2020, forty-five (45) days later, at 144 pounds. This was a loss of 21.4 pounds, or 12.94 percent, which was considered a severe weight loss. Continued review revealed no evidence Resident #7/23 was weighed again on 08/22/2020, the following day. Per policy, after a five (5) percent or greater weight loss, to verify this weight loss, the resident was to be re-weighed the next day. Review of the Weight Exception Report, from 04/21/2020 to 09/21/2020, revealed the EHR alerted with a warning stating Resident #7/23 had a 7.5 percent weight change, on 08/21/2020, compared to the weight obtained on 06/03/2020. However, there was no evidence of immediate intervention once the facility became aware of the resident's weight loss. Review of the facility's Nutritionally at Risk/Person at Risk (NAR/PAR) weekly meeting notes, revealed Resident #7/23's severe weight loss was not identified. As stated in the facility's Plan of Correction (POC), residents with significant/severe weight loss would be reviewed in the weekly NAR/PAR meeting. Interview with the Regional Liaison, on 10/06/2020 at 4:54 PM, revealed Resident #7/23 was weighed per facility protocol even though resident went forty-five (45) days without a weight as the facility's policy did not specify a number of days to be considered a month. She stated they noted the resident had a severe weight loss, on 08/21/2020, and interventions were implemented, on 09/02/2020, of Magic Cup twice a day. However, this was twelve (12) days after the weight loss was identified. 5. Review of Resident #34's medical record revealed the facility admitted the resident on 09/22/2015, with [DIAGNOSES REDACTED]. Review of Resident #34's Comprehensive Care Plan (CCP) revealed a focus of the resident had nutritional problems related to obesity; had a history of [REDACTED]. The goal, with a target date of 12/25/2020, stated the resident would not develop complications related to obesity, including skin breakdown, ineffective breathing pattern, altered cardiac output, Diabetes and impaired mobility. Further review revealed interventions, initiated on 03/23/2020 included: monitor and document and report any signs or symptoms of dysphagia; obtain and monitor labs and diagnostic work as ordered, report results to the Physician with follow-up as indicated; provide/serve diet as ordered and monitor and record intake for each meal; and weigh per facility protocol. Other interventions, initiated on 06/09/2020 included resident was independent with meals and required set up assistance; and, the RD was to evaluate and make diet change recommendations as needed. Other interventions were: fortified foods with meals, initiated on 06/11/2020; the resident preferred sweets and Diet Coke, initiated on 09/01/2020; and give house supplement as per order for weight loss, initiated on 09/18/2020. However, the facility failed to ensure implementation of the CCP related to monitoring of the resident's meal intakes. Review of Resident #34's Quarterly MDS, dated [DATE], revealed the facility assessed the resident with a fifteen (15) out of fifteen (15) on BIMS, indicating the resident was cognitively intact. The MDS also assessed the resident as independent, with meals requiring set up assistance only. Review of Resident #34's weights revealed the resident was weighed on 07/03/2020 at 220.3 pounds and was not weighed again until 08/23/2020, fifty-one (51) days later, at 204 pounds. This was a loss of 16.3 pounds, or 7.39 percent, which was considered a severe weight loss. Continued review revealed no documented evidence Resident #34 was weighed again on 08/24/2020, the following day. Per policy, after a five (5) percent or greater weight loss, to verify this weight loss, the resident was to be re-weighed the next day. Review of the Weight Exception Report, from 04/21/2020 to 09/21/2020, revealed the EHR alerted with a warning stating Resident #34 had a 7.5 percent weight change on 08/24/2020 compared to the weight obtained on 06/19/2020. However, there was no documented evidence of immediate intervention once the facility became aware of the resident's weight loss. Review of the facility's Nutritionally at Risk/Person at Risk (NAR/PAR) weekly meeting notes revealed Resident #34's severe weight loss was not identified. As stated in the facility's POC, residents with significant/severe weight loss would be reviewed in the weekly NAR/PAR meeting. Interview with Resident #34, on 09/29/2020 at 10:30 AM, revealed the resident did not like the food served at the facility. Resident #34 stated the facility did offer alternative choices, but sometimes those alternative choices were not available. The resident stated he/she had expressed concerns to the Administrator, approximately a week ago, regarding the food and was told it would get better; but, it had not gotten better yet. Interview with the Regional Liaison, on 10/06/2020 at 4:54 PM, revealed Resident #34 was weighed appropriately, even though the resident went fifty-two (52) days without a weight obtained and had a noted weight loss of 16.3 pounds. She stated the resident and the resident's family wanted him/her to lose weight. However, she stated the resident was not on a weight loss program or regimen approved by the Physician or Registered Dietician. Interview with the facility's Registered Dietician, on 10/02/2020 at 10:36 AM, revealed he was in the facility weekly around the first of June; however, when COVID-19 was confirmed in the facility he did not go in person and relied on remote access to review residents. He stated when he would go in person he would interview residents about their preferences and ensure these were passed on to dietary so they could add the resident's preferences at meals. He stated he felt the facility did the best they could obtaining weights, but he did notice they were slow on obtaining some residents' monthly weights. He stated he could see where the facility would need to be reminded to weigh residents monthly for accurate assessments. Additional interview with the Registered Dietician, on 10/08/2020 at 8:36 AM, revealed when he reviewed resident weights he often did not have their monthly weights, and he would have to tell the facility the resident required a weight before the nutritional assessment could be performed. He stated if the weight was not done, he would have to work with the last weight the facility had obtained which could be an almost two (2) month old weight. Interview with the facility's Director of Nursing (DON), on 10/06/2020 at 1:45 PM, revealed it was his duty to ensure the weight audits were being completed and accurate. He stated weights were obtained and filled out on the audit report and given to him. The DON stated he skimmed the report and put it in a binder to review in Quality Assurance Performance Improvement (QAPI) meetings that were being held monthly. He stated there were no issues identified with the audits. He further stated the audits helped to identify weight loss, notification, and appropriate interventions. Per interview, residents identified with weight loss would be discussed in morning meetings with the Interdisciplinary Team (IDT) and then discussed in the NAR/PAR meetings to ensure interventions were appropriate and working to stabilize those residents. Interview with the Vice President of Compliance (VPOC), on 10/01/2020 at 5:01 PM, revealed he believed a monthly weight was anytime between two (2) months. However, he did state if the residents had been weighed more timely then the loss could have been identified and addressed with more timely implemented interventions. He stated, around the beginning of July he became responsible for obtaining residents' weights and inputting them into the EHR. He stated he made therapy responsible for the residents who required weekly weights; therapy staff would report the weights to him; and he would input the weights into the resident's EHR. Continued interview with the VPOC, on 10/06/2020 at 6:28 PM, revealed he felt staff had followed their policy and obtained weights monthly, and no residents missed their weight. He did note there was a delay in when the weights were identified and the timeliness of the Registered Dietician notification and nursing collaboration. He stated there was an issue with timeliness of obtaining the weights as weights were not available in order for them to be reviewed in their weekly NAR/PAR meetings. The VPOC stated a stable weight meant the resident was no longer losing weight; for instance, Resident #3/31 would still be considered stable even with the increase of 5.14 percent within seven (7) days, and it was okay for the resident to be weighed monthly since his/her weights were stable for four (4) weeks. Further interview revealed the facility relied on the Weight Exception Report to alert when there was a significant/severe weight loss in a resident. He stated the program calculated from the weights entered if there was a weight loss. However, if the weights were not obtained monthly then the residents would not trigger for weight loss on the Weight Exception Report. Interview with the Regional Liaison and the Administrator, on 10/06/2020 at 4:54 PM, revealed the DON was responsible to ensure the weight audits were completed and accurate. They stated it was not their duty to obtain the weights for the audits, but they were ultimately responsible to ensure the audits were being completed. Per interview, the audits were completed to ensure residents who had weight loss were identified and appropriate interv (TRUNCATED)

Based on observation, interview, record review, review of Job Descriptions, and review of the facility's Plan of Correction (POC), it was determined the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility failed to have a system in place to ensure audits were completed per the Acceptable Plan of Correction, dated 09/22/2020, with an allegation of compliance on 09/25/2020 for F-689, F-692, F-700, F-758, and F-865. The facility also failed to identify concerns with Range of Motion (ROM) resulting in failure to ensure residents with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence, unless a reduction in mobility was demonstrably unavoidable, for seven (7) of thirty (30) sampled residents with limited ROM (Resident #4, #7, #13, #11/37, #39, #16/42, and #44). Due to the facility's non-compliance, actual harm was identified for three (3) residents (Residents #4, #11/37, and #39). Substandard Quality of Care (SQC) was identified related to the facility's systemic failure to provide the nursing care needed to prevent a decline in functional status. (Refer to F-688). The findings include: Review of the Administrator's Job Description, undated, revealed the purpose of the Administrator's job was to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing facilities to assure the highest degree of quality of care could be provided to residents at all times. Continued review revealed the Administrator was to assist the Quality Assurance and Assessment Committee in developing and implementing appropriate plans of action to correct identified quality deficiencies. 1. Review of the Plan of Correction (POC) for F-689, revealed incident reports for the previous day would be reviewed Monday through Friday in the Morning Clinical Meeting to ensure appropriate interventions were implemented and an updated plan of care was complete. In addition, audits would be performed to ensure appropriate interventions had been put into place, timely, to reduce the risk of resident falls/accidents and care plans had been updated to reflect these interventions. Review of the Audits for F-689 revealed the purpose of the audits were to review incident reports to ensure appropriate interventions had been put in place, timely, to reduce the risk or resident falls/accidents and care plans had been updated to reflect the interventions. Continued review revealed an audit was performed on 09/27/2020 for Resident #2. The audit stated Resident #2's incident report was reviewed and completed, ice offered with neurological checks completed, and the Comprehensive Care Plan (CCP) updated. Resident #5/2 had three (3) falls within eleven (11) hours, on 09/27/2020 and 09/28/2020. However, the CCP was not revised to include provide ice water with neurological checks and routine rounding, or change bed, low position closer to the floor, until 09/29/2020, two (2) days after, the fall occurred on 09/27/2020 at 2:45 PM and 6:40 PM. Further, the CCP was not revised to reflect the bolsters, in use at the time of each fall occurrence, on 09/27/2020. (Refer to F-689 and F-657). Interview with the Director (DON), the Administrator, and the Regional Liaison, on 10/06/2020 at 4:54 PM, revealed all staff had been inserviced on the Fall Policy and Procedures, by 09/11/2020, and were aware of the expectations related to implementing interventions after a fall. The process was if a resident fell over the weekend, then the fall would be reviewed in the Monday through Friday Morning Clinical Meeting to ensure appropriate interventions were implemented and the care plan updated. They stated the audits were the responsibility of the DON to ensure interventions were in place and care plans were updated timely. Further interview revealed their audit should have identified Resident #5/2's interventions were not in place. Interview revealed Resident #5/2's CCP was not updated timely. Continued interview revealed on 10/05/2020 a new process was started that required the DON be called 24/7 to update the care with new interventions. 2. Review of the Plan of Correction (POC) for F-692, revealed the DON would conduct an audit of five (5) resident charts weekly for four (4) weeks, then five (5) resident charts biweekly for eight (8) weeks to ensure any significant/severe weight losses had been identified and their Care Plans reflected more person-centered interventions. Any deficient practice found during the audits would be corrected immediately by the DON and education and/or corrective action done as appropriate. Continued review revealed significant/severe weight loss would be reviewed in the weekly Nutritionally at Risk (NAR) meeting. Review of the facility's audits and interview with staff revealed they failed to identify residents' weights were not being obtained monthly per the facility's policy and their POC. Residents #3/31, #11/37, #4/20, #7/23, and #34, who were not weighed monthly, suffered significant and severe weight loss, and their meal intakes were not completed, and omissions related to the meal intakes were not identified. During the survey, it was identified that Residents #4/20, #7/23, 3/31, #34, and #11/37 had severe weight loss during the months of July and August 2020. However, only Resident #3/31 was identified in the NAR meeting, on 09/10/2020, with weight loss. (Refer to F-692). Interview with the DON, the Administrator, and Regional Liaison, on 10/06/2020 at 4:54 PM, revealed it was the DON's responsibility to ensure the audits related to weights were completed and accurate, and the Vice-President of Compliance oversaw the weights to ensure they were completed and carried out by the nursing staff. The DON stated he skimmed the audits and placed them in the binder for review in the QAPI meetings. Further interview revealed they relied on the Weight Exception Report to trigger for weight loss by using the weights provided. They stated by using this, it allowed staff to identify residents with weight loss. However, they could not explain why Residents #11/37, #4/20, #7/23, and #34 were not identified or picked up in the NAR meetings. Continued interview with the DON, Administrator and Regonal Liaison revealed they believed their audits were effective as they thought when their policy stated a monthly weight, this was anytime within two (2) months. Therefore, they stated Residents #3/31, #11/37, #4/20, #7/23, and #34 were weighed monthly per their policy, even though these residents had a date range from forty-five (45) days to fifty-seven (57) days without a weight. However, they stated they realized weights were not being obtained timely enough to review in the NAR meetings, as they would not have had the needed weights for residents to be reviewed. Further interview revealed they were attempting to implement all residents' weights to be obtained on the same day each month. 3. Review of the Plan of Correction (POC) for F-700, revealed side rails would be removed from all resident beds, and the Administrator would audit all resident beds one (2) time per week for twelve (12) weeks to ensure that no bed rails were on any of the residents' beds. Review of the Audits for F-700, revealed bed rails were audited weekly, on 09/17/2020, 09/23/2020, and 09/30/2020, indicating there were no side rails present on any resident beds. However, observation, on 09/28/20 at 10:00 AM, revealed Resident #7/23's bed, in room [ROOM NUMBER], had a ¼ side rail on the left lower quadrant. The ¼ side rail continued to be observed during the course of the survey, including, on 09/29/20 at 9:50 AM, and again at 2:45 PM, on 09/30/20 at 3:10 PM, and, on 10/01/20 at 11:15 AM. The side rail remained on the bed until the State Survey Agency alerted the DON and Administrator, on 10/02/2020 at 6:00 PM. Interview with the DON, the Administrator, and the Regional Liaison, on 10/06/2020 at 4:54 PM, revealed they audited the whole building as thoroughly as they could, and this was the Administrator's responsibility. They stated their audit failed, as there was still a bed that had a side rail present. Further interview revealed the bed was brought in from storage. They stated there was a lot of remodeling to the rooms happening around that time and they assumed the resident had a bed brought in from storage that had not been assessed as having a bed rail. 4. Review of the Plan of Correction (POC) for F-758, revealed all licensed nursing staff were inserviced regarding the facility's policy for Use of [MEDICAL CONDITION] Drugs and Behavioral Assessment, Intervention, and Monitoring. The DON/Nurse Supervisor would complete random weekly audits of five (5) residents on [MEDICAL CONDITION] medications for four (4) consecutive weeks and then five (5) residents biweekly for eight (8) weeks to ensure that the appropriate diagnosis, behavioral documentation, and Gradual Dose Reductions (GDR) were clearly documented in the medical record. Review of the Audits for F-758, revealed the purpose of the audits was to ensure resident's taking [MEDICAL CONDITION] medications had an appropriate [DIAGNOSES REDACTED]. Further review revealed Resident #11/37 was audited, on 09/14/2020, and had an appropriate [DIAGNOSES REDACTED]. Record review revealed Resident #11/37 had on order for [MEDICATION NAME] 0.5 milligram (mg) every twenty-four (24) hours as needed for Anxiety, starting on 08/05/2020, with no stop date. The resident's [MEDICATION NAME] was discontinued, on 08/14/2020. However, there was an active order for [MEDICATION NAME] 0.5 milligrams (mg), started on 08/14/2020, as needed, with no stop date and no evidence of non-pharmacological interventions prior to use. Interview with the DON, the Administrator, and the Regional Liaison, on 10/06/2020 at 4:54 PM, revealed all staff and the Medical Director were educated on the [MEDICAL CONDITION] Medication policy so staff would be aware that as needed (PRN) [MEDICAL CONDITION] medications should have a stop date and be re-evaluated to prevent polypharmacy. The DON stated he was aware there were issues in the facility regarding [MEDICAL CONDITION] drugs and PRN [MEDICAL CONDITION] drugs not having a stop date. However, Resident #11/37's medication still failed to have a stop date for the PRN [MEDICATION NAME], on 10/08/2020, during the survey. Continued interview revealed this should have been corrected as soon as it was identified. They also stated there should be a rationale for needing to increase the use of the PRN medication from twenty-four (24) hours to every twelve (12) hours, as the medication used every twenty-four (24) had been shown to be effective in managing Resident #11/37's Anxiety. 5. Review of the Plan of Correction (POC) for F-865, revealed any deficient practice found by any of the audits would be corrected immediately, by the DON or the Assistant Director of Nursing (ADON), and education would be provided and/or corrective action done by the DON or ADON, as appropriate. The POC revealed the audit findings would be reported in a monthly QAPI meeting for a minimum of three (3) months. The IDT (interdisciplinary team)would meet weekly until placed into compliance. At IDT meetings, weights would be monitored as recorded from the previous day, and if triggered weight loss was identified, recommendations were made by the Registered Dietician (RD), the Advanced Practice Registered Nurse (APRN) and the Medical Director (MD) was notified, family was notified, and care plans were updated appropriately. Audits from the previous day were also discussed and any identified issues were addressed. Review of the document Staff Inservice revealed, on 09/11/2020, all staff were re-educated on all deficiencies cited on 06/26/2020: F-689 regarding how all falls and incidents would be reviewed Monday through Friday in the Clinical Meetings to ensure implementation of interventions and updating Care Plans. F-692 regarding weight assessment, interventions, ensuring interventions were in place and carried out for residents with weight loss, residents who had triggered for weight loss were added to the NAR, and monitoring meal intakes for adequate intake. F-700 regarding bed rail removal from all resident beds. F-758 regarding how licensed staff were educated on the Use of [MEDICAL CONDITION] Drugs, Behavioral Assessment, Intervention and Monitoring, and monitoring for behaviors and proper documentation related to [MEDICAL CONDITION]. F-865 regarding the IDT being in-serviced on the QAPI plan and the objectives of the plan pertaining to the structure and processes to correct identified quality and/or safety deficiencies, establish and implement plans to correct deficiencies, and to monitor the effects of these action plans on resident outcomes. Interview with the DON, the Administrator, and the Regional Liaison, on 10/06/2020 at 4:54 PM, revealed, as the Administrator, he was ultimately responsible for ensuring the audits were completed per the POC. They stated if there was an issue identified in the audits, then the issue should be addressed and corrected immediately. Further interview revealed they felt their POC was executed almost perfectly. Interview with the Vice-President of Compliance, on 10/06/2020 at 6:28 PM, revealed he helped to create the POC and ensured it was being followed through. He stated he was not responsible for completing the audits or ensuring they were complete.

Based on observation, interview, record review, review of job descriptions, and review of the facility's policy, it was determined the facility failed to ensure the Governing Body, or designated persons functioning as a Governing Body, that was legally responsible for establishing and implementing policies regarding the management and operation of the facility, was responsible and accountable for the QAPI program, related to the facility's Acceptable Plan of Correction (POC), provided on 09/22/2020. The facility submitted a Plan of Correction for deficiencies, cited on 06/26/2020, alleging compliance on 09/25/2020. However, during a noncompliance revisit, conducted on 09/28/2020 through 10/08/2020, it was determined the facility failed to implement their plans of correction as described in the documents issued to the State Survey Agency for F-689, F-692, F-700, F-758, and F-865. The findings include: Review of the facility's policy, Quality Assurance and Performance Improvement (QAPI) Plan, revised 04/2014, revealed the facility shall develop, implement, and maintain an ongoing, facility-wide QAPI plan designed to monitor and evaluate the quality and safety of resident care, pursue methods to improve care quality, and resolve identified problems. The owner and/or Governing Board (body) of the facility shall be ultimately responsible for the QAPI program, and the Administrator was responsible for assuring the facility's QAPI Program complied with federal, state, and local regulatory requirements. Review of the Administrator's Job Description, undated, revealed the purpose of the Administrator's job was to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing facilities to assure the highest degree of quality of care could be provided to residents at all times. Continued review revealed the Administrator was to assist the Quality Assurance and Assessment Committee in developing and implementing appropriate plans of action to correct identified quality deficiencies. Review of the Compliance Officer's Job Description, undated, revealed the position's purpose was to provide direction and oversight of the operating organization's compliance and ethics program. Further review revealed the major duties and responsibilities of the position were to assist with overseeing and monitoring implementation of the compliance program. Review of the QAPI Meeting attendance sign-in sheets, revealed no documented evidence any member of the Governing Body (CEO, Compliance Officer, and/or Board of Director's member) attended. Interview with the Administrator and Regional Liaison, on 10/08/2020 at 3:23 PM, revealed they did not consider the Regional Staff members part of their Governing Body. They stated the Governing Body was the CEO of the facility and the Board of Director's members. Further interview revealed they were available as needed and corresponded with the Governing Body over the phone to relay information. The Administrator stated he was ultimately responsible for the actions that happened in the facility and to ensure the Plan of Correction was acted upon as to what the facility stated would occur. He stated, as the Administrator, he reported to the Governing Body, and the Governing Body was updated on the day-to-day operations in regard to the POC. Interview with the Vice-President of Compliance, on 10/08/2020 at 3:47 PM, revealed he was not considered part of the Governing Body. He stated his job duties were to provide support to the facility and provide any help where it was needed. He stated he had been helping with the facility's Plan of Correction and helping to collect audits and attend QAPI meetings to discuss findings. The Vice-President stated any issues identified with the audits would be corrected immediately.

Based on interview, record review, review of the facility's policy, and review of the Plan of Correction (POC) for the Abbreviated/Partial Extended Survey, dated 06/26/2020, and the Revisit Survey, dated 10/08/2020, and audits, it was determined the facility failed to maintain a Quality Assurance Performance Improvement (QAPI) Program that developed and implemented effective plans of action to correct quality deficiencies. This was evidenced by the repeat deficiency from the Abbreviated/Partial Extended Survey, conducted on 10/08/2020, at CFR 483.25 Quality of Care, F-689; CFR 483.25 Quality of Care, F-692; CFR 483.25 Quality of Care, F-700; and CFR 483.45 Pharmacy Services, F-758. Further, the facility failed to develop and implement restorative nursing care as needed to residents to promote optimal safety and independence; at 483.25 Quality of Care, F-688. The Interdisciplinary Team (IDT) was in-serviced on the QAPI plan and the objectives of the plan: to provide a means to identify and resolve present and potential negative outcomes related to resident care and services; to reinforce and build upon effective systems and processes related to the delivery of quality care and services; to provide structure and processes to correct identified quality and/or safety deficiencies; to establish and implement plans to correct deficiencies; and to monitor the effects of these action plans on resident outcomes. However, the facility failed to ensure plans and actions implemented for the deficiencies cited, on 06/26/2020, were carried out to correct the identified deficiencies by the Acceptable Plan of Correction, dated 09/22/2020, with an allegation of compliance date of 09/25/2020. The findings include: Review of the facility's policy, Quality Assurance and Performance Improvement (QAPI) Plan, revised 04/2014, revealed the facility shall develop, implement, and maintain an ongoing, facility-wide QAPI plan designed to monitor and evaluate the quality and safety of resident care, pursue methods to improve care quality, and resolve identified problems. Further review of the policy revealed the owner and/or Governing Board (body) of the facility shall be ultimately responsible for the QAPI program, and the Administrator was responsible for assuring that the facility's QAPI Program complied with federal, state, and local regulatory requirements. Refer to related policy(s) at CFR 483.25 Quality of Care, F-689; CFR 483.25 Quality of Care, F-692; CFR 483.25 Quality of Care, F-700; CFR 483.45 Pharmacy Services, F-758; at 483.25 Quality of Care, F-688. Based on interview and record review, it was determined the facility failed to implement procedures to ensure residents were provided restorative nursing care as needed to promote optimal safety and independence. During the survey, it was identified the facility failed to ensure residents with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence, unless a reduction in mobility was demonstrably unavoidable for seven (07) of thirty (30) sampled residents with limited ROM, Resident #4, #7, #13, #11/37, #39, #16/42, and #44. Additionally, due to the facility's non-compliance, actual harm was identified for three (3) residents, Resident #4, #11/37, and #39. Further, Substandard Quality of Care (SQC) was identified related to the facility's systemic failure to provide the nursing care needed to prevent a decline in functional status. Interview with the Occupational Therapist, on 10/01/2020 at 2:18 PM, revealed she did not make Restorative Nursing Program (RNP) recommendations, because the facility did not have a RNP. Continued interview revealed, in June of 2020, she discussed her concerns related to the facility not having a RNP, with the Administrator, and offered assistance with establishing a RNP. However, she was told because of the pandemic with the COVID-19 virus and staffing issues, a RNP was on hold. Interview with the Director of Nursing, on 10/02/2020 at 5:04 PM, revealed the facility was not aware Resident #4, Resident #7, Resident #13, Resident #11/37, Resident #39, Resident #16/42, and Resident #44 had not consistently been provided ROM or assistance with their devices for contractures. Additionally, the facility had not identified that Resident #4, Resident #37, and Resident #39 had a decline in functional status since admission to the facility. Per interview, the facility did not have a RNP; however, services, treatment, equipment, and assistance to maintain or improve a resident's mobility was a standard of care with State Registered Nurse Aides (SRNA), and the ultimate goal was for residents to have a baseline of functioning without decline. Further interview revealed the facility ensured residents received appropriate treatment and services to maintain mobility through utilizing therapy, by screening and referring residents for functional status changes, which was discussed in the Morning Clinical Meeting and monthly Quality Assurance (QA) meetings; however, these process had not identified deficient practice related to restorative nursing care. Interview with the Administrator, on 10/02/2020 at 2:55 PM, revealed he expected the rehabilitative department to ensure residents were as independent as possible, with movement as much as possible, and to set attainable goals in that regard. Additionally, he expected the Restorative Nursing Services policy to be maintained and followed to ensure the highest functional ability for residents as possible per goals set by the rehabilitation department or the Physician. He stated services such as ROM, mobility exercises, and use of devices to be carried out by the nursing department because the facility did not have a restorative nurse or restorative nursing assistants. Further, the Administrator stated the facility ensured these processes by discussing therapy case load (which residents were in therapy, discharging from therapy, referred to therapy, new orders, changes in condition, devices) and changes in resident conditions during the Monday through Friday, Morning Clinical Meeting. Further interview with the Administrator, on 10/02/2020 at 5:58 PM, revealed the facility's processes, (Morning Clinical Meeting, monthly Quality Assurance (QA) meetings and Quality Assurance Performance Improvement (QAPI)) to ensure residents were receiving appropriate care and services and to maintain or improve a resident's mobility, did not identify the facility practices related to Increase/Prevent Decrease in ROM/Mobility were deficient. Per interview, these established processes did not identify Resident #4, Resident #11/37, and Resident #39 had developed a decline in functional mobility/contractures since admission to the facility. Additionally, per interview, he stated the facility had identified the need for a RNP in QA several months ago; however, he determined the current practice of SRNA's to provide appropriate services and treatment was effective. Therefore, the facility had not implemented a RNP related to other prioritized concerns in the facility, such as COVID-19 and staffing. Interview with the Regional Liaison, on 10/06/2020 at 4:28 PM, revealed the facility held a monthly QAPI meetings, which the IDT attended. Additional interview revealed during the QAPI meeting, the IDT reviewed the POC and the audits for F-689, F692, F700, and F758. Per interview, after the Interdisciplinary (IDT) discussed those audits in the QAPI meetings, there was no identified concerns. Additional interview revealed during the daily clinical Meetings, Monday through Friday, the IDT reviewed those audits to ensure the audits were being completed per the Plan of Correction and any identified issues were being corrected. Further, she stated they felt as though they executed the POC, perfectly. Interview with the DON, on 10/06/2020 at 4:28 PM, revealed he had the responsibility to collect the audits for F-689, F-692, F-700, and F-758, and to ensure their completion. He stated he gathered the audits, glance over them, and placed them into a binder, until the monthly QAPI meeting. Continued interview revealed during the QAPI meeting, the audits were then thoroughly reviewed. Additional interview revealed he was aware there were issues with PRN [MEDICAL CONDITION] medications; however, the faiclity had not implemented a plan of action to correct the identified issues. Further interview revealed the facility identified failures in the F-689 audit related to revising the Care Plan timely with interventions. Interview the facility's Administrator, on 10/06/2020 at 4:28 PM, revealed all staff had been in-serviced related to all deficiencies on 09/11/2020. Per interview, he had also discussed his expectations of the QAPI process with staff. Additionally, he stated the DON was responsible for the audits, which included ensuring audits were completed, accurate and were brought to QAPI monthly meeting. Further, the Administrator stated the facility did not identify any issues with the F-689, F-692, F-700, and F-758 audits that were brought to monthly QAPI meetings. Continued interview revealed, the Administrator was responsible for ensuring the overall execution of the POC.

Based on record review, staff interviews, review of the facility's policy, and review of the Administrator's Job Description, it was determined the Quality Assurance and Program Improvement (QAPI) committee failed to identify quality deficiencies, take actions aimed at performance improvement, track performance to ensure that improvements were realized and sustained related to citations of F-689, F-692, F-700, F-758, and F-865. This resulted in harm to five (5) of thirty (30) sampled residents (Resident #4/20, #7/23, #3/31, #34, and #11/37) related to the facility's failure to have an effective plan to self-identify quality of care concerns, and implement a plan, to prevent the worsening significant/severe weight loss for these residents. The facility provided an acceptable Plan of Correction (POC), on 09/22/2020. The POC stated the facility was in compliance, as of 09/25/2020. The findings include: Review of the facility's policy, Quality Assurance and Performance Improvement (QAPI) Plan, revised 04/2014, revealed the facility shall develop, implement, and maintain an ongoing, facility-wide QAPI plan, designed to monitor and evaluate the quality and safety of resident care, pursue methods to improve care quality, and resolve identified problems. Further review of the policy revealed the owner and/or Governing Board (Body) of the facility shall be ultimately responsible for the QAPI program, and the Administrator was responsible for assuring the facility's QAPI Program complies with federal, state, and local regulatory requirements. Review of the Administrator's Job Description, undated, revealed the purpose of the Administrator's job was to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing facilities to assure the highest degree of quality of care could be provided to residents at all times. Continued review revealed the Administrator was to assist the Quality Assurance and Assessment Committee in developing and implementing appropriate plans of action to correct identified quality deficiencies. 1. Review of the facility's Plan of Correction (POC) for F-689, signed by the Administrator on 09/21/2020, revealed the facility was cited F-689 with a completion date of 09/25/2020. Continued review revealed incident reports for the previous day would be reviewed Monday through Friday in the Clinical Meeting to ensure appropriate interventions were implemented and an updated plan of care was complete. In addition, review revealed audits would be performed to ensure that appropriate interventions were put into place timely, to reduce the risk of resident falls/accidents and care plans have been updated to reflect these interventions. Review of the audits for F-689 revealed the purpose of the audits were to review incident reports to ensure appropriate interventions have been put in place timely to reduce the risk or resident falls/accidents and that care plans have been updated to reflect the interventions. Review of a facility Audit, with dates ranging from 09/27/2020 through 10/02/2020, revealed Resident #5/2 had sustained a fall on 09/27/2020. The Audit stated Resident #5/2's Incident Report was reviewed and completed, ice was offered with neurological checks completed and the Comprehensive Care Plan (CCP) was updated. However, after review of the medical record, Resident #5/2 had three (3) falls within eleven (11) hours: on 09/27/2020 at 2:45 PM, on 09/27/2020 at 6:40 PM, and on 09/28/2020 at 2:00 AM. However, the Audit, which included dates 09/27/2020 through 10/02/2020, did not included two of the resident's falls, the fall on 09/27/2020 at 6:40 PM, and fall on 09/28/2020 at 2:00 AM. Additional review revealed the CCP was not revised on 09/27/2020 to include providing ice water, performing neurological checks, routine rounding, until 09/29/2020, two (2) days after the fall occurrences and the Audit, on 09/27/2020. Further, the Audit did not identify the CCP was not revised to reflect the bolsters, in use at the time of the fall occurrence on 09/27/2020. (Refer to F-689 and F-657) Interview with the Facility's Administrator, on 10/06/2020 at 4:54 PM revealed their audit did not identify Resident #5/2's CCP interventions were not in place. However, when he became aware they started, on 10/05/2020, a new process that required the DON be called 24/7 to update the care with new interventions. 2. Review of the facility's Plan of Correction (POC) for F-692, signed by the Administrator on 09/21/2020, revealed the facility was cited F-692, with a completion date of 09/25/2020. Continued review revealed the Director of Nursing (DON) would conduct an audit of five (5) resident charts weekly for four (4) weeks then five (5) resident charts biweekly for eight (8) weeks to ensure any significant/severe weight losses were identified and their Care Plans with significant/severe weight loss reflected a more person-centered interventions. Any deficient practice found during the audits would be corrected immediately by the DON and education and/or corrective action done as appropriate. Continued review revealed Significant/Severe weight loss would be reviewed in the weekly Nutritionally at Risk (NAR) meeting. Review of the facility's audits revealed the failed to identify resident's weights were not being obtained monthly per the facility's policy and their POC. Resident #3/31, #11/37, #4/20, #7/23, and #34 who were not weighed monthly and suffered significant and severe weight loss. Resident #3/31, #11/37, #4/20, #7/23, and #34 meal intakes were not complete and had omissions. The State Survey Agency identified Resident #4/20, #7/23, 3/31, #34, and #11/37 with significant/severe weight loss; however, only Resident #3/31 was identified in the NAR meeting on 09/10/2020 with weight loss. (Refer to F-692). Interview with the Regional Liaison on, 10/06/2020 at 4:54 PM, revealed it was the DON's responsibility to ensure the audits related to weights were complete and accurate. These audits would then be brought to QAPI for review and to see if any changes needed to be made to the current process. They stated the weights were obtained per their policy and the policy does not define a month; the audits were completed correctly with the weights that were available. 3. Review of the facility's Plan of Correction (POC) for F-700, signed by the Administrator on 09/21/2020, revealed the facility was cited F-700 with a completion date of 09/25/2020. Continued review revealed side rails would be removed from all resident beds, and the administrator would audit all resident beds one (1) time per week for twelve (12) weeks to ensure that no bed rails were on any of the resident beds. Review of the Audits for F-700, revealed bed rails were audited weekly starting 09/17/2020, 09/23/2020, and 09/30/2020, indicating there were no side rails present on any resident beds. However, observation, on 09/28/20 at 10:00 AM, revealed Resident #7/23's bed, in room [ROOM NUMBER], had a ¼-side rail on the left lower quadrant. This side rail was never observed to be in use. The ¼-side rail continued to be observed during the course of the survey, including, on 09/29/20 at 9:50 AM and again at 2:45 PM, on 09/30/20 at 3:10 PM, and, on 10/01/20 at 11:15 AM. The side rail remained on the bed until the State Survey Agency alerted the DON and Administrator, on 10/02/2020 at 6:00 PM. Interview with the facility's Administrator on 10/02/2020 at 5:58 PM, revealed he as well as others audited the whole building as thoroughly as they could, and this was his responsibility as the Administrator. He admitted their audit must have not worked, as there was still a bed that had a side rail present. 4. Review of the facility's Plan of Correction (POC) for F-758, signed by the Administrator on 09/21/2020, revealed the facility was cited F-758 with a completion date of 09/25/2020. Continued review revealed all licensed nursing staff were in-serviced regarding the facility's policy for the Use of [MEDICAL CONDITION] Drugs and Behavioral Assessment, Intervention, and Monitoring. Per the POC, the DON/Nurse Supervisor would complete random weekly audits of five (5) residents on [MEDICAL CONDITION] medications for four (4) consecutive weeks and then five (5) residents biweekly for eight (8) weeks to ensure that appropriate diagnosis, behavioral documentation and Gradual Dose reductions were clearly documented in the medical record. Review of the audits for F-758, revealed the purpose of the audits were to ensure [MEDICAL CONDITION] medications have a diagnosis, behavioral documentation, and Gradual Dose Reductions were documented appropriately. Resident #11/37 was audited on 09/14/2020 stating resident had the appropriate [DIAGNOSES REDACTED]. Record review revealed Resident #11/37 had on order for [MEDICATION NAME] 0.5 milligram (mg) every 24 hours as needed for anxiety starting on 08/05/2020 with no stop date. The Resident's [MEDICATION NAME] was discontinued on 08/14/2020, however, an active order for [MEDICATION NAME] 0.5 milligrams (mg) started on 08/14/2020, as needed with no stop date and no evidence of non-pharmacological interventions prior to use. Interview with the DON, on 10/06/2020 at 4:54 PM, revealed there was issues identified in the facility, regarding [MEDICAL CONDITION] drugs and PRN [MEDICAL CONDITION] drugs not having a stop date, which was noted when performing the audits. However, Resident #11/37 still failed to have a stop date for PRN [MEDICATION NAME], on 10/08/2020 at the time of exit. He stated this should have been corrected as soon as it was identified. 5. Review of the facility's Plan of Correction (POC) for F-865, signed by the Administrator on 09/21/2020, revealed the facility was cited F-865, with a completion date of 09/25/2020. Continued review revealed any deficient practice found by any of the audits would be corrected immediately by the DON or Assistant Director of Nursing (ADON) and education would be provided and/or corrective action by DON or ADON as appropriate. The audit findings would be reported in a monthly QAPI meeting for a minimum of three months. The Interdisciplinary Team (IDT) meeting would be held weekly until placed into compliance. Per the POC, during the IDT meeting, weights would be monitored as recorded from the previous day, if triggered weight loss was identified, recommendations were made by the Registered Dietician (RD), APRN/MD was notified, family was notified, and care plans were updated appropriately. Audits from the previous day were also discussed and any identified issues were addressed. The facility failed to identify any issues until the SSA brought it to their attention, however, with F-692 they failed to identify issues as they stated they obtained the weights on the residents monthly. Review of the audits above for deficiencies F-689, F-692, F-700, and F-758 revealed the facility failed to identify issues or concerns with their audits. Review of the document Staff In-service revealed on 09/11/2020, all staff were re-educated on all deficiencies cited on 06/26/2020: F-689 regarding how all falls and incidents would be reviewed Monday through Friday in the Clinical Meetings to ensure implementation of interventions and updating Care Plans. F-692 regarding weight assessment, interventions, ensuring interventions were in place and carried out for residents with weight loss, residents who have triggered for weight loss were added to the NAR, and monitoring meal intakes for adequate intake. F-700 regarding bed rail removal from all resident beds. F-758 regarding how licensed staff were educated on the Use of [MEDICAL CONDITION] Drugs, Behavioral Assessment, Intervention and Monitoring, and monitoring for behaviors and proper documentation related to [MEDICAL CONDITION] medications. F-865 regarding the Interdisciplinary Team (IDT) was in-serviced on the QAPI plan and the objectives of the plan pertaining to the structure and processes to correct identified quality and/or safety deficiencies, establish and implement plans to correct deficiencies and to monitor the effects of these action plans on resident outcome. The facility ensured education was reiterated on 09/11/2020; however, the facility failed to follow their policy's in regards to obtaining weights, ensuring PRN [MEDICAL CONDITION] medications had a stop date and documented non-pharmacological interventions prior to use, interventions implemented after falls, and no bed rails present in the facility. Interview with the Regional Liaison, on 10/06/2020 at 4:28 PM, revealed the IDT met monthly for the QAPI meetings, per the POC and reviewed the audits. She stated they have been holding Clinical Meetings every day, Monday through Friday, to ensure the audits were being completed and any identified issues were being corrected. She stated they felt as though they executed the POC, almost near perfectly. Continued interview revealed the IDT went over the audits in the QAPI meetings, she stated no real concerns were identified during these meetings. Interview with the DON, on 10/06/2020 at 4:28 PM, revealed it was his responsibility to collect the audits and ensure their completion. He stated he gathered them and skimmed them, and placed them into a binder to take to QAPI for review. Continued interview revealed he was aware there were issues with PRN [MEDICAL CONDITION] medications however, had not implemented a plan into action. He stated in regards to F-689 their audit failed related to timely interventions updated to the care plan. Interview the facility's Administrator, on 10/06/2020 at 4:28 PM, revealed he in-serviced all staff again over all deficiencies on 09/11/2020, and went over expectations of the QAPI process. He stated the DON was responsible for the audits, which included ensuring audits were completed, accurate and were brought to QAPI. He stated that as the Administrator he was responsible for ensuring the overall execution of the POC. He stated they did not identify any issues when audits were brought to QAPI.

Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to provide services per the resident's care plan as related to incontinence for one (1) of twelve (12) sampled residents (Resident #1). Resident #1 was care planned for bladder incontinence related to [MEDICAL CONDITION] and had interventions to use disposable briefs, check every two (2) hours, and as required for incontinence, change clothing as needed after incontinence episodes. Observation and interview revealed on 08/25/2020, Resident #1, who was assessed to be incontinent and required assistance with Activities of Daily Living (ADL's), went several hours after soiling himself/herself, before staff provided assistance with changing. Per observation and interview Resident #1 had to ask several times and waited for hours to be changed. According to an interview with the Hospice Nurse, Resident #1 called her (she was not in the facility) to ask her to assist him/her with changing. She stated the resident was very upset and tearful and that his/her voice was quivering. The Hospice Nurse further revealed that Resident #1 stated he/she was embarrassed and at his/her wits end, but didn't know how else to get the help he/she needed. The findings include: Review of the facility's policy, Baseline Care Plan, revised December 2016, revealed a baseline plan of care to meet the resident's immediate needs would be developed within forty-eight (48) hours of admission. The baseline care plan would be used until staff could conduct a comprehensive assessment and develop an interdisciplinary person-centered care plan. Review of the facility's policy, Comprehensive Person-Centered Care Plan, revised December 2016, revealed a comprehensive, person-centered care plan, that included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs was developed and implemented for each resident. The comprehensive, person-centered care plan would describe the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Review of Resident #1's medical record revealed the facility admitted the resident, on 07/06/2020, with [DIAGNOSES REDACTED]. Review of Resident #1's Significant Change Minimum Data Set (MDS) Assessment, dated 07/31/2020, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fifteen (15), indicating the resident was cognitively intact. The facility assessed the resident as frequently incontinent (seven or more episodes of urinary incontinence) of urine and always incontinent (no episodes of continent bowel movements) of bowel. Continued review of Resident #1's mobility revealed the facility assessed Resident #1 to require two (2) person physical assistance in the areas of dressing, toileting, and personal hygiene. Review of Resident #1's Comprehensive Care Plan (CCP), initiated on 07/06/2020, revealed a focus problem of the potential for incontinence of bladder related to [MEDICAL CONDITION], with a goal, initiated on 07/06/2020, stating the resident would be continent at all times through the review date of 10/31/2020. Further review revealed interventions included brief use, change per schedule and as needed, clean perineal-area with each incontinence episode, check every two (2) hours and as required for incontinence, and change clothing as needed after incontinence episodes. Further review of the CCP, initiated on 07/06/2020, for Activities of Daily Living (ADL) revealed a focus problem of self-care deficit related to needing assistance with ADL's. The goal for this problem, initiated on 07/06/2020, stated the resident would show improvement in ADL performance through the next review on 10/31/2020. The CCP included interventions of extensive assistance by two (2) staff with bathing/showering, bed mobility, dressing, toilet use, and transfer. In addition, the nursing staff was to ensure daily needs were met. Resident #1 required extensive assistance by one (1) staff member with personal and oral care. Observation, on 08/25/2020 at approximately 2:15 PM, while conducting a medication administration observation with Kentucky Medication Aide (KMA)/State Registered Nursing Aide (SRNA) #3, Resident #1 told KMA/SRNA #3 he/she had messed himself/herself, needed to be cleaned, and had called out four (4) times via the call light, which someone answered, but no one came. The observation revealed Resident #1 told KMA/SRNA #3 he/she asked the facility's Administrator, around lunchtime (12:00 PM to 12:30 PM), to send him/her help, but help never came. The resident stated the Administrator had a lot going on and appeared overwhelmed. Further observation revealed Resident #1 was behind his/her privacy curtain when talking to KMA/SRNA #3. Per observation, KMA/SRNA #3 requested help to Resident #1's room, stating he/she needed help cleaning up, then continued passing medications. Additional observation of Resident #1, on 08/26/2020 at 11:30 AM, revealed the resident lying in bed wearing only a t-shirt, with his/her bottom half-naked. Resident #1 spontaneously and voluntarily lifted the scrotum, and then turned from side to side, saying he/she was concerned he/she might be getting skin breakdown in those two (2) areas due to recent incontinence episodes. Observation revealed the groin appeared slightly excoriated, but there was no skin breakdown or increased redness observed. Interview with Resident #1, on 08/26/2020 at 11:30 AM, revealed he/she went twelve (12) hours yesterday (08/25/2020) without briefs or pull-ups on after requesting them. He/she stated he/she was on four (4) fluid pills per day and had diarrhea yesterday. The resident said he/she asked to be changed, but no one ever came. Continued interview revealed he/she had not had a shower in several days. Interview with KMA/SRNA #3, on 08/25/2020 at 2:00 PM, stated she had been employed seventeen (17) years at the facility, and staffing was bad. Continued conversation revealed the facility was using agency staff to fill-in, but the staff was still working short. She stated today, there was only one (1) SRNA working Wing A, and one (1) KMA working between Wing A & Wing B. She stated a second aide stayed over from the night shift to help the one aide but left at noon. Additional interview with KMA/SRNA #3, on 08/26/2020 at approximately 2:00 PM, revealed she was asked, around 3:30 PM on 08/25/2020, after completing medication passes, to clean up Resident #1 because the request she made around 2:15 PM to have someone clean him/her up had not happened yet. Additional interview via telephone with KMA/SRNA #3, on 08/30/2020 at 12:20 PM, revealed she cleaned up Resident #1 after completing her medication passes around 3:30 PM. Continued interview revealed that Resident #1 told KMA/SRNA #3 he/she had called out for help since lunchtime, but no one came. She stated Resident #1 had on a shirt and a pair of gym shorts, which were soiled, and he/she was not wearing briefs or pull-ups under the shorts. KMA/SRNA #3 stated her scheduled shift ended at 3:00 PM, but she stayed until 11:00 PM due to short staffing. A Post Exit interview on 09/23/2020 at 3:45 PM, with Resident #1's Hospice Nurse, Hospice Nurse #1, revealed she received a call from Resident #1 on 08/25/2020 at approximately 3:00 PM. She stated the resident called her to ask her to come to the facility and assist him/her with changing as he/she had asked for help all day and no one had changed him/her. The Hospice Nurse stated the resident told her that he/she normally wore incontinence briefs at night but he/she did not have a brief to put on the previous night. She stated the resident told her that he/she had soiled and urinated in his/her shorts and it had dried. She stated Resident #1 was very upset and almost tearful and that his/her voice was quivering. She further revealed that Resident #1 stated he/she was embarrassed and at his/her wits end, but didn't know how else to get the help he/she needed. Interview with the Administrator, on 08/24/2020 at 3:00 PM and again on 08/27/2020 at 4:00 PM, revealed he had been employed at the facility for almost one (1) year, and staffing was currently a challenge due to vacancies and staff out due to the Coronavirus epidemic. He stated he was recruiting, hiring, and utilizing agency staff to supplement vacancies. The Administrator stated he expected care for residents to continue in its highest form and expected each resident's Care Plan be implemented. This included meeting basic care needs along with providing high-quality care to mitigate the spread of the COVID 19 virus through observation, spot-checking, education, and following policies and procedures. Interview with the Corporate Chief Operating Officer (COO), on 08/27/2020 at 3:00 PM, revealed he expected the facility to continue to help residents, keep staff and residents safe and healthy, utilize resources to the fullest, and pay whatever had to be paid from the top down to meet the needs of the residents. Also, the COO stated he expected the residents' care plans to be implemented.

Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to ensure a resident who was unable to carry out Activities of Daily Living (ADL's) received the necessary services to maintain good personal hygiene for one (1) of twelve (12) sampled residents (Resident #1). Observation and interview revealed on 08/25/2020, Resident #1, who was assessed to be incontinent and required assistance with Activities of Daily Living (ADL's), went several hours after soiling himself/herself, before staff provided assistance with changing. Per observation and interview Resident #1 had to ask several times and waited for hours to be changed. According to an interview with the Hospice Nurse, Resident #1 called her (she was not at the facility) to ask her to assist him/her with changing. She stated the resident was very upset and almost tearful and that his/her voice was quivering. The Hospice Nurse stated that Resident #1 was embarrassed and at his/her wits end, but didn't know how else to get the help he/she needed. The findings include: Review of the facility's policy, Activities of Daily Living (ADL), Supporting Policy, revised March 2018, revealed residents would be provided care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADL's). The policy stated residents who were unable to carry out ADL's independently would receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Review of the facility's policy, Resident Rights, revised December 2016, revealed employees would treat all residents with kindness, respect, and dignity. These rights included the resident's right to a dignified existence. Review of Resident #1's medical record revealed the facility admitted the resident, on 07/06/2020, with [DIAGNOSES REDACTED]. Review of Resident #1's Significant Change Minimum Data Set (MDS) Assessment, dated 07/31/2020, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fifteen (15), indicating the resident was cognitively intact. Continued review of the MDS revealed the facility assessed Resident #1 to require two (2) person physical assistance in the areas of dressing, toileting, and personal hygiene. Review of Resident #1's Comprehensive Care Plan (CCP), initiated 07/06/2020, for Activities of Daily Living (ADL) revealed a focus problem of self-care deficit related to needing assistance with ADL's. The goal for this problem, initiated on 07/06/2020, stated the resident would show improvement in ADL performance through the next review on 10/31/2020. The CCP included interventions of extensive assistance by two (2) staff with bathing/showering, bed mobility, dressing, toilet use, and transfer. In addition, the nursing staff was to ensure daily needs were met; and Resident #1 required extensive assistance by one (1) staff member with personal and oral care. Further review of the CCP, initiated on 07/06/2020, revealed a focus problem of the potential for incontinence of bladder related to [MEDICAL CONDITION], with a goal, initiated on 07/06/2020, stating the resident would be continent at all times through the review date of 10/31/2020. Further review revealed interventions included brief use, change per schedule and as needed, clean perineal (peri)-area with each incontinence episode, check every two (2) hours and as required for incontinence, and change clothing as needed after incontinence episodes. Observation, on 08/25/2020 at approximately 2:15 PM, while conducting a medication administration observation with Kentucky Medication Aide (KMA)/State Registered Nursing Aide (SRNA) #3, Resident #1 told KMA/SRNA #3 he/she had messed himself/herself, needed to be cleaned, and had called out four (4) times, but no one came. The observation revealed Resident #1 told KMA/SRNA #3 he/she asked the facility's Administrator, around lunchtime (12:00 PM to 12:30 PM), to send him/her help, but help never came, adding the Administrator had a lot going on and appeared overwhelmed. Further observation revealed Resident #1 was behind his/her privacy curtain when talking to KMA/SRNA #3. Per observation, KMA/SRNA #3 requested help to Resident #1's room, stating he/she needed cleaning up, then continued passing medications. Additional observation of Resident #1, on 08/26/2020 at 11:30 AM, revealed the resident lying in bed wearing only a t-shirt, with his/her bottom half-naked. Resident #1 turned from side to side, saying he/she was concerned he/she might be getting skin breakdown due to recent incontinence episodes. Observation revealed the resident's groin appeared slightly excoriated, but there was no skin breakdown or increased redness observed. Interview with Resident #1, on 08/26/2020 at 11:30 AM, revealed he/she went twelve (12) hours yesterday (08/25/2020) without briefs or pull-ups on after requesting them. He/she stated he/she was on four (4) fluid pills per day and yesterday he/she had diarrhea. The resident said he/she asked to be changed, but no one ever came. Resident #1 stated he/she had not had a shower in several days. Interview with KMA/SRNA #3, on 08/25/2020 at 2:00 PM, revealed she had been employed seventeen (17) years at the facility, and staffing was bad. Continued interview revealed the facility was using agency staff to fill-in, but the staff was still working short. She stated today there was only one (1) SRNA working Wing A, and one (1) KMA working between Wing A & Wing B. She stated a second aide stayed over from the night shift to help the one aide but left at noon. Additional interview with KMA/SRNA #3, on 08/26/2020 at approximately 2:00 PM, revealed she was asked, around 3:30 PM on 08/25/2020, after completing medication administration, to assist Resident #1 to clean up, because the request she made around 2:15 PM to have someone clean him/her up had not happened yet. Additional interview via telephone with KMA/SRNA #3, on 08/30/2020 at 12:20 PM, revealed she assisted Resident #1 after completing her medication administration around 3:30 PM. Continued interview revealed Resident #1 told KMA/SRNA #3, he/she had called out for help to get assistance because he/she had soiled himself/herself since lunchtime, but no one came to assist. She stated Resident #1 had on a shirt and a pair of gym shorts, which were soiled. A Post Exit interview on 09/23/2020 at 3:45 PM, with Resident #1's Hospice Nurse, Hospice Nurse #1, revealed she received a call from Resident #1 on 08/25/2020 at approximately 3:00 PM. She said the resident called her to ask her to come and assist him/her with changing as he/she had asked for help all day and no one had changed him/her. She stated the resident told her that he/she normally wore incontinence briefs at night but he/she did not have a brief to put on the previous night, and that he/she had soiled and urinated in his/her shorts and it was dried. She stated Resident #1 was very upset and almost tearful and his/her voice was quivering. She further revealed that Resident #1 stated he/she was embarrassed and at his/her wits end, but didn't know how else to get the help he/she needed. Interview with the Administrator, on 08/24/2020 at 3:00 PM and again on 08/27/2020 at 4:00 PM, revealed staffing was currently a challenge due to vacancies and staff out due to the Covid-19. The Administrator stated he expected care for residents to continue in its highest form and expected each resident to receive the care and services they had been assessed to receive, including incontinence care. He stated this included meeting basic care needs along with providing high-quality care through observation, spot-checking, education, and following policies and procedures. Interview with the Corporate Chief Operating Officer (COO), on 08/27/2020 at 3:00 PM, revealed he expected the facility to continue to help residents, keep staff and residents safe and healthy, utilize resources to the fullest. Also, the COO stated he expected the residents' care needs to be met timely.

Based on observation, interview, record review, and review of facility Policies, it was determined the facility failed to have an effective system to ensure the Physician, Registered Dietician, and the residents' representative(s) were notified when there was a significant change in the resident's physical status and/or a need to alter treatment for [REDACTED].#2, #3, #4, #5, #6, #7, #8, #9, and #11). Resident #9's Fluid Intake Report, revealed the resident did not meet his/her fluid requirements of 1250-1500 milliliters per day from 04/20/2020 through 05/15/2020. However, there was no documented evidence the RD or Physician/Provider was notified. On 05/15/2020, the resident had a change in behavior and laboratory values were obtained revealing the resident's Blood Urea Nitrogen (BUN) level was 67 (High) which indicated dehydration. Furthermore, the resident suffered a 17.4 percent (%) severe weight loss from admission on 04/20/2020 until 05/27/2020; however, there was no documented evidence the RD, or Physician/Provider was notified of the resident's weight loss. Resident #2 experienced a severe weight loss of 9.65% in less than one (1) month, from 12/21/2019 to 01/06/2020; however, there was no documented evidence the Registered Dietician (RD), Physician/Provider or resident representative was notified of the severe weight loss. Two (2) months later, the RD wrote a Note dated 03/16/2020, stating the resident experienced a weight loss of 11% in three (3) months and made dietary recommendations to prevent further weight loss. However, there was no documented evidence the Physician/Provider was notified of these recommendations until 04/27/2020, over a month later. Further, Resident #2 experienced a weight loss of 4.37% in seven (7) days from 03/18/2020 through 03/25/2020. However, there was no documented evidence the Registered Dietician (RD), Physician/Provider or resident representative was notified of the weight loss. Resident #4 was newly admitted on [DATE] and a weight was obtained on that date of 151.0 pounds. Another weight was obtained on 03/09/2020 at 144.0 pounds, revealing a 4.64% weight loss in seven (7) days. However, there was no documented evidence the RD, Physician/Provider or resident representative was notified of the weight loss. Moreover, Resident #4 was weighed on 04/05/2020 (142.3 pounds) and was not weighed again until 05/22/2020 (138.0 pounds), over six (6) weeks later. The weight obtained on 05/22/2020, revealed the resident experienced a severe weight loss of 8.61% in less than three (3) months as compared to the weight on 03/02/2020 of 151 pounds. However, there was no documented evidence the RD, Physician/Provider was notified of the severe weight loss. On 05/28/2020, after State Survey Agency (Surveyor) intervention, the RD made recommendations for Magic Cup; however, there was no documented evidence the Physician/Provider was notified of the recommendations as there were no new orders for the dietary supplement. Resident #5's Weight Report revealed the weight obtained on 05/23/2020 of 95.2 pounds revealed a severe weight loss of 13.45% in less than six (6) months as compared to the weight of 110.0 pounds on 01/20/2020. However, there was no documented evidence the RD, Physician/Provider, or resident representative was notified of this severe weight loss. Resident #6's Weight Report, revealed a weight of 163.0 pounds on 12/17/2019, and a weight of 150.0 pounds on 02/06/2020, revealing a severe weight loss of 7.9% in less than two (2) months. There was no documented evidence of a weight from 04/13/2020 (142.0 pounds) until 05/27/2020. After Surveyor intervention a weight was obtained on 05/27/2020 at 134.0 pounds, revealing a severe weight loss of 17.79% in six (6) months compared to the 12/17/2019 weight of 163.0 pounds. However, there was no documented evidence the RD, Physician/Provider or resident representative was notified of the weight loss until Surveyor intervention. Resident #8's Weight Report, revealed the resident was re-admitted to the facility on [DATE] with a weight of 104.2 pounds. The RD made recommendations on 03/12/2020, for Medication Pass, sixty (60) milliliters (ml) three (3) times a day, and added fortified oatmeal at breakfast; however, there was no documented evidence the Physician/Provider was notified of the RD's recommendations from 03/12/2020. Resident #7's Weight Report, revealed a weight of 174.0 pounds on 01/20/2020 and a weight of 165.0 pounds on 02/05/2020, revealing a severe weight loss of 5.17% in less than one (1) month. However, there was no documented evidence the RD, Physician/Provider or resident representative was notified. Further review of Resident #7's Weight Report, revealed the resident weighed 174.0 pounds on 04/07/2020, and 162.3 pounds on 05/22/2020, revealing a weight loss of 11.7 pounds (6.9%) in less than two (2) months. However, there was no documented evidence the RD, Physician/Provider or resident representative was notified of the weight loss. Resident #11's Weight Report, revealed a weight was obtained on 03/06/2020 at 184.0 pounds, which was a severe weight loss of 5.6% in one (1) month compared to the resident's weight of 195.0 pounds on 02/06/2020. However, there was no documented evidence the RD was notified until 04/27/2020, over four (4) weeks later when recommendations were made for Med Pass supplement. Further, there was no documented evidence the Physician/Provider was notified of the weight loss or RD recommendations until 04/30/2020 when orders were received for High Calorie sixty (60) milliliters once a day nutritional supplement. Resident #3 weighed 142.0 pounds on 02/05/2020 and 135.0 pounds on 03/16/2020, revealing a weight loss of 4.9% in approximately five (5) weeks. Although the RD Quarterly Nutrition Note, dated 03/16/2020, revealed recommendations were made for Magic Cup at each meal and at night, there was no documented evidence the Physician/Provider was notified of the recommendation for Magic Cups, as there was no order for this supplement. (Refer to F-692) The facility's failure to have an effective system in place to ensure Physician/Provider, Registered Dietician (RD) and resident representative notification when there was a need to alter treatment related to nutrition/hydration has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) was identified on 06/04/2020, and determined to exist on 01/06/2020. The facility provided an acceptable credible Allegation of Compliance (AoC) on 06/13/2020 alleging removal of the Immediate Jeopardy on 06/13/2020. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on 06/13/2020, prior to exit on 06/26/2020, with remaining non-compliance at a Scope and Severity of an E while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's Change in Resident's Condition or Status Policy, dated May 2017, revealed it is the policy of the facility to promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status. Notifications will occur when there has been a significant change in the resident's physical/emotional/mental condition or a need to alter the resident's medical treatment significantly. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when there is a significant change in the resident's physical, mental, or psychosocial status. Except in medical emergencies, notification will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status. Review of the facility's Hydration-Clinical Protocol, revised 09/2017, revealed the staff will identify and report to the physician individuals with signs and symptoms or lab test results that might reflect existing fluid and electrolyte imbalance. Review of the facility's Nutrition (Impaired)/Unplanned Weight Loss - Clinical Protocol Policy, revised September 2017, revealed staff will monitor and document the weight and dietary intake of residents in a format which permits comparisons over time. Continued review revealed staff will report to the Physician significant weight gains or losses or any abrupt or persistence change from baseline appetite or food intake. The Physician will review for medical causes of weight gains or losses before ordering interventions. Review of the facility's Weight Assessment and Intervention Policy, revised December 2019, revealed any weight change of five percent (5%) or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will notify the Dietician by receipt of the resident's weights. 1. Review of Resident #9's medical record revealed the facility admitted the resident on 04/20/2020 with [DIAGNOSES REDACTED]. Review of Resident #9's Weight Report, revealed the resident's weight on 04/20/2020 upon admission was 109.0 pounds. Review of Resident #9's Admission Nutrition Assessment, dated 04/27/2020, completed by the RD, revealed the resident's estimated fluid requirement was 1250-1500 milliliters per day. Review of Resident #9's Fluid Intake Report, revealed the resident did not meet his/her fluid requirements of 1250-1500 milliliters of fluid a day from 04/20/2020 through 05/15/2020. However, there was no documented evidence the RD, Physician/Provider, or resident representative was notified of the resident's poor fluid intake. Per the Nurse's Note, dated 05/15/2020, the resident had a change in behavior and labs were ordered. Review of the Laboratory Report, dated 05/15/2020 at 3:37 PM, revealed: Blood Urea Nitrogen (BUN) level was 67 High (reference range 7-18, indicating dehydration). physician's orders [REDACTED]. Review of the Weight Report, the resident's weight on 05/27/2020, was 90.0 pounds, which revealed a weight loss of nineteen (19) pounds in one (1) month, indicating a 17.4% severe weight loss in five (5) weeks. However, there was no documented evidence the RD, or Physician/Provider was notified of the weight loss. Interview with the RD on 06/01/2020 at 9:32 AM, revealed she was unaware of Resident #9's weight loss from the weight obtained on 05/27/2020, until the Surveyor brought the weight loss to her attention as she had not been notified by nursing staff. Continued interview revealed she should have been notified of the resident's low fluid intake in order to promote interventions to prevent dehydration. Interview with the Advanced Registered Nurse Practitioner (ARNP), on 06/04/2020 at 10:20 AM, revealed if staff had informed her the resident was refusing food/fluid intake, it would have been plausible that the resident would not have required the intravenous fluids on 05/15/2020 related to the resident being severely dehydrated. 2. Review of Resident #2's medical record revealed the facility admitted the resident on 11/13/2019, with [DIAGNOSES REDACTED]. Resident #2's Weight Report, revealed a weight of 114.0 pounds on 12/21/2019, and a weight of 103.0 pounds on 01/06/2020, revealing a severe weight loss of 9.65% in less than one (1) month. However, there was no documented evidence the RD or resident representative was notified regarding the severe weight loss. Review of Resident #2's RD Quarterly Progress Note, dated 01/06/2020, revealed the resident's weight was 114.0 pounds with no significant weight change in the past three (3) months. However, this Note was inaccurate as it did not address the resident's severe weight loss of 9.65% in less than one (1) month, revealing the RD was not notified of the resident's weight loss. In addition, there was no documented evidence the Physician was notified of the resident's severe weight loss of 9.65% in less than one (1) month. Per the ARNP Progress Note, dated 01/14/2020, Resident #2 voiced his/her appetite had been good, and the resident received Ensure and Hi Calorie Supplements. Interview with the ARNP, on 06/04/2020 at 10:43 AM, revealed she was unaware of Resident #2's weight loss at the time she wrote the above Progress Note. Review of Resident #2's RD Quarterly Progress Note, dated 03/16/2020, revealed the resident's weight was 102.0 pounds revealing the resident had an 11% weight loss in the past three (3) months. Recommendations were made for [MEDICATION NAME] for appetite (a medication that can help stimulate appetite). Further review revealed this was the first reference the RD made to indicate she was aware of the resident's weight loss, even though the weight indicating the severe weight loss was obtained on 01/06/2020, over two (2) months prior. Interview with the RD, on 05/28/2020 at 11:10 AM, revealed at the time she wrote the Note, dated 01/06/2020, she was unaware of the severe weight loss of 9.65% in less than one (1) month, as she did not have the 01/06/2020 weight to review. She stated she requested Resident #2's weight to be obtained on 01/06/2020. However, staff did not notify her of the weight obtained on 01/06/2020, which reflected the severe weight loss. Further, there was no documented evidence the Physician/Provider was notified of the dietary recommendations from the RD to start [MEDICATION NAME] until the Nurse's Note, dated 04/27/2020 at 6:22 PM, which stated the Nurse Practitioner reviewed the recommendations from the RD and did not want to start [MEDICATION NAME] at this time. This recommendation was made on 03/16/2020, with no documented evidence the Provider was notified of the recommendation until 04/27/2020, over a month later. Review of Resident #2's Weight Report, revealed a weight of 103.0 pounds on 03/18/2020 and a weight of 98.5 pounds on 03/25/2020, revealing a 4.37% weight loss in seven (7) days. However, there was no documented evidence the RD, Physician/Provider or resident representative was notified related to the weight loss. Interview with the RD, on 05/28/2020 11:10 AM, revealed she was not notified and she expected the facility to notify her of this weight loss and stated, That weight loss in a week is hard to believe. Interview with the ARNP on 06/04/2020 at 10:43 AM, revealed she should have been notified of the resident's weight loss of 4.37% weight in seven (7) days. 3. Review of Resident #4's clinical record revealed the facility admitted the resident on 03/02/2020, with [DIAGNOSES REDACTED]. Review of the Weight Report, revealed the resident weighed 151.0 pounds upon admission on 03/02/2020, and 144.0 pounds on 03/09/2020, revealing a loss of seven (7) pounds within seven (7) days and a 4.64% weight loss. However, there was no documented evidence the RD or Physician was notified of the weight loss. Review of the RD Initial Nutritional Note, dated 03/09/2020, revealed the resident's current weight was 151.0 pounds. Per the Note, the RD failed to identify the weight loss of 4.64% from 03/02/2020 to 03/09/2020. Interview with the RD on 05/28/2020 at 11:10 AM, revealed she did not have the 03/09/2020 weight, when she wrote the note on that date, in order to complete an accurate review for this resident. She stated staff did not notify her of the weight loss. According to the Weight Report, Resident #4 was weighed on 04/05/2020 (142.3 pounds) and was not weighed again until 05/22/2020 (138.0 pounds). The weight of 138.0 pounds on 05/22/2020, revealed a severe weight loss of 8.61% in less than three (3) months, as compared to the weight obtained on 03/02/2020 of 151 pounds. However, there was no documented evidence the RD, Physician/Provider or resident representative was notified related to the severe weight loss, nor were there interventions placed to prevent further weight loss. Record review revealed after Surveyor intervention, the RD wrote a Nutrition Note, dated 05/28/2020 at 7:18 PM, revealing Resident #4 had a significant weight loss in the past two (2) months, and a 9% weight loss since admission. Additional review revealed the resident's current weight was 138 pounds and she suggested Magic Cup with lunch and dinner. However, there was no documented evidence the Physician/Provider was notified of the recommendation for the Magic Cup supplement as there were no new orders, and no documentation revealing the Provider did not approve the supplement. Interview with the RD, on 06/01/2020 at 9:32 AM, revealed she was unaware of any weight loss for Resident #4 until 05/28/2020, when she wrote the Nutrition Note. Per interview, she stated she should have been notified of this resident's decreased meal consumption and ensured the Provider was notified of her recommendations. Further, she was unaware the Provider was not notified of her recommendations from 05/28/2020 for Magic Cup. 4. Review of Resident #5's medical record revealed the facility admitted the resident on 09/11/2019, with [DIAGNOSES REDACTED]. Review of Resident #5's Weight Report, revealed a weight of 108.0 pounds on 02/05/2020, revealing a two (2) pound weight loss since 01/20/19 when the resident's weight was obtained at 110 pounds. Resident #5's Weight Report, revealed a weight of 95.2 pounds on 05/23/2020, and compared to the weight of 110.0 pounds on 01/20/2020, the resident experienced a severe weight loss of 13.45% in less than six (6) months. However, there was no documented evidence the RD and Physician/Provider was notified of this severe weight loss in order to implement appropriate interventions to prevent further weight loss. In addition, there was no documented evidence the resident's representative was notified of the weight loss. On 05/25/2020, the Surveyor brought the resident's weight loss to the facility's attention, and the RD completed a Dietary Consultant Review on that date. Recommendations were made to add Magic Cup at lunch and dinner to prevent future weight loss. physician's orders [REDACTED]. Interview with the RD, on 06/01/2020 at 9:32 AM, revealed she was unaware of the resident's continued weight loss until 05/25/2020 when she made further nutritional recommendations. The RD stated the resident had suffered a severe weight loss in less than six (6) months. Per interview, she was aware the resident was declining and she should have been informed of the resident's weight loss. 5. Review of Resident #6's medical record revealed the facility admitted the resident on 05/14/2012, with [DIAGNOSES REDACTED]. Review of Resident #6's Weight Report, revealed there was no documented evidence of a weight from 04/13/2020 (142.0 pounds) until 05/27/2020, after State Surveyor intervention. On 05/27/2020, the resident's weight was obtained at 134.0 pounds, revealing a severe weight loss of 17.79% in six (6) months compared to the 12/17/2019 weight of 163.0 pounds. However, there was no documented evidence the RD, Physician/Provider or resident representative was notified of the weight loss. Interview with the RD, on 06/01/2020 at 9:32 AM, revealed she was unaware the resident was not weighed from 04/13/2020 until 05/27/2020, which was over a month, nor was she notified of the further weight loss after the weight was obtained on 05/27/2020. Further, she should have been notified of this resident's weight loss in order to make recommendations to prevent further weight loss. 6. Review of Resident #8's medical record revealed the facility admitted the resident on 10/22/2012, with [DIAGNOSES REDACTED]. Further review revealed the resident was admitted to a Behavioral Health facility on 02/21/2020, and re-admitted to the facility on [DATE]. Per the Weight Report, Resident #2 weighed 104.2 pounds upon re-admission on 03/06/2020. Review of Resident #8's RD Nutrition Note, dated 03/12/2020, revealed the resident experienced a weight loss of 10%, as the resident's weight on 01/22/2020 was 116.0 pounds. Recommendations were made for Medication Pass (a supplement to provide calories and nutrition that can help to increase or maintain weight) sixty (60) milliliters (ml) three (3) times a day; and add fortified oatmeal to breakfast. However, there was no documented evidence the Physician/Provider was notified of the RD recommendations from 03/12/2020, for Med Pass and fortified oatmeal, in order for these interventions to be implemented. Interview with the RD, on 06/01/2020 at 9:32 AM, revealed she was unaware the Provider was not notified of her RD recommendations from 03/12/2020, and was unaware the recommendations were not implemented. 7. Review of Resident #7's medical record revealed the facility admitted the resident on 02/11/2013, with [DIAGNOSES REDACTED]. Review of the Weight Report, revealed a weight of 174.0 pounds on 01/20/2020 and a weight of 165.0 pounds on 02/05/2020, revealing a severe weight loss of 5.17% in less than one (1) month. However, there was no documented evidence the RD, Physician/Provider or resident representative were notified of the weight loss. Review of Resident #7's Weight Report, revealed the resident weighed 174.0 pounds on 04/07/2020, and weighed 162.3 pounds on 05/22/2020, revealing a weight loss of 11.7 pounds (6.9%) in less than two (2) months. However, there was no documented evidence of notification to the RD, Physician/Provider or resident representative of the weight loss. Interview with the RD on 06/01/2020 at 9:32 AM, revealed she should have been notified of the 02/05/2020 weight, when the weight was obtained showing a severe weight loss of 5.17% in less than one (1) month. Furthermore, she stated the weight obtained on 05/22/2020, revealed a weight loss of 11.7 pounds (6.9%) in less than two (2) months time and she should have been notified of this weight loss. Per interview, the resident's weight did fluctuate and she was aware the resident's goal was to lose weight; however, losing weight this fast was unhealthy. Interview with the ARNP, on 06/03/2020 at 9:45 AM, revealed she was aware of the weight loss from January to February 2020 for this resident, but was unaware of the resident's current weight loss of 11.7 pounds and she did not think the facility notified her regarding this weight loss. 8. Review of Resident #11's medical record revealed the facility admitted the resident on 07/27/2016, with [DIAGNOSES REDACTED]. Review of Resident #11's Weight Report, revealed a weight was obtained on 03/06/2020 at 184.0 pounds, which was a severe weight loss of 5.6% in one (1) month compared to the resident's weight of 195.0 pounds on 02/06/2020. However, there was no documented evidence the RD, Physician/Provider or resident representative was notified. Review of Resident #11's RD Quarterly Nutrition Note, dated 04/27/2020, revealed the resident had a decrease in weight of 6% in the past month and recommendations were made for Med Pass sixty (60) milliliters three (3) times a day to help stabilize weight. However, this Note was written over a month after the resident's weight was obtained on 03/06/2020, revealing the severe weight loss, the RD was not notified timely of the weight loss. 9. Review of Resident #3's medical record revealed the facility admitted the resident on 05/28/2019, and readmitted him/her on 12/10/2019 with [DIAGNOSES REDACTED]. Review of Resident #3's Weight Report, revealed the resident weighed 142.0 pounds on 02/05/2020 and 135.0 pounds on 03/16/2020, revealing a weight loss of 4.9% in approximately six (6) weeks. Review of the RD Quarterly Nutrition Note, dated 03/16/2020, revealed the resident weighed 132.0 pounds which was a decrease of 7% in one (1) month and 8% in three (3) months. Recommendations were made to add Magic Cup at each meal and at night, monitor oral intake, weights, labs, and add resident to the NAR. However, there was no documented evidence the Physician/Provider was notified of the recommendation for Magic Cups as there was no order for this supplement. Interview with LPN #8, on 05/28/2020 at 6:30 PM, revealed the Unit Managers were responsible for obtaining and documenting the weights into the Electronic Health Record (EHR), and notifying the Provider if there were significant weight losses. Interview with LPN #6, on 05/28/2020 at 6:41 PM, who worked A Wing Unit on 2nd shift, revealed it was not her responsibility to monitor food/fluid intakes or weights, but if she noticed a resident was frequently refusing meals and supplements, she would alert the Physician. Per interview, she was unaware of any residents having weight loss and; therefore, she did not recall notifying the RD or Physician of weight losses. Interview with LPN #2, on 05/29/2020 at 3:59 PM, who worked A Wing Unit on 2nd shift, revealed she was not responsible for obtaining weights. Further, if there was a dietary recommendation from the RD she would fax it to the Physician's office to get approval and the Unit Managers would input the approved recommendations into the computer. She stated she was unaware of residents having weight loss, but if she was notified of the weight loss she would notify the RD and the Physician. Interview with LPN #5 and Registered Nurse (RN) #1, on 06/01/2020 at 12:13 PM, revealed they both worked B Wing Unit. Per interview, it was not the nurses' responsibility to obtain weights or reweighs, or to monitor weights as this was the responsibility of the Unit Managers. RN #1 stated if she was notified of a weight loss she would notify the RD and Physician to get recommendations or new orders which would be entered into the EHR in the computer. Interview with the RD, on 06/01/2020 at 9:32 AM, revealed it was her expectation staff notify her of any resident's significant weight loss or decreased food and fluid in order for her to make dietary recommendations to promote weight gain, maintain weight, or to prevent dehydration. Continued interview revealed it was her expectation the Provider was notified of her dietary recommendations. Interview with the Unit Manager for B Wing Unit, on 06/01/2020 at 10:26 AM, revealed she had worked at the facility for several years, and was responsible for obtaining the weights on her unit and monitoring the residents for weight loss. Per interview, if she determined there was an actual weight loss that was significant she was responsible to notify the RD, and Provider and obtain new recommendations or orders. She further stated the ARNP visited every Tuesday and she tried to notify her of any weight changes. The Unit Manager acknowledged the RD, Providers, and residents' representatives were not always notified of weight losses timely. Interview with the Unit Manager for A Wing Unit, on 06/01/2020 at 2:00 PM, revealed she had only been in this position for about two (2) weeks and her job duties included obtaining weights on her unit for residents every week for four (4) weeks if they were a new admit or re-admit and then monthly, or per the physician's orders [REDACTED]. However, she acknowledged she was just learning her job duties. Interview with the ARNP, on 06/04/2020 at 10:24 AM, revealed she was at the facility almost weekly and it was her expectation to be notified regarding any resident with significant weight loss in order to provide interventions to prevent further weight loss. Further interview revealed if there was a recommendation from the RD, the Unit Manager would provide it, and she would approve it, and then give it back to the Unit Managers to input the recommendation as an order. She stated it was her expectation that she be notified of all RD recommendations and after approval, the recommendations were to be inputted into the EHR as physician's orders [REDACTED]. Interview with the Physician, on 06/02/2020 at 1:59 PM, revealed it was his expectation that he or the ARNP be notified of any significant weight changes. Per interview, after notification he would attempt to identify the underlying issue and implement appropriate interventions to address the weight loss. He stated if he was not aware of the resident's weight loss, he could not intervene with new orders or interventions. He further stated it was his expectation the Provider be notified of any RD recommendations. Interview with the DON and the Administrator, on 06/04/2020 at 4:07 PM, revealed it was their expectation significant weight losses as well as decreased food and fluid consumption should be immediately reported to the RD, Physician/Provider in order to ensure interventions were implemented to prevent further weight loss or dehydration. Further, the resident representative should also be notified. Continued interview revealed it was their expectation the Physician/Provider be notified of any RD recommendations in order to promote weight gain or weight maintenance. However, they acknowledged the Provider was not always notified of RD recommendations and the Provider was not always notified of weight loss or decreased food and fluid intake in a timely manner. Further interview revealed it was their expectation the facility's Change in Resident's Condition or Status Policy be followed. The facility provided an acceptable credible Allegation of Compliance (AoC) on 06/13/2020 that alleged removal of the immediate Jeopardy (IJ) on 06/13/2020. Review of the AoC revealed the facility implemented the following: 1. On 06/05/2020 The Vice President (VP) of Compliance arrived and immediately met with the Administrator and Director of Nursing (DON) to determine the root cause of the deficiencies. They reviewed all policies related to the IJs received and determined the root cause of the deficient practice. On 06/05/2020 the DON recommended Registered Dietician (RD) review for Residents #2, #3, #4, #5, #6, #7, #8, #9, and #11. On 06/06/2020 the VP of Compliance in-serviced the DON and Administrator on the Change in Resident's Condition or Status policy and the Nutrition Unplanned Weight Loss Policy. 2. On 06/05/2020, the Medical Director was contacted by the Administrator and DON. They discussed with him his role in the QA process, which will allow all residents identified with any significant or severe weight loss, to be clinically evaluated in a timely manner. They discussed that his involvement will aid facility nursing staff in setting interventions as necessary to avoid any future trending weight loss in an attempt to improve the overall quality of care. 3. On 06/06/2020 and 06/07/2020 the DON, Administrator and VP Compliance worked on developing an abatement plan. 4. The DON notified the Physician and Power of Attorney (POA) of weight loss on 06/05/2020 for Residents #2 and #3 and on 06/06/2020 for Residents #4, #5, #6, #7, and #8. On 06/06/2020, the POA for Resident #9 and the Physician for Resident #11 were notified. On 06/07/2020, the Physician for Resident #9 and the POA (TRUNCATED)

Based on observation, interview, record review, review of the facility's Policy, and review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, it was determined the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for sixteen (16) of eighteen (18) sampled residents (Residents #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, and #17) Comprehensive Care Plans (CCPs) were not developed and/or implemented related to monitoring intake and recording each meal; weekly weights x four (4) weeks for new admissions and monthly weights as per policy, and weights as indicated as per orders; notification to the Registered Dietician (RD) and the Physician/Provider of significant and severe weight loss; notification to the Physician/Provider of significant signs and symptoms of fluid deficit, observing for the appearance of mucous membranes and skin turgor; or communicating RD recommendations to the Provider/Physician. Further, the CCPs were not developed or implemented related to ensuring the residents received the amount of assistance needed with eating as per the MDS Assessment. The failure to develop and implement CCPs related to nutrition and/or hydration affected Residents #2, #4, #5, #7, 8, #9, and #11. (Refer to F-580, F-641, F-657, and F-692) Additionally, Resident #3, Resident #17 and Resident #13 sustained numerous falls; however, the CCPs were not developed or implemented related to fall interventions in order to prevent further falls of the same nature. This resulted in the residents sustaining further falls and injury. On 06/18/2020, Resident #3 sustained a laceration to the forehead measuring 0.5 to 2.5 cm long, when he/she fell off the porch after staff failed to lock the wheelchair brakes as per the CCP, during an activity. (Refer to F-689) Furthermore, Resident #16's physician's orders [REDACTED]. However, the CCP was not developed and implemented related to observing at least every thirty (30) minutes; allowing opportunity for motion and exercise for a period of not less than ten (10) minutes during each two (2) hour period in which restraints are employed, and repositioning at least every two (2) hours on all shifts as per policy. Staff interview and record review revealed staff was not checking or releasing the seat belt to allow the resident exercise. Further the CCP was not developed and implemented related to ongoing re-evaluation of the need for the restraint. The Physical Restraint Elimination Assessment, dated 06/01/2020, revealed the resident was a priority candidate for restraint elimination, and a trial with a Velcro seatbelt would begin on 06/22/2020; however, there was no documented evidence of a trial with this less restrictive alternative. Refer to F-604) In addition, there was no documented evidence the CCPs were developed and/or implemented related to ensuring risks and benefits of side rails were reviewed with the Resident/Resident Representative, and consent was obtained prior to use of side rails. In addition, the the CCPs were not developed and/or implemented related to ensuring Side Rail Assessments were completed and interventions were in place for monitoring and supervising side rail use to prevent risk of entrapment. This affected Residents #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, and #15. (Refer to F-700) Furthermore, Residents #3, #4, #6, and #7 were receiving [MEDICAL CONDITION] medications; however, there was no documented evidence the CCP was developed to include target behaviors nor developed with behavioral interventions to be implemented for specific behaviors. Additionally, there was no documented evidence the CCP was implemented related to monitoring target behaviors/symptoms and documenting the behaviors with the exception of Progress Notes, no documented evidence of monitoring for side effects of the [MEDICAL CONDITION] medications and no documented evidence the medications were being evaluated for effectiveness. (Refer to F-758) The facility's failure to have an effective system in place to ensure Comprehensive Care Plans were developed and implemented has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) was identified on 06/04/2020, and determined to exist on 01/06/2020. The facility provided an acceptable credible Allegation of Compliance (AoC) on 06/13/2020 alleging removal of the Immediate Jeopardy on 06/13/2020. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on 06/13/2020, prior to exit on 06/26/2020, with remaining non-compliance at a Scope and Severity of an E while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's Care Plans, Comprehensive Person-Centered Policy, dated December 2016, revealed it is the facility's policy to ensure the comprehensive, person-centered care plan includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements the comprehensive, person-centered care plan. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The IDT includes: the Attending Physician; a Registered Nurse who has responsibility for the resident; a nurse aide who has responsibility for the resident; a member of the food and nutrition services staff; the resident and the resident's legal representative (to the extent practicable); and other appropriate staff or professionals as determined by the resident's needs or as requested by the resident. Further review of the Policy, revealed the comprehensive, person-centered care plan will include the resident's stated goals upon admission and desired outcomes; incorporate identified problem area; incorporate risk factors associated with identified problems; build on the resident's strength; reflect the resident's expressed wishes regarding care and treatment goals; reflect treatment goals, timetables and objective in measurable outcomes; aid in preventing or reducing decline in the resident's functional status and/or functional levels; enhance the optimal functioning of the resident by focusing on a rehabilitative program; and reflect currently recognized standards of practice for problem areas and conditions. Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision-making. Review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, dated October 2016, revealed the Comprehensive Care Plan is an interdisciplinary communication tool and must include measurable objectives and time frames and must describe the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Further review revealed the services provided or arranged must be consistent with each resident's written Plan of Care. 1. Review of Resident #9's clinical record revealed the facility admitted the resident on 04/20/2020 with [DIAGNOSES REDACTED]. Record review revealed Resident #9's CCP, Focus of risk for alteration in nutritional status related to [MEDICAL CONDITION] and Poor Appetite was initiated 04/20/2020. The goal stated the resident would have no unplanned weight change by next review, with a target date of 08/01/2020. Interventions, initiated on 04/20/2020, included monitor food and fluids for appropriate texture and consistency; diet as ordered; educate family on risks of bringing in foods not allowed on diet; monitor intake after each meal and record; obtain and monitor labs as ordered; reassess as needed to help ensure adequate nutritional needs are being met daily; and, supplements as ordered, initiated 04/30/2020; and weight every month and as needed as clinically indicated and monitor for significant weight changes, initiated 04/20/2020. Continued review of Resident #9's Comprehensive Care Plan, with an initiation date of 04/20/2020, revealed a Focus of the potential for alteration in hydration related to poor intake. The goal stated the resident would remain free of signs and symptoms of fluid deficit: decreased urine output, poor skin turgor, dry mucous membranes, confusion, [MEDICAL CONDITIONS] headache, fatigue/weakness, dizziness, fever, thirst, and weight loss with a target date of 08/01/2020. Interventions, initiated on 04/20/2020 included: notify physician of significant signs and symptoms of fluid excess or fluid deficit; observe appearance of mucous membranes and skin turgor; observe for mental status changes/mood behavior changes; and obtain and monitor lab/diagnostic work per physician's orders [REDACTED]. Review of Resident #9's Admission MDS Assessment, dated 04/24/2020, revealed the facility assessed the resident as having a BIMS (Brief Interview for Mental Status) of fifteen (15) out of fifteen (15) revealing intact cognition. Additional review revealed the facility assessed the resident as requiring supervision and one (1) person physical assistance with eating. Per the MDS Assessment, Resident #9 had a weight of 109.0 pounds and a height of sixty-one (61) inches. Further, the resident was assessed as not receiving a therapeutic diet, having no weight loss, and having no signs of swallowing problems. Review of Resident #9's Care Plan revealed it was not implemented related to notification to the Physician for significant signs and symptoms of fluid deficit, observing for the appearance of mucous membranes and skin turgor, and monitoring food and fluids. Further, the CCP was not developed and implemented related to notification to the RD and Physician/Provider for significant or severe weight loss. Review of the Meal Intake Report, dated May 2020, revealed missing meal intakes, refusal of twenty (20) meals, and consumption of 0-25% of thirty-five (35) meals. Further, the Fluid Intake Report, revealed the resident did not meet his/her fluid requirements of 1250-1500 milliliters of fluid a day from 04/20/2020 to 05/15/2020. However, there was no documented evidence of monitoring the resident's fluid intake, and no documented evidence of a hydration assessment completed as per the CCP. Further, there was no documented evidence of notification to the Physician/Provider of the resident's poor food and fluid intake. Per the Nurse's Note, dated 05/15/2020 at 10:00 AM, the resident had a change in behavior and the Provider was notified. Labs indicated dehydration. physician's orders [REDACTED]. Further record review revealed there was no documented evidence Resident #9's CCP was developed related to interventions for weekly weights x four (4) weeks for new admissions, nor was there documented evidence the resident's weight was obtained monthly as per the CCP. In addition, there was no documented evidence the resident was monitored for significant weight changes as per the CCP. Resident #9 weighed 109.0 pounds upon admission 04/20/2020; however, there was no documented evidence the resident was weighed again until 05/27/2020, over a month later, after Surveyor intervention. According to the Weight Report, the resident's weight on 05/27/2020, was 90.0 pounds, revealing a weight loss of nineteen (19) pounds in one (1) month, indicating a 17.4% severe weight loss in five (5) weeks. However, there was no documented evidence the Physician/Provider was notified of the weight loss. Continued review of the CCP, revealed it was not developed and implemented with interventions for one (1) person physical assist with feeding as per the facility's Admission MDS assessment dated [DATE]. Observation of Resident #9, on 05/28/2020 at 12:35 PM, revealed the resident was in bed with the head of the bed elevated and the meal tray in front of him/her on the bedside table. Further observation revealed the resident was attempting to eat with his/her left hand while his/her right hand was in the sling. The resident appeared to be struggling as the tray would slide when the resident attempted to pick up food with the fork. There was no staff assisting the resident with the meal. 2. Review of Resident #2's clinical record revealed the facility admitted the resident on 11/13/2019, with [DIAGNOSES REDACTED]. Review of Resident #2's Comprehensive Care Plan (CCP), initiated 11/13/19, revealed a Focus of nutritional problem related to history of malnutrition and Vitamin D deficiency, Dysphagia, and receives a mechanically altered diet order. The goal stated the resident would have a gradual weight gain within 10% of his/her Ideal Body Weight for his/her sex and height by review date, of 07/21/2020. Interventions, also developed on 11/13/19 included: administer medications as ordered and monitor and document for side effects and effectiveness; administer nutritional supplements per physician's orders [REDACTED].) month, greater than 7.5% in three (3) months, and greater than 10% in six (6) months; obtain and monitor lab/diagnostic work as ordered and report results to physician and follow up as indicated; provide and serve supplements as ordered; provide, serve diet as ordered; monitor intake and record each meal; Registered Dietician to evaluate and make diet change recommendations as needed; and, weight weekly per orders initiated 03/17/2020. However, there was no documented evidence this Care Plan was implemented. Review of Resident #2's Quarterly Minimum Data Set (MDS) Assessment, dated 01/09/2020, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) of four (4) out of fifteen (15) indicating severe cognitive impairment. Further, the facility assessed the resident as requiring supervision such as cueing and setup help with eating. The facility also assessed Resident #2 as weighing 114.0 pounds and as not having a weight loss of 5% weight loss or more in the last month or loss of 10% or more in the last six (6) months. Continued review revealed the facility assessed the resident as having no swallowing problems. However, this MDS Assessment was inaccurate, as the resident had experienced a severe weight loss of 9.65% in less than one (1) month. (Refer to F-641). Review of Resident #2's CCP revealed it was not implemented related to monitor/record/report to physician for significant weight loss. Review of Resident #2's Weight Report revealed a weight of 114.0 pounds on 12/21/2019 and a weight of 103.0 pounds on 01/06/2020, indicating a severe weight loss of 9.65 percent (%) in less than one (1) month; however, there was no documented evidence the Physician/Provider was notified of the severe weight loss, as per policy. Further review of the Weight Report, revealed the resident weighed 103.0 pounds on 03/18/2020 and weighed 98.5 pounds on 03/25/2020, revealing a 4.7% weight loss in seven (7) days. Additionally, there was no documented evidence the CCP was implemented related to weekly weights as per orders. Per record review, a weight was obtained on 04/02/2020 (102.1 pounds); however, there was no documented evidence of another weight obtained until 05/20/2020 (102.5 pounds), almost seven (7) weeks later. Furthermore, there was no documented evidence the CCP was implemented related to monitoring intake and recording each meal as there were numerous meals in which meal intakes were not documented on the Meal Intake Reports for the months of January 2020, February 2020 and March 2020. 3. Review of Resident #4's clinical record revealed the facility admitted the resident on 03/02/2020, with [DIAGNOSES REDACTED]. Review of Resident #4's Comprehensive Care Plan, initiated 03/02/2020, revealed a Focus of risk for alteration in nutritional status related to Body Mass Index and nutritional approach. The goal with a target date of 06/19/2020, revealed the resident would have no significant weight change by next review. Interventions developed 03/02/2020 included: continue to monitor food and fluids for appropriate texture and consistency; diet as ordered; educate family on risks of bringing in foods not allowed on diet; monitor intake after each meal and record; obtain and monitor labs as ordered; reassess as needed to help ensure adequate nutritional needs are being met daily; set up each meal tray and assist as needed; and, weigh every month and as clinically indicated and monitor for significant weight changes. However, there was no documented evidence this Care Plan was developed to be person centered and individualized or implemented. Review of Resident #4's Admission MDS Assessment, dated 03/10/2020, revealed the facility assessed the resident as having a BIMS of eight (8) out of fifteen (15), indicating moderate cognitive impairment. Continued review revealed the resident was assessed as requiring supervision and set up help for eating. Further review revealed the resident was assessed to weigh 151.0 pounds and received a therapeutic diet. However, Resident #4's latest weight at the time of this MDS Assessment was 144 pounds. (Refer to F-641) Further review of the CCP, revealed it was not developed or implemented related to notification to the RD and Physician/Provider of significant weight loss. Review of Resident #4's Weight Report, revealed the resident weighed 151.0 pounds upon admission on 03/02/2020, and 144.0 pounds on 03/09/2020. This was a weight loss of seven (7) pounds within seven (7) days; indicating a 4.64% weight loss. However, there was no documented evidence the RD or Physician/Provider was notified of the weight loss. Continued review of the CCP, revealed it was not developed or implemented related to obtaining weekly weights x four (4) weeks for new admissions as per policy. Review of Resident #4's Weight Report, revealed no documented evidence the resident was weighed from 03/09/2020 (144.0 pounds) until 04/05/2020 (142.3 pounds), almost four (4) weeks later, even though the resident was a new admission on 03/02/2020. Continued review of the CCP, revealed it was not implemented related to obtaining monthly weights and weights as clinically indicated and for significant weight changes. Review of Resident #4's Order Summary Report, revealed active orders with a start date of 04/06/2020, for weekly weights times four (4) weeks and then monthly thereafter. However, there was no documented evidence weekly weights were obtained as per the physician's orders [REDACTED].#4 was weighed on 04/05/2020 (142.3 pounds) and was not weighed again until 05/22/2020 (138.0 pounds). The weight of 138.0 pounds on 05/22/2020 revealed a severe weight loss of 8.61% in less than three (3) months, compared to the weight obtained on 03/02/2020 of 151 pounds. Additional review of the CCP, revealed it was not developed and implemented related to interventions for supervision and set up help for eating, as per the Admission MDS Assessment, dated 03/10/2020. Observation of Resident #4, on 06/01/2020 at 12:13 PM, revealed the resident was leaning to the left side in bed with the bedside table over his/her lap in front of him/her. Although the meal tray was set up, the resident's eyes were closed and no staff was observed assisting/supervising the resident with the meal. However, there was no documented evidence the RD or, Physician/Provider was notified of this severe weight loss in order to implement appropriate interventions to prevent further weight loss. 4. Review of Resident #5's clinical record revealed the facility admitted the resident on 09/11/2019, with [DIAGNOSES REDACTED]. Review of Resident #5's Comprehensive Care Plan, initiated 09/11/2019, revealed a Focus of at risk for potential nutritional problem related to [MEDICAL CONDITION], Hypertension, [MEDICAL CONDITION] Ulcer, [MEDICAL CONDITION] Reflux Disease, [MEDICAL CONDITION], and Anxiety. The goal stated the resident would maintain usual body weight and skin integrity throughout review, with a target date of 07/26/2020. Interventions to be initiated: included, diet as ordered, to be initiated 09/24/2019; invite resident to activities that promote additional intake, to be initiated 09/11/2019; monitor/document/report as needed any signs or symptoms of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, appears concerned during meals, to be initiated 09/11/2019; monitor/ record/report to Physician as needed signs or symptoms of malnutrition: emaciation (cachexia), muscle wasting, significant weight loss: three (3) pounds in one (1) week, greater than 5% in one (1) month, greater than 7.5% in three (3) months, greater than 10% in six (6) months, to be initiated 09/11/2019; obtain and monitor lab/diagnostic work as ordered (CBC, Comprehensive Metabolic Panel every four (4) months), report results to Physician and follow up as indicated; provide, serve diet as ordered: monitor intake and record every meal; RD to evaluate and make diet change recommendations as needed; supplements as ordered; and weigh per facility protocol, initiated 09/11/2019. However, there was no documented evidence this Care Plan was implemented. Review of Resident #5's CCP revealed it was not implemented related to notifying the Physician of significant weight losses. Per the Weight Report, weights were not obtained from 04/06/2020 until 05/23/2020, over six (6) weeks. The weight obtained on 05/23/2020 revealed a weight of 95.2 pounds, revealing the resident experienced a severe weight loss of 13.45% in less than six (6) months as compared to the weight of 110.0 pounds on 01/20/2020. However, there was no documented evidence the RD or, Physician/Provider was notified of this severe weight loss in order to implement appropriate interventions to prevent further weight loss until 05/25/2020. Review of Resident #5's Quarterly MDS Assessment, dated 01/29/2020, revealed the facility assessed the resident as having a BIMS of thirteen (13) out of fifteen (15), indicating intact cognition. Continued review revealed the facility assessed the resident as requiring supervision and setup help with eating. Per the MDS Assessment, the resident's weight was 110.0 pounds, with no significant weight loss. 5. Review of Resident #8's clinical record revealed the facility admitted the resident on 10/22/2012, with [DIAGNOSES REDACTED]. Review of Resident #8's Annual MDS Assessment, dated 12/15/2019, revealed the facility assessed the resident as having a BIMS of five (5) out of fifteen indicating severe cognitive impairment. Further review revealed the facility assessed the resident as independent with eating with tray set up and as having a weight of 123 pounds and a height of sixty (60) inches. Per the MDS, weight loss or gain was unknown. (Refer to F-641) Review of Resident #8 Behavioral Health Discharge Summary, dated 03/06/2020, revealed the resident was admitted on [DATE], and discharged back to the facility on [DATE]. Per the Weight Report, upon re-admit on 03/06/2020, the resident weighed 104.2 pounds. Although the RD made recommendations on 03/12/2020, for Medication Pass, sixty (60) milliliters (ml) three (3) times a day, and add fortified oatmeal to breakfast, there was no documented evidence the recommendations were communicated to the Physician/Provider, and no documented evidence the resident's weights were monitored. A weight was obtained on 03/06/2020; however, there was no documented evidence of another weight obtained until 05/28/2020, over two (2) months later. However, there was no documented evidence of a Comprehensive Care Plan developed to address the resident's nutritional status. Interview with the MDS Nurse, on 06/01/2020 at 2:34 PM, revealed there was no care plan developed related to nutritional status in order to address the resident's weight loss. She stated this was an oversite on her part, as she was responsible for developing Care Plans. She further stated it was important to ensure interventions were care planned to promote weight gain or maintenance for a resident experiencing weight loss. 6. Review of Resident #7's clinical record revealed the facility admitted the resident on 02/11/2013, with [DIAGNOSES REDACTED]. Review of Resident #7's Quarterly MDS Assessment, dated 03/26/2020, revealed the facility assessed the resident as having a BIMS of fifteen (15) out of fifteen (15) indicating intact cognition. Further, the facility assessed the resident as being independent with eating and only requiring set up help. The resident was assessed to have a weight of 173.0 pounds and to have had a weight gain of 5% in the last month or gain of 10% in the past six (6) months. Review of Resident #7's Comprehensive Care Plan, initiated 04/02/2020, revealed a Focus for at risk for alteration in nutritional status related to: consumption of excessive portions of food, disordered eating patterns, excessive consumption of high calorie-high fat food, obese with Body Mass Index greater than thirty (30), physical inactivity-sedentary. The goal stated the resident would have a gradual weight loss one (1) to two (2) pounds per month through review date, with no target date included. Interventions, dated 04/02/2020 included: continue to monitor food and fluids for appropriate texture and consistency; diet as ordered; educate family on risk of bringing in foods not allowed on diet; monitor intake after each meal and record; obtain and monitor labs as ordered; reassess as needed to help ensure adequate nutritional needs are being met daily; set up each meal tray, assist as needed, and weigh each month and as needed as clinically indicate and monitor for significant weight changes. However, there was no documented evidence this Care Plan was implemented. Record review revealed there was no documented evidence the CCP was implemented related to monitor for significant weight changes. Review of Resident #7's Weight Report, revealed a weight of 174.0 pounds on 01/20/2020 and a weight of 165.0 pounds on 02/05/2020, revealing a severe weight loss of 5.17% in less than one (1) month. However, weights were not monitored as per the CCP, as there was no documented evidence the resident's weight loss was addressed until 03/17/2020, when Ensure and Juven was ordered related to low protein levels and the resident was diagnosed with [REDACTED]. 7. Review of Resident #11's clinical record revealed the facility admitted the resident on 07/27/2016, with [DIAGNOSES REDACTED]. Review of Resident #11's Annual MDS Assessment, dated 02/19/2020, revealed the resident was assessed as having a BIMS of ten (10) out of fifteen (15) indicating moderate cognitive impairment. Continued review revealed the resident was assessed as requiring supervision and tray set up with meals. According to the MDS Assessment, the resident weighed 195.0 pounds and had no known weight loss. Review of Resident #11's Comprehensive Care Plan, initiated 02/29/2020, revealed a Focus of risk for alteration in nutritional status related to Depression; [MEDICAL CONDITION]; weight loss noted; fair appetite, and requires staff assistance at times with meals. The goal revealed the resident will have no significant unplanned weight change by the next review date with a target date of 07/26/2020. The interventions, dated 02/29/2020 included continue to monitor food and fluids for appropriate texture and consistency; diet as ordered; educate family on bringing in foods not allowed on diet; monitor intake after each meal and record, and obtain and monitor labs as ordered; reassess as needed to help ensure nutritional needs are being met daily; set up meal tray and assist as needed; and weigh every month and as needed as clinically indicated and monitor for significant weight changes. Further review revealed there was no documented evidence this Care Plan was person centered and individualized or implemented. Review of Resident #11's CCP revealed it was not developed or implemented related to notification to RD and Physician/Provider of significant weight loss. Review of Resident #11's Order Summary Report, revealed active orders, dated 03/02/2020, to weigh the resident weekly x four (4) weeks and then monthly thereafter. A weight was obtained on 03/06/2020 at 184.0 pounds, which was a severe weight loss of 5.6% in one (1) month compared to the resident's weight of 195.0 pounds on 02/06/2020. However, there was no documented evidence the RD or Physician/Provider was notified. On 04/27/2020, over two (2) months later, the RD made recommendations for Med Pass sixty (60) milliliters three (3) times a day to help stabilize weight related to this weight loss. Record review revealed there was no documented evidence the CCP was implemented related to weight every month and as clinically indicated. physician's orders [REDACTED]. However, after the weight was obtained on 03/06/2020, there was no weight recorded until 06/01/2020, almost three (3) months later. In addition, the resident's CCP was not implemented related to monitoring intake after each meal and recording. Resident #11's Meal Intake Reports, dated February 2020 and March 2020, revealed missing meal intakes documentation. Interview with the MDS Nurse, on 06/01/2020 at 2:34 PM, revealed she attended the Morning Meetings where any changes in residents' condition was discussed and developed the Care Plans. Per interview, she had not identified the CCPs were not developed with pertinent interventions such as ensuring weights were obtained as per policy and as ordered, ensuring meal intakes were monitored and recorded and ensuring the RD and Physician were he residents had actual significant or severe weight loss, or dehydration. Further, she should have ensured the CCP reflected the residents' status and there were appropriate interventions related to be implemented related to nutrition/hydration. Interview with the DON and the Administrator on 06/04/2020 at 4:07 PM, revealed person-centered care plan Care Plans related to nutrition/hydration should be developed for residents who were nutritionally at risk to ensure weight loss did not occur and weight was maintained. Further, CCPs should be developed related to obtaining weights as per policy and as per orders, monitoring intake, and notification to the RD and the Physician of significant weight loss or signs of dehydration. Continued interview revealed the CCPs

Based on observation, interview, record review, review of the facility's Policy, and review of the Centers for Medicare and Medicaid Services (CMS), Resident Assessment Instrument (RAI) Manual 3.0, it was determined the facility failed to have an effective system in place to review and revise the Comprehensive Care Plan for sixteen (16) of eighteen (18) sampled residents (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #11, #13, #14, #15, #16, #17, and #18). There was no documented evidence Comprehensive Care Plans (CCPs) were reviewed and revised to include measurable objectives and individualized interventions to meet the resident's nutrition/hydration needs resulting in significant or severe weight loss and/or dehydration. This failure affected Residents #2, #3, #4, #5, #6, #7, #9, and #11. (Refer to F-580, F-641, F-656, and F-692) Additionally, Resident #3 sustained numerous falls; however, the facility failed to review and revise the CCP with new fall interventions after these falls. On 06/13/2020, Resident #3 sustained major injury after sustaining a fall from the bed, resulting in the resident being transferred to the hospital and receiving treatment of [REDACTED]. In addition, Resident #13 and Resident 17 sustained numerous falls and sustained injuries with some falls; however, the facility failed to revise the CCPs to include new fall interventions to prevent further falls of the same nature. Moreover, Resident #3's physician's orders [REDACTED]. Use lap tray for activities, and remove at mealtime every shift; however, there was no documented evidence the CCP was revised to include restraint use of the lap tray. (Refer to F-689) Furthermore, Resident #14's physician's orders [REDACTED].#15's Physician order [REDACTED]. However, neither resident's CCPs were revised to include interventions as per facility policy related to checking and releasing the restraints. (Refer to F-604) In addition, there was no documented evidence the CCPs were revised related to ensuring Side Rail Assessments were completed and interventions were in place for monitoring and supervising side rail use to prevent risk of entrapment. This affected Residents #1, #2, #3, #4, #5, #6, #7, #8, #11, #14, #15, #16, #17, and #18. (Refer to F-700 and F-656) The facility's failure to have an effective system in place to ensure Comprehensive Care Plans were reviewed and revised has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) was identified on 06/04/2020, and determined to exist on 01/06/2020. The facility provided an acceptable credible Allegation of Compliance (AoC) on 06/13/2020 alleging removal of the Immediate Jeopardy on 06/13/2020. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on 06/13/2020, prior to exit on 06/26/2020, with remaining non-compliance at a Scope and Severity of an E while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's Care Plans, Comprehensive Person-Centered Policy, dated December 2016, revealed it is the facility's policy to ensure the comprehensive, person-centered care plan includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Further review of the Policy, revealed the comprehensive, person-centered care plan will aid in preventing or reducing decline in the resident's functional status and/or functional levels and reflect currently recognized standards of practice for problem areas and conditions. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. The interdisciplinary Team must review and update the care plan: when there has been a significant change in the resident's condition; when the desired outcome is not met; when the resident has been readmitted to the facility from a hospital stay; and at least quarterly, in conjunction with the required Quarterly MDS Assessment. Review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, dated October 2016, revealed the care plan must be reviewed and revised periodically, and the services provided or arranged should be consistent with each resident's written plan of care. Continued review of the Manual, revealed the care plan was driven not only by identified resident issues and/or conditions, but also by a resident's unique characteristics, strengths, and needs. Furthermore, a care plan based on a thorough assessment and effective clinical decision making, was compatible with current standards of clinical practice that provide a strong basis for optimal approaches to quality of care and quality of life needs of individual residents. A well developed and executed assessment and care plan: re-evaluates the resident's status at prescribed intervals (quarterly, annually, or if a significant change in status occurs) using the RAI and then modifies the individualized care plan as appropriate and necessary. 1. Review of Resident #9's clinical record revealed the facility admitted the resident on 04/20/2020 with [DIAGNOSES REDACTED]. Review of Resident #9's CCP, which was initiated on 04/20/2020, revealed a Focus of at risk for alteration in nutritional status related to [MEDICAL CONDITION] and Poor Appetite. The goal stated the resident would have no unplanned weight change by next review, with a target date of 08/01/2020. Interventions, dated 04/20/2020 included: monitor food and fluids for appropriate texture and consistency; diet as ordered; educate family on risks of bringing in foods not allowed on diet; monitor intake after each meal and record; obtain and monitor labs as ordered; reassess as needed to help ensure adequate nutritional needs are being met daily; supplements as ordered, dated 04/30/2020; and weight every month and as needed as clinically indicated and monitor for significant weight changes. Additional review of Resident #9's Comprehensive Care Plan, with an initiation date of 04/20/2020, revealed a Focus of potential for alteration in hydration related to poor intake. The goal revealed the resident would remain free of signs and symptoms of fluid deficit: decreased urine output, poor skin turgor, dry mucous membranes, confusion, [MEDICAL CONDITIONS] headache, fatigue/weakness, dizziness, fever, thirst, and weight loss with a target date of 08/01/2020. Interventions, dated 04/20/2020 included notify Physician of significant signs and symptoms of fluid excess or fluid deficit; observe appearance of mucous membranes and skin turgor; observe for mental status changes/mood behavior changes; and obtain and monitor lab/diagnostic work per physician's orders [REDACTED]. Review of the Admission MDS Assessment, dated 04/24/2020, revealed the facility assessed the resident as having a BIMS of fifteen (15) out of fifteen (15) revealing intact cognition. Additional review revealed the facility assessed the resident as requiring supervision and one (1) person physical assistance with eating. According to the MDS Assessment, Resident #9 had a weight of 109.0 pounds and a height of sixty-one (61) inches. Further review revealed the resident was assessed as not receiving a therapeutic diet, having no weight loss, and having no signs of swallowing problems. Per the Nurse's Note, dated 05/15/2020 at 10:00 AM, the resident had a change in behavior and the Provider was notified. Labs were ordered and the resident was diagnosed with [REDACTED]. However, there was no documented evidence the CCP was revised related to actual dehydration or interventions for IV fluids. Further the CCP was not revised to indicate the resident was receiving [MEDICATION NAME] for appetite stimulant. In addition, review of the Urinalysis results, dated 05/15/2020, revealed the resident had a urinary tract infection [MEDICAL CONDITION]. Although physician's orders [REDACTED]. According to the Weight Report, Resident #9 weighed 109.0 pounds upon admission 04/20/2020. According to the Weight Report, the resident's weight on 05/27/2020, was 90.0 pounds, revealing a weight loss of nineteen (19) pounds in one (1) month, indicating a 17.4% severe weight loss in five (5) weeks. However, there was no documented evidence the CCP was revised to indicate the resident's actual weight loss, nor was the CCP revised with further interventions to promote weight gain or weight maintenance. 2. Review of Resident #2's clinical record revealed the facility admitted the resident on 11/13/2019, with [DIAGNOSES REDACTED]. Review of Resident #2's Quarterly Minimum Data Set (MDS) Assessment, dated 01/09/2020, revealed the facility assessed the resident to have a Brief Interview for Mental Status score (BIMS) of four (4) out of fifteen (15) indicating severe cognitive impairment. Further review revealed the facility assessed the resident as requiring supervision such as cueing and setup help with eating. Resident #2 was also assessed as weighing 114.0 pounds and as not having a weight loss of 5% weight loss or more in the last month or loss of 10% or more in the last six (6) months. Review of Resident #2's Comprehensive Care Plan (CCP), which was initiated 11/13/19, revealed a Focus of nutritional problem related to history of malnutrition and Vitamin D deficiency, Dysphagia, and receives a mechanically altered diet order. The goal stated the resident would have a gradual weight gain within 10% of Ideal Body Weight for sex and height by review date, of 07/21/2020. Interventions included administer medications as ordered and monitor and document for side effects and effectiveness dated 11/13/19; administer nutritional supplements per physician's orders [REDACTED].) month, greater than 7.5% in three (3) months, and greater than 10% in six (6) months; obtain and monitor lab/diagnostic work as ordered and report results to Physician and follow up as indicated; provide and serve supplements as ordered; provide, serve diet as ordered; monitor intake and record each meal; Registered Dietician to evaluate and make diet change recommendations as needed; and, weight weekly per orders initiated 03/17/2020. Review of Resident #2's Weight Report revealed a weight of 114.0 pounds on 12/21/2019 and a weight of 103.0 pounds on 01/06/2020, revealing a severe weight loss of 9.65 percent (%) in less than one (1) month. However, Resident #2's CCP was not revised to indicate the resident experienced actual weight loss, nor was the CCP revised with additional interventions to promote weight gain or weight maintenance. Further review of the Weight Report, revealed the resident weighed 103.0 pounds on 03/18/2020 and weighed 98.5 pounds on 03/25/2020, revealing a 4.7% weight loss in seven (7) days. However, there was no no documented evidence the CCP was revised related to this actual weight loss, nor was the CCP revised with interventions to promote weight gain or weight maintenance. 3. Review of Resident #4's clinical record revealed the facility admitted the resident on 03/02/2020, with [DIAGNOSES REDACTED]. Review of Resident #4's Comprehensive Care Plan, which was initiated on 03/02/2020, revealed a Focus of risk for alteration in nutritional status related to Body Mass Index and nutritional approach. The goal with a target date of 06/19/2020, revealed the resident would have no significant weight change by next review. Review of the Admission MDS Assessment, dated 03/10/2020, revealed the facility assessed the resident as having a BIMS score of (8) out of fifteen (15), indicating moderate cognitive impairment. Record review revealed Resident #4 weighed 142.3 pounds on 04/05/2020 and was not weighed again until 05/22/2020 when the weight was obtained at 138.0 pounds. Although the weight of 138.0 pounds on 05/22/2020 revealed a severe weight loss of 8.61% in less than three (3) months, compared to the weight obtained on 03/02/2020 of 151 pounds, there was no documented evidence the CCP was revised to indicate the resident had actual weight loss, nor was the CCP revised with further interventions to promote weight gain or weight maintenance. 4. Resident #5's clinical record revealed the facility admitted the resident on 09/11/2019, with [DIAGNOSES REDACTED]. Review of the Comprehensive Care Plan, initiated 09/11/2019, revealed a Focus of at risk for potential nutritional problem related to [MEDICAL CONDITION], Hypertension, [MEDICAL CONDITION] Ulcer, [MEDICAL CONDITION] Reflux Disease, [MEDICAL CONDITION], and Anxiety. The goal revealed the resident would maintain usual body weight and skin integrity throughout review, with a target date of 07/26/2020. The interventions included, diet as ordered, initiated 09/24/2019. Further review revealed interventions, dated 09/11/2019: invite resident to activities that promote additional intake; monitor/document/report as needed any signs or symptoms of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, appears concerned during meals; monitor/ record/report to Physician as needed signs or symptoms of malnutrition: emaciation (cachexia), muscle wasting, significant weight loss: three (3) pounds in one (1) week, greater than 5% in one (1) month, greater than 7.5% in three (3) months, greater than 10% in six (6) months; obtain and monitor lab/diagnostic work as ordered (CBC, Comprehensive Metabolic Panel every four (4) months), report results to Physician and follow up as indicated; provide, serve diet as ordered: monitor intake and record every meal; RD to evaluate and make diet change recommendations as needed; supplements as ordered, and weigh per facility protocol. Review of the Quarterly MDS Assessment, dated 01/29/2020, revealed the facility assessed Resident #5 as having a BIMS of thirteen (13) out of fifteen (15), indicating intact cognition. Additional review revealed the facility assessed the resident as requiring supervision and setup help with eating. According to the MDS Assessment, the resident's weight was 110.0 pounds, with no significant weight loss. Per Resident #5's Weight Report, weights were not obtained from 04/06/2020 until 05/23/2020, over six (6) weeks. The weight obtained on 05/23/2020 of 95.2 pounds, revealed the resident experienced a severe weight loss of 13.45% in less than six (6) months as compared to the weight of 110.0 pounds on 01/20/2020. However, there was no documented evidence the CCP was revised to indicate the resident experienced actual weight loss, nor was the CCP revised with further interventions to promote weight gain or weight maintenance. 5. Review of Resident #6's clinical record revealed the facility admitted the resident on 05/14/2012, with [DIAGNOSES REDACTED]. Review of Resident #6's Quarterly MDS Assessment, dated 01/24/2020, revealed the resident was assessed as having a BIMS of eleven (11) out of fifteen (15) indicating moderate cognitive impairment. Resident #6 was assessed as only requiring supervision and tray set up with meals. Per the MDS Assessment, the resident weighed 163.0 pounds and had no known weight loss. According to Resident #6's Weight Report, the resident weighed 163.0 pounds on 12/17/2019 and weighed 150.0 pounds on 02/06/2020, revealing a severe weight loss of 7.9% in less than two (2) months; however, there was no documented evidence the resident's CCP was revised to address the resident's nutrition status and actual weight loss. Review of physician's orders [REDACTED]. The weight on 03/06/2020 of 143.0 pounds revealed the resident experienced a severe weight loss of 10.06% in less than three (3) months compared to the weight of 159.0 pounds on 01/06/2020; and a 12.27% severe weight loss compared to the weight of 163.0 pounds on 12/17/2019. However, there was no documented evidence the resident's CCP was revised to indicate these severe weight losses nor revised with interventions to promote weight gain or weight maintenance. Furthermore, there was no documented evidence the CCP was revised to indicate a Focus related to nutritional status until 04/18/ . Review of the Comprehensive Care Plan, initiated 04/18/2020, revealed a Focus of risk for alteration in nutritional status related to an eating pattern disorder, [MEDICAL CONDITION], and physical inactivity-sedentary; and receives a therapeutic diet. The goal, with a target date of 07/09/2020, revealed the resident would have no significant unplanned weight change by next review. The interventions, dated 04/18/2020 included: continue to monitor food and fluids for appropriate texture and consistency; diet as ordered; educate family on risk of bringing in food not allowed on diet; monitor intake after each meal and record; obtain and monitor labs as ordered; reassess as needed to help ensure adequate nutritional needs are being met daily; set up each meal tray, assist as needed; supplements as ordered; and weigh every month and as clinically indicated, and monitor for significant weight changes. However, the CCP was not revised to indicate the resident had sustained actual weight loss nor did the CCP include the RD recommendation dated 02/07/2020. 6. Review of Resident #7's clinical record revealed the facility admitted the resident on 02/11/2013, with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated 03/26/2020, revealed the facility assessed the resident as having a BIMS of fifteen (15) out of fifteen (15) indicating intact cognition. Further, the facility assessed Resident #7 as being independent with eating and only requiring set up help. In addition, the resident was assessed to have a weight of 173.0 pounds and to have had a weight gain of 5% in the last month or gain of 10% in the past six (6) months. According to Resident #7's Weight Report, the resident weighed 174.0 pounds on 01/20/2020 and 165.0 pounds on 02/05/2020, revealing a severe weight loss of 5.17% in less than one (1) month. However, there was no documented evidence the CCP was revised to include a focus related to nutritional status until 04/02/2020. Review of the Comprehensive Care Plan, initiated 04/02/2020, revealed a Focus for at risk for alteration in nutritional status related to: consumption of excessive portions of food, disordered eating patterns, excessive consumption of high calorie-high fat food, obese with Body Mass Index greater than thirty (30), physical inactivity-sedentary. The goal revealed the resident would have a gradual weight loss of one (1) to two (2) pounds per month through the review date, with no target date included. The interventions, dated 04/02/2020 included, continue to monitor food and fluids for appropriate texture and consistency; diet as ordered; educate family on risk of bringing in foods not allowed on diet; monitor intake after each meal and record; obtain and monitor labs as ordered; reassess as needed to help ensure adequate nutritional needs are being met daily; set up each meal tray, assist as needed, and weigh each month and as needed as clinically indicated and monitor for significant weight changes. Continued review of Resident #7's Weight Report, revealed the resident weighed 174.0 pounds on 04/07/2020, and weighed 162.3 pounds on 05/22/2020, revealing a weight loss of 11.7 pounds (6.9%) in less than two (2) months. However, there was no documented evidence the CCP was revised to indicate the resident experienced severe weight loss or revised with further interventions to promote weight gain or weight maintenance. 7. Review of Resident #11's clinical record revealed the facility admitted the resident on 07/27/2016, with [DIAGNOSES REDACTED]. Review of the Annual MDS Assessment, dated 02/19/2020, revealed the facility assessed Resident #11 as having a BIMS of ten (10) out of fifteen (15) indicating moderate cognitive impairment. Additional review revealed the resident was assessed as requiring supervision and tray set up with meals. According to the MDS Assessment, Resident #11 weighed 195.0 pounds and had no known weight loss. Review of the Comprehensive Care Plan, initiated 02/29/2020, revealed a Focus of risk for alteration in nutritional status related to Depression; [MEDICAL CONDITION]; weight loss noted; fair appetite, and requires staff assistance at times with meals. The goal revealed the resident will have no significant unplanned weight change by the next review date with a target date of 07/26/2020. The interventions, dated 02/29/2020 included: continue to monitor food and fluids for appropriate texture and consistency; diet as ordered; educate family on bringing in foods not allowed on diet; monitor intake after each meal and record, and obtain and monitor labs as ordered; assess as needed to help ensure nutritional needs are being met daily; set up meal tray and assist as needed; and weigh every month and as needed, as clinically indicated and monitor for significant weight changes. Review of Resident #11's Order Summary Report, revealed active orders, dated 03/02/2020, to weigh the resident weekly x four (4) weeks and then monthly thereafter. However, there was no documented evidence the CCP was revised related to this physician's orders [REDACTED].>Record review revealed a weight was obtained on 03/06/2020 at 184.0 pounds, which was a severe weight loss of 5.6% in one (1) month compared to the resident's weight of 195.0 pounds on 02/06/2020. However, there was no documented evidence the CCP was revised related to this actual weight loss nor was the CCP revised with additional interventions to promote weight gain or weight maintenance. Record review revealed on 04/27/2020, over two (2) months later, the RD made recommendations for Med Pass sixty (60) milliliters three (3) times a day to help stabilize the resident's weight. However, there was no documented evidence the CCP was revised with this intervention. 8. Review of Resident #3's clinical record revealed the facility admitted the resident on 05/28/2019, and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated 03/16/2020, revealed the facility assessed Resident #3 as having a BIMS of zero (00) indicating severe cognitive impairment. Further, the resident was assessed as requiring supervision and setup help with eating. According to the MDS Assessment, the resident's current weight was 132.0 pounds and the resident had a weight loss of 5% or more in the last month or a loss of 10% or more in the last 6 (six) months. Review of Resident #3's Weight Report, revealed a weight of 142.0 pounds on 02/05/2020 and a weight of 135.0 pounds on 03/16/2020, revealing a weight loss of 4.9% in approximately five (5) weeks. Review of the RD Quarterly Nutrition Note, dated 03/16/2020, revealed the resident had a weight loss of 7% in one (1) month and 8% in three (3) months and recommendations were made for Magic Cup at each meal and at night, and to add the resident to the NAR list. However, there was no documented evidence the CCP was revised related to the significant weight loss, the recommendation to add the resident to the NAR list, or any interventions to promote weight gain or weight maintenance. Furthermore, additional review revealed the resident's Comprehensive Care Plan was not revised to address nutrition until 03/23/2020. Review of the CCP, initiated 03/23/2020, revealed a Focus of at risk for alteration in nutritional status related to Depression, and disordered eating pattern; receives a mechanically altered diet; low protein levels; refuses meals; inattention and restlessness; oral intake fluctuates, and noted weight loss. The goal with a target date of 06/14/2020, stated the resident would have no significant unplanned weight change by next review. The interventions, dated 03/23/2020 included: continue to monitor food and fluids for appropriate texture and consistency; diet as ordered; educate family on bringing in foods not allowed on diet; monitor intake after each meal and record; and obtain and monitor labs as ordered. Interview with the MDS Nurse, on 06/01/2020 at 2:34 PM, revealed she attended the Morning Meetings where any changes in residents' condition was discussed and she revised care plan during the meetings. Per interview, she was responsible for updating the CCP, but until the Survey she had not identified the CCPs were not revised to indicate that the residents had actual significant or severe weight loss, or dehydration. Further, she should have ensured the CCPs reflected the residents' status and ensured there were appropriate interventions related to nutrition/hydration. Interview with the DON and the Administrator, on 06/04/2020 at 4:07 PM, revealed the CCP was a guide staff used as a reference for providing care and should be revised ongoing with new information related to any significant changes in the resident's status including nutritional concerns such as weight loss, or dehydration. Further, if a resident was diagnosed and treated for [REDACTED]. Per interview, during the Morning Meetings the Interdisciplinary Team met to address any changes in residents' status. Further, the residents' CCP should have been revised to indicate actual weight loss had occurred and revised to include further interventions to prevent weight loss and maintain residents' weight in a timely manner. Review of the Falls and Fall Risk, Managing, Policy, revised March 2018, revealed if falling recurs despite initial interventions, staff will implement additional or different interventions or indicate why the current approach remains relevant. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. 9. Review of Resident #3's clinical record revealed the facility originally admitted the resident on 05/28/2019 and readmitted the resident on 12/10/2019, with [DIAGNOSES REDACTED]. Review of Resident #3's Order Summary Report, revealed an order with a start date of 12/10/2019 for sensatec alarm to bed and wheelchair, rear anti-tip bars to wheelchair, and tall Incredlback (a [MEDICATION NAME] center section allows precise contours for any spinal curvature, which offers increased support and comfort) to wheelchair. However, there was no documented evidence the CCP was revised to include these interventions. Review of Resident #3's Quarterly Minimum Data Set (MDS) Assessment, dated 12/16/2019, revealed the facility assessed the resident as having both short term and long term memory loss and as rarely understood, and there was no BIMS conducted. Further review revealed the facility assessed the resident as requiring extensive assistance of one (1) person with bed mobility and transfers. Continued review revealed the resident had not sustained a fall prior to this MDS Assessment. A. Review of Resident #3's Progress Note and Fall Tracking Log, dated 01/31/2020 at 7:55 PM, revealed the resident was found on the floor in another resident's room, lying on his/her stomach and the fall was not witnessed. Review of the Morning Meeting minutes, dated 02/04/2020, revealed Resident #3 fell on [DATE] and the suggested intervention was to put the resident's name or picture by his/her door. However, there was no documented evidence the CCP was revised to reflect the fall that occurred on 01/31/2020, or revised with any fall interventions including the intervention related to placing the resident's name or picture by his/her door. B. Review of Resident 3's Progress Note and Fall Tracking Log, dated 03/07/2020 at 5:40 AM, revealed the A wing nurse reported to the resident's nurse that the resident was seen walking at the end of the hallway, attempted to sit back in the wheelchair, and fell to the floor. Review of the Morning Meeting minutes, dated 03/09/2020, revealed Resident #3 fell on [DATE], and the suggested intervention was to consider rear anti-tip or anti-roll back to wheelchair; however, this was already an active order for the resident at that time. Further, there was no documented evidence the CCP was reviewed and revised with new interventions after this fall to prevent further falls of the same nature. C. Review of Resident #3's Progress Note and Fall Tracking Log, dated 03/11/2020 at 7:33 PM, revealed the resident was found in his/her room lying on the floor on his/her right side. Further review revealed a skin tear and bleeding to top of right arm measuring 4.0 centimeter (cm) by 2.75 cm and bruising to the right elbow was noted. Continued review revealed Resident #3 removed the lap buddy from his/her wheelchair. However, there was no documented evidence the facility reviewed and revised the CCP with interventions to prevent further falls of the same nature. Review of Resident #3's Quarterly MDS assessment, dated 03/16/2020, revealed the facility assessed the resident as having both short term and long term memory loss, and there was no BIMS conducted. Further, the facility assessed the resident to require extensive physical assistance of two (2) persons with bed mobility and transfers. Continued review revealed the resident sustained [REDACTED]. Continued review revealed the resident required two (2) person physical assistance with bathing. Further record review revealed, although the resident sustained [REDACTED]. In addition, there was no documented evidence the CCP was revised with interventions to prevent further falls of the same nature until 03/23/2020. Review of Resident #3's CCP initiated 0

Based on observation, interview, record review, and review of facility Policies, it was determined the facility failed to have an effective system to ensure each resident maintains acceptable parameters of nutritional and hydration status unless the resident's clinical condition demonstrates this is not possible for nine (9) of eighteen (18) sampled residents (Residents #2, #3, #4, #5, #6, #7, #8, #9, and #11). Resident #9 was admitted to the facility on [DATE], and was assessed to be at nutritional risk. However, there was no documented evidence the resident's fluids were monitored. Per the Fluid Intake Report, the resident did not meet his/her fluid requirements of 1250-1500 milliliters of fluid per day from 04/20/2020 through 05/15/2020. On 05/15/2020, the resident had a change in behavior and laboratory values were obtained which revealed the resident's Blood Urea Nitrogen (BUN) level was 67 High (reference range 7-18) indicating dehydration, and intravenous (IV) fluids were ordered. In addition, the facility failed to follow its policy related to weights weekly x four (4) weeks for new admissions, as there was no documented evidence the resident was weighed from admission on 04/20/2020 until 05/27/2020, which was over a month later. Per the Weight Report, the resident experienced a 17.4% severe weight loss in five (5) weeks, from 04/20/2020 until 05/27/2020. Resident #2 weighed 114.0 pounds on admission (12/21/2019). Per record review on 01/06/2020, the resident weighed 103.0 pounds, a loss of 9.65% in one month; however, there was no documented evidence the resident was reweighed per facility policy nor was the weight loss addressed by the facility. Further, on 03/16/2020, the facility's Registered Dietitian (RD) recommended the resident be placed on the Nutritionally at Risk (NAR) program and also recommended [MEDICATION NAME] (appetite stimulant medication); however, the Provider did not order the [MEDICATION NAME] and there was no documented evidence the resident was assessed in NAR until 04/28/2020, over six (6) weeks later. In addition, weekly weights were ordered, but not consistently completed. The resident's weight on 05/27/2020 was 101.0 pounds revealing an 11.4% weight loss in six (6) months. Resident #4 was newly admitted on [DATE], and his/her weight was obtained on that date at 151.0 pounds. A weight was obtained on 03/09/2020 at 144.0, revealing a 4.64% weight loss in seven (7) days. However, there was no documented evidence of a re-weight to determine the accuracy of the weight obtained, nor interventions implemented to prevent further weight loss. Moreover, physician's orders [REDACTED]. Resident #4 was weighed on 04/05/2020 at 142.3 pounds and was not weighed again until 05/22/2020 at 138.0 pounds, which was over six (6) weeks later. The weight of 138 pounds on 05/22/2020, revealed a severe weight loss of 8.61% in less than three (3) months as compared to the weight on 03/02/2020 of 151 pounds. However, there was no documented evidence of interventions implemented to prevent further weight loss until 05/28/2020. Resident #5's Weight Report revealed weights were not obtained from 04/06/2020 until 05/23/2020, over six (6) weeks, although the resident was to receive monthly weights as per policy. The resident was weighed on 05/23/2020 at 95.2 pounds and compared with the previous weight on 04/06/2020 at 104 pounds, this was an 8.46% severe weight loss in less than three (3) months. However, there was no documented evidence of further interventions to prevent weight loss until 05/25/2020, after the State Survey Agency brought the resident's weight loss to the RD's attention. Resident #6 weighed 163.0 pounds on 12/17/2019 and 150.0 pounds on 02/06/2020, revealing a severe weight loss of 7.9% in less than two (2) months. On 02/07/2020, the RD recommended adding the resident to the NAR list so that weights could be monitored; however, there was no documented evidence the resident was added to the NAR list until 04/14/2020. physician's orders [REDACTED]. A weight was obtained on 03/06/2020 (143.0 pounds); however, there was no documented evidence of another weight obtained until 04/13/2020 (142.0) pounds, over a month later. Furthermore, there was no documented evidence of a weight from 04/13/2020 (142.0 pounds) until 05/27/2020. The 05/27/2020 weight of 134.0 pounds, revealed a severe weight loss of 17.79% in six (6) months compared to the 12/17/2019 weight of 163.0 pounds. Resident #8 weighed 104.2 pounds upon re-admission from a Behavioral Health facility on 03/06/2020. Although the RD made recommendations on 03/12/2020, there was no documented evidence the recommendations were implemented. Furthermore, there was no documented evidence weights were obtained from 03/06/2020 until a weight was requested by the Surveyor on 05/28/2020, over two (2) months later, even though weekly weights were ordered by the Physician on 03/06/2020. Resident #7's Weight Report, revealed a weight of 174.0 pounds on 01/20/2020 and a weight of 165.0 pounds on 02/05/2020, revealing a severe weight loss of 5.17% in less than one (1) month. However, there was no documented evidence of a reweight to ensure accuracy. Further review of Resident #7's Weight Report, revealed the resident weighed 174.0 pounds on 04/07/2020, and weighed 162.3 pounds on 05/22/2020, revealing a weight loss of 11.7 pounds (6.9%) in less than two (2) months; however, there was no documented evidence of a reweight to ensure accuracy. Resident #11's Order Summary Report, revealed active orders, dated 03/02/2020, to weigh the resident weekly x four (4) weeks and then monthly thereafter. A weight was obtained on 03/06/2020 at 184.0 pounds, which was a severe weight loss of 5.6% in one (1) month compared to the resident's weight of 195.0 pounds on 02/06/2020. However, there was no documented evidence of a reweight to ensure accuracy and no documented evidence of further interventions implemented until 04/30/2020, when orders were received for a nutritional supplement. Furthermore, there was no documented evidence physician's orders [REDACTED]. After the weight was obtained on 03/06/2020, there was no weight recorded until 06/01/2020, almost three (3) months later after Surveyor intervention. Resident #3 weighed 142.0 pounds on 02/05/2020 and 135.0 pounds on 03/16/2020, revealing a weight loss of 4.9% in approximately five (5) weeks. However, there was no documented evidence of a reweight to determine accuracy. Review of the RD Quarterly Nutrition Note, dated 03/16/2020, revealed the resident had weight loss of 7% in one (1) month and 8% in three (3) months and recommendations were made for Magic Cup supplement and add the resident to the NAR list. However, there was no documented evidence the resident was added to the NAR list, and no documented evidence the resident received a supplement. Refer to 42 CFR 483.10 Resident Rights, F-580; 42 CFR 483.20 Resident Assessments, F-641; 42 CFR 483.21 Comprehensive Resident Centered Care Plans, F-656 and F-657; 42 CFR 483.35 Nursing Services, F-725; 42 CFR 483.70, F-835; and 42 CFR 483.75 Quality Assurance and Performance Improvement, F-865. The facility's failure to have an effective system in place to ensure residents maintain acceptable parameters of nutritional status and hydration status caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) was identified on 06/04/2020, and determined to exist on 01/06/2020. The facility provided an acceptable credible Allegation of Compliance (AoC) on 06/13/2020 alleging removal of the Immediate Jeopardy on 06/13/2020. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on 06/13/2020, prior to exit on 06/26/2020, with remaining non-compliance at a Scope and Severity of an E while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's Nutrition (Impaired)/Unplanned Weight Loss - Clinical Protocol Policy, revised September 2017, revealed staff will monitor and document the weight and dietary intake of residents in a format which permits comparisons over time. Continued review revealed staff will report to the Physician significant weight gains or losses or any abrupt or persistence change from baseline appetite or food intake. The Physician will review for medical causes of weight gains or losses before ordering interventions. For individuals with rapid weight gains or losses, staff will review for possible fluid and electrolyte imbalance as a cause and the Physician will identify medical conditions and medications that may be causing weight gain or loss. Staff and the Physician will identify pertinent interventions based on identified causes and overall condition, prognosis, and wishes. Staff and the Physician will review and consider existing dietary restrictions and modified consistency diets. Further review revealed Staff and the Physician will monitor nutritional status, and individual's response to interventions. Review of the facility's Nutritional Assessment Policy, revised October 2017, revealed as part of the comprehensive assessment, a nutritional assessment, including current nutritional status and risk factors for impaired nutrition, shall be conducted for each resident. Review of the facility's Weight Assessment and Intervention Policy, revised December 2019, revealed the multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents. Continued review under the Section titled, Implementation of Weight Assessment, revealed the nursing staff will measure the resident's weight upon admission, the next day, and weekly for four (4) weeks thereafter. Any weight change of five percent (5%) or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will notify the Dietician by receipt of the resident's weights. The Dietician will review the Weight Record by the 15th of the month to follow individual weight trends over time. Negative trends will be evaluated by the treatment team whether or not the criteria for significant weight change has been met. Review of the facility's Hydration-Clinical Protocol, revised 09/2017, revealed the Physician and staff will help define the individual's current hydration status (fluid and electrolyte balance or imbalances). Staff will identify and report to the Physician individuals with signs and symptoms or lab test results that might reflect existing fluid and electrolyte imbalance. The Physician and staff will identify significant risk for subsequent fluid and electrolyte imbalance such as residents who are not eating or drinking well. 1. Review of Resident #9's medical record revealed the facility admitted the resident on 04/20/2020 with [DIAGNOSES REDACTED]. Review of Resident #9's History and Physical from the transferring Hospital, revealed the resident was admitted to the hospital on [DATE] and his/her weight on that date was 102.4 pounds. Review of the Hospital labs, dated 04/16/2020 at 1:40 PM, revealed a Blood Urea Nitrogen (BUN) lab value of 44 (reference range 10-20 mg/deciliter (dL), (The BUN test measures the level of nitrogen in the blood to assess the functions of the kidneys and liver); Creatinine of 1.8 (reference range of 0.5 to 1.1 mg/dL) (A creatinine blood test measures kidney function); Total Protein of 6.7 (reference range of 6 to 9 grams per dL) [MEDICATION NAME] 4.5 (reference range of 3.5-5.4 g/dL), and [MEDICATION NAME] of 2.2 (reference range of 2.0 to 3.5 grams/dL). Per the Discharge Summary, dated 04/20/2020, the resident was discharged to the facility on [DATE]. Review of Resident #9's Comprehensive Care Plan (CCP), initiated 04/20/2020, revealed a Focus of risk for alteration in nutritional status related to [MEDICAL CONDITION] and Poor Appetite. The goal stated the resident will have no unplanned weight change by next review, with a target date of 08/01/2020. Interventions, initiated on 04/20/2020, included monitor food and fluids for appropriate texture and consistency; diet as ordered; educate family on risks of bringing in foods not allowed on diet; monitor intake after each meal and record; obtain and monitor labs as ordered; reassess as needed to help ensure adequate nutritional needs are being met daily; and weight every month and as needed as clinically indicated and monitor for significant weight changes, initiated 04/20/2020; and supplements as ordered, initiated 04/30/2020. Continued review of Resident #9's Comprehensive Care Plan, with an initiation date of 04/20/2020, revealed a Focus of the potential for alteration in hydration related to poor intake. The goal stated the resident will remain free of signs and symptoms of fluid deficit: decreased urine output, poor skin turgor, dry mucous membranes, confusion, [MEDICAL CONDITIONS] headache, fatigue/weakness, dizziness, fever, thirst, and weight loss with a target date of 08/01/2020. Interventions included: notify physician of significant signs and symptoms of fluid excess or fluid deficit; observe appearance of mucous membranes and skin turgor; observe for mental status changes/mood behavior changes; and, obtain and monitor lab/diagnostic work per physician's orders [REDACTED]. Review of the Order Summary Report, revealed orders for a regular diet with fortified oatmeal and active orders to weigh the resident per facility protocol with a start date of 04/20/2020. Review of Resident #9's Weight Report, revealed the resident was a new admission and his/her weight on 04/20/2020 was 109.0 pounds. Review of Resident #9's Admission Minimum Data Set (MDS) Assessment, dated 04/24/2020, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15) indicating intact cognition. Further review revealed the facility assessed the resident as requiring supervision and one (1) person physical assistance with eating. Per the MDS Assessment, Resident #9 had a weight of 109.0 pounds and a height of sixty-one (61) inches. Further, the resident was assessed as not receiving a therapeutic diet, having no weight loss, and having no signs of swallowing problems. Review of Resident #9's Meal Intake Report, dated 04/20/2020 - 04/30/2020, revealed the resident refused a total of five (5) meals; consumed 0-25% of six (6) meals; consumed 26-50% of seven (7) meals; consumed 51-75% of five (5) meals; and consumed 76-100% of six (6) meals. Review of Resident #9's Admission Nutrition Assessment, dated 04/27/2020, completed by the RD, revealed the resident weighed 109.0 pounds, received a regular diet, and had the potential to be at nutritional risk related to recent fracture and a history of anorexia. Per the Assessment, the resident was independent with eating after tray set up. The RD recommended to add fortified oatmeal, offer snacks as needed, Magic Cup at lunch and dinner, and Med Pass 60 mls twice a day. Further review revealed the resident's estimated fluid requirement was 1250-1500 milliliters per day. Review of the Order Summary Report, revealed active orders with a start date of 04/30/2020 for High Calorie sixty (60) milliliters nutritional supplement twice a day and Magic Cup twice a day for nutritional supplement with lunch and dinner. Review of Resident #9's Meal Intake Report, dated May 2020, revealed the resident refused a total of twenty (20) meals; consumed 0-25% of thirty-five (35) meals; consumed 26-50% of twenty (20) meals; consumed 51-75% of six (6) meals; and consumed 76-100% of eight (8) meals. However, there was no meal intake recorded for breakfast on 05/26/2020; and no meal intake recorded for lunch on 05/03/2020 and 05/26/2020. Review of the Fluid Intake Report, revealed the resident did not meet his/her fluid requirements of 1250-1500 milliliters of fluid a day from 04/20/2020 to 05/15/2020. On 04/20/2020, the resident consumed 180 milliliters of fluid; 04/21/2020, the resident consumed 600 milliliters of fluid; 04/22/2020, the resident consumed 480 milliliters of fluid; 04/23/2020, the resident consumed 600 milliliters of fluid; 04/24/2020, the resident consumed 840 milliliters of fluid; 04/25/2020, the resident consumed 960 milliliters of fluid; 04/26/2020, the resident consumed 740 milliliters of fluid; 04/27/2020, the resident consumed 720 milliliters of fluid; 04/28/2020, the resident consumed 1200 milliliters of fluid; 04/29/2020, the resident consumed 360 milliliters of fluid; 04/30/2020, the resident consumed 480 milliliters of fluid; 05/01/2020, the resident consumed 480 milliliters of fluid; 05/02/2020, the resident consumed 600 milliliters of fluid; 05/03/2020, the resident consumed 120 milliliters of fluid; 05/04/2020, the resident consumed 720 milliliters of fluid; 05/05/2020, the resident consumed 840 milliliters of fluid; 05/06/2020, the resident consumed 600 milliliters of fluid; 05/07/2020, the resident consumed 580 milliliters of fluid; 05/08/2020, the resident consumed 720 milliliters of fluid; 05/09/2020, the resident consumed 480 milliliters of fluid; 05/10/2020, the resident consumed 300 milliliters of fluid; 05/11/2020, the resident consumed 120 milliliters of fluid; 05/12/2020, the resident consumed 720 milliliters of fluid; 05/13/2020, the resident consumed 360 milliliters of fluid; 05/14/2020, the resident consumed 360 milliliters of fluid, and 05/15/2020, the resident consumed 380 milliliters of fluid. Record review revealed there was no documented evidence the resident was placed on Intake and Output in order to closely monitor the resident's fluid intake, and no documented evidence of a hydration assessment completed. Further, there was no documented evidence the RD, or Physician/Provider, was notified of the resident's poor food and fluid intake. Review of Resident #9's Nurse's Note, dated 05/15/2020 at 10:00 AM, revealed, Resident sitting in hallway, yelling out at staff to lay him/her in bed. Spoke with resident regarding change in behavior and family requested a urine or blood work to be drawn. Nurse Practitioner ordered a Complete Blood Count (CBC), a Complete Metabolic Panel (CMP), and a urinalysis (UA). Review of the CBC dated 05/15/2020, revealed Red Blood Cell count of 3.6 (L) (reference range 4.2-6.4); a Hemoglobin level of 10.7 (L) (reference range 12.5-16.0); and Hematocrit of 33.7 (L) (reference range 37.0-47.0). Review of Resident #9's Laboratory Report, dated 05/15/2020 at 3:37 PM, revealed: Blood Urea Nitrogen (BUN) level was 67 High (reference range 7-18, indicating dehydration). Continued review revealed an unsigned notation on the Report, stating, APRN ordered Intravenous (IV) fluids for forty-eight (48) hours of Normal Saline at seventy-five (75) milliliters per hour, continue to push fluids, [MEDICATION NAME] fifteen (15) milligrams at bedtime for sleep and appetite. physician's orders [REDACTED]. Review of the Urinalysis results, dated 05/15/2020, revealed blood, protein, and white blood cells. Review of the Culture and Sensitivity, dated 05/18/2020, revealed the urine grew Escherichia coli (E-coli) and Pseudomonas aeruginosa. physician's orders [REDACTED]. Review of the Order Summary Report, revealed orders with a start date of 05/19/2020 for Ensure for nutritional supplement twice a day. Review of the clinical record revealed no documented evidence the facility's policy was implemented for Resident #9 related to weekly weights x four (4) weeks for new admissions. Resident #9 weighed 109.0 pounds upon admission on 04/20/2020; however, there was no documented evidence the resident was weighed again until 05/27/2020, over a month later, after Surveyor intervention. Per the Weight Report, the resident's weight on 05/27/2020, was 90.0 pounds, revealing a weight loss of nineteen (19) pounds in one (1) month, indicating a 17.4% severe weight loss in five (5) weeks. However, there was no documented evidence the RD, or Physician/Provider were notified of the weight loss. Observation of Resident #9, on 05/28/2020 at 9:55 AM, revealed the resident was in bed with the head of the bed elevated, and the resident's right hand was in a sling. Interview with the resident at the time of observation, revealed he/she fell at home and suffered a break in his/her arm. Per interview the cast had just been removed from his/her right; however, it was nearly impossible to use his/her right hand. Further observation of Resident #9, on 05/28/2020 at 12:35 PM, revealed the resident was in bed with the head of the bed elevated and the meal tray was in front of him/her on the bedside table. Resident #9 was attempting to eat with his/her left hand while his/her right hand was in the sling. Resident #9 appeared to be struggling as the tray would slide when the resident would attempt to pick up food with the fork. Interview with the resident, at the time of this observation, revealed he/she did not want help with eating, and could ask the staff if he/she truly thought he/she needed help. Interview with the RD on 06/01/2020 at 9:32 AM, revealed she was unaware of Resident #9's weight loss until the Surveyor brought the weight loss to her attention. She stated with this resident being a new admission his/her weights should have been performed weekly for the first few weeks, in order to monitor the resident for weight loss. She further stated due to the resident's fractures some weight loss could be attributed to the decrease in swelling of his/her arm; however, she highly doubted the resident lost nineteen (19) pounds due to decreased swelling. Per interview, weights should have been obtained as per policy in order for her to track the resident's weight and implement interventions to promote weight gain. Further, she should have been notified of the resident's low fluid intake, which led to dehydration. Observation of Resident #9, on 06/03/2020 at 2:39 PM, revealed the resident was weighed in the wheelchair on the wheelchair scale and the total weight of the resident and the wheelchair was 131.0 pounds. Continued observation at 2:43 PM, revealed the wheelchair weighed 38.3 pounds, indicating the resident weighed 92.7 pounds, revealing a severe weight loss of 14.86% since admission on 04/20/2020. Interview with the ARNP (Advanced Registered Nurse Practitioner), on 06/04/2020 at 10:20 AM, revealed it was her expectation Resident #9 would have lost a few pounds during the first couple of weeks in the facility related to decrease in swelling and [MEDICAL CONDITION] from his/her fractures. However, she stated she doubted if a 14.86% weight loss since admission could be from [MEDICAL CONDITION] and swelling. She stated staff should have obtained weights as per policy in order for new interventions to be placed to prevent severe weight loss. Further, she stated if staff had monitored the resident's meal consumption and informed her the resident was refusing food/fluid intake, it would have been plausible that the resident would not have required the Intravenous fluids on 05/15/2020 related to the resident being severely dehydrated. 2. Review of Resident #2's medical record revealed the facility admitted the resident on 11/13/2019, with [DIAGNOSES REDACTED]. Review of the Admission Comprehensive Nutritional Assessment, undated and unsigned, revealed the resident's admission weight on 11/13/2019 was 112.0 pounds, and the resident's Goal Weight Range was 110-120 pounds. Further, the resident was independent with tray set up and received a mechanical soft diet with thin liquids and Ensure (nutritional supplement) eight (8) ounces twice a day. Per the Assessment, the resident's average PO (by mouth) intake was 25 percent (%) to 50% and the resident was alert and able to make needs known. Review of Resident #2's Comprehensive Care Plan (CCP), initiated 11/13/19, revealed a Focus of nutritional problem related to history of malnutrition and Vitamin D deficiency, Dysphagia, and receives a mechanically altered diet order. The goal stated the resident will have a gradual weight gain to within 10% of Ideal Body Weight for sex and height by review date, of 07/21/2020. Interventions included administer medications as ordered and monitor and document for side effects and effectiveness initiated 11/13/19; administer nutritional supplements per physician's orders [REDACTED]. of three (3) pounds in one (1) week, greater than 5% in one (1) month, greater than 7.5% in three (3) months, and greater than 10% in six (6) months; obtain and monitor lab/diagnostic work as ordered and report results to physician and follow up as indicated; provide and serve supplements as ordered; provide, serve diet as ordered; monitor intake and record each meal. Registered Dietician to evaluate and make diet change recommendations as needed initiated 11/13/19; and weight weekly per orders initiated 03/17/2020. Review of Resident #2's Physician order [REDACTED]. Continued review revealed an active order with a start date of 11/19/2019 for Hi-Cal thirty (30) milliliters (ml) by mouth twice a day secondary to poor nutrition. The facility was unable to submit the December 2019 Meal Intake Report for review. Review of Resident #2's Meal Intake Report for January 2020, revealed the resident consumed 0-25% of thirteen (13) meals; consumed 26-50% of twenty-three (23) meals; consumed 51-75% of eight (8) meals; and consumed 76-100% of two (2) meals. However, there was no meal intake recorded for breakfast on 01/15/2020 and 01/19/2020; and no meal intake recorded for lunch on 01/15/2020, 01/19/2020, and 01/29/2020. Review of Resident #2's Weight Summary, revealed a weight of 114.0 pounds on 12/21/2019, and a weight of 103.0 pounds on 01/06/2020, indicating a severe weight loss of 9.65% in less than one (1) month. However, there was no documented evidence the resident was re-weighed per policy to ensure accuracy. In addition, there was no documented evidence the Registered Dietician (RD) or resident representative was notified regarding the severe weight loss. Review of Resident #2's RD Quarterly Progress Note, dated 01/06/2020, revealed the resident received a mechanical soft diet with thin liquids for ease of chewing. Further, diet supplemented with fortified foods, Ensure three (3) times a day and High Calorie supplement to help maintain weight. Meals were served in his/her room at breakfast and lunch and dinner meals were usually served on the sun porch area. PO (by mouth) intake fair, averages 50% of meals. Weight at 114.0 pounds with no significant weight change in the past three (3) months. Monitor oral intake and weights. However, review of the clinical record revealed this Note did not address the resident's severe weight loss of 9.65% in less than one (1) month. Interview with the RD, on 05/28/2020 at 11:10 AM, revealed at the time she wrote the Note, dated 01/06/2020, she did not have the resident's weight to review which was obtained on that same date. She stated she was unaware of the severe weight loss of 9.65% in less than one (1) month at the time of the quarterly review. Per interview, the facility did not consistently obtain weights needed and in this instance, she requested Resident #2's weight to be obtained on 01/06/2020. However, she stated no one from the facility contacted her regarding the weight loss after the weight was obtained on 01/06/2020, and she did not have documented evidence she followed up to ensure the weight was obtained. Review of Resident #2's Quarterly Minimum Data Set (MDS) Assessment, dated 01/09/2020, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) of a four (4) out of fifteen (15) indicating severe cognitive impairment. Further, the facility assessed the resident as requiring supervision such as cueing and setup help with eating. The facility also assessed Resident #2 as weighing 114.0 pounds and as not having a weight loss of 5% or more in the last month or loss of 10% or more in the last six (6) months. Continued review revealed the resident was assessed as having no swallowing problems. This MDS was inaccurate, as the resident had experienced a severe weight loss of 9.65% in less than one (1) month. (Refer to F-641) Furthermore, there was no documented evidence the Physician was notified of the resident's severe weight loss of 9.65% in less than one (1) month. Review of the Advanced Registered Nurse Practitioner's (ARNP) Progress Note, dated 01/14/2020, revealed Resident #2 stated his/her appetite had been good. Review of the ARNP Progress Note, dated 02/04/2020, revealed Resident #2 stated his/her appetite had been good, and the resident received Ensure and Hi Calorie Supplements. Interview with ARNP on 06/04/2020 at 10:43 AM, revealed she was unaware of Resident #2's weight loss at the time she wrote the above Progress Notes. Review of Resident #2's Order Summary Report, revealed active orders to add fortified foods with meals secondary to poor nutrition with an order date of 02/09/2020; active orders for weekly weights times four (4), then monthly with an order date of 03/02/2020 and a start date of 03/18/2020; and active orders for Regular Diet with pureed texture, regular consistency with a start date of 03/05/2020. Review of Resident #2's Meal Intake Report, dated February 2020, revealed the resident refused a total of seven (7) meals; consumed 0-25% of thirty-eight (38) meals; consumed 26-50% of twenty (20) meals; consumed 51-75% of seventeen (17) meals; and consumed 76-100% of four (4) meals. In addition, there was no meal recorded for lunch on 02/29/2020. Review of Resident #2's Meal Intake Report, dated March 2020, revealed the resident refused a total of one (1) meal; consumed 0-25% of eighteen (18) meals; consumed 26-50% of thirty-nine (39) meals; consumed 51-75% of nineteen (19) meals; and consumed 76-100% of eleven (11) meals. In addition, there was no meal intake recorded for breakfast on 03/17/2020 and 03/21/2020; and no meal intake recorded for lunch on 03/17/2020, 03/21/2020, and 03/24/2020. Review of Resident #2's RD Quarterly Progress Note, dated 03/16/2020, revealed the resident's diet was recently downgraded by the Speech Therapist to puree consistency due to excessive chewing with the previous diet. Resident continues to do the excessive chewing with the puree diet; and diet was supplemented with Ensure, fortified oatmeal, and High Calorie supplement. Weight obtained at 102.0 pounds indicating the resident had an 11% weight loss in the past

Based on observation, interview, record review, and review of the facility's Policies, it was determined the facility failed to have an effective system in place to ensure sufficient numbers of nursing staff, including Registered Nurses (RN), Licensed Practical Nurses (LPN) and State Registered Nurse Aides (SRNA), were available to provide nursing care on a twenty-four (24) hour basis to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for nine (9) of eighteen (18) sampled residents (Residents #2, #3, #4, #5, #6, #7, #8, #9, and #11). The facility failed to ensure there was oversight related to providing sufficient numbers of staff to assure residents were provided meal assistance as needed in order to maintain acceptable parameters of nutritional status. Observations of meal service on 05/28/2020 and 05/29/2020 revealed residents were not being assisted, as per the facility's assessed needs. In addition, staff interviews revealed the facility was often short staffed which resulted in assigned duties not being completed. Furthermore, review of the Daily Assignment Sheets, revealed numerous days in the past five (5) months from February 2020 to June 2020, in which the facility had not met their required/assessed number of staff as outlined in the Facility Assessment based on resident acuity to ensure residents' needs were met related to feeding assistance. Resident #2 suffered a 13.6% severe weight loss in one (1) month and a 11.4% severe weight loss in six (6) months; Resident #4 suffered a 4.64% weight loss in one (1) week and a 11.26% severe weight loss in three (3) months; Resident #5 suffered a 13.6% severe weight loss in six (6) months; Resident #6 suffered a 12.27% severe weight loss in three (3) months and a severe 17.79% weight loss in six (6) months; Resident #7 suffered a 6.72% severe weight loss in one (1) month and a 9.2% severe weight loss in three (3) months; Resident #8 suffered a 15% severe weight loss in less than four (4) months and an 18.7% severe weight loss in six (6) months; Resident #9 suffered a 17.43% severe weight loss in one (1) month; and, Resident #3 suffered a significant weight loss of 5% percent in one (1) month and 6.9% weight loss in 6 months. Refer to F-692 The facility's failure to have an effective system in place to ensure sufficient numbers of nursing staff, including Registered Nurses (RN), Licensed Practical Nurses (LPN) and State Registered Nurse Aides (SRNA), were available to provide nursing care on a twenty-four (24) hour basis to attain or maintain the highest practicable physical, mental, and psychosocial well-being caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) was identified on 06/04/2020, and determined to exist on 01/06/2020. The facility provided an acceptable credible Allegation of Compliance (AoC) on 06/13/2020 alleging removal of the Immediate Jeopardy on 06/13/2020. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on 06/13/2020 prior to exit on 06/26/2020, with remaining non-compliance at a Scope and Severity of an E while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's Staffing Policy, revised October 2017, revealed the facility should provide sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with the residents' care plans and the Facility Assessment. Review of the Facility Assessment Tool, dated 08/18/2017, revealed the facility will conduct, document, and annually review a facility-wide assessment, which includes both their resident population and the resources the facility needed to care for their residents. Review of the facility resources needed revealed the facility would identify the type of staff members, other healthcare professionals, and medical practitioners that were needed to provide support and care for residents. The staffing plan evaluates the overall number of facility staff needed to ensure a sufficient number of qualified staff were available to meet each resident's needs. Review of the guideline revealed the facility assessed the need to have eleven (11) to fourteen (14) licensed nurses and sixteen (16) to twenty-two (22) State Registered Nurse Aides (SRNA) to provide direct care in a twenty-four (24) hour period. However, continued review of the Facility Assessment revealed the facility was to utilize the staffing tool by filling in the number of staff per resident ratio; furthermore, this was not filled in on the Facility Assessment. The assessment did not list the amount of staff, per resident ratio by each eight (8) hour shift. Review of the Daily Assignment Sheet - Nursing Department revealed a section at the bottom, which stated how many nurses and SRNAs were needed based upon the census total for a twenty-four (24) hour timeframe: A Census of 79 - 80 would require thirteen (13) Nurses and twenty (20) SRNAs; A Census of 81 would require thirteen (13) Nurses and twenty-one (21) SRNAs; A Census of 82 - 85 would require fourteen (14) Nurses and twenty-one (21) SRNAs. Review of the twenty-four (24) hour Daily Assignment Sheets for the month of February 2020, revealed the facility did not schedule the number of staff to meet their assessed staffing needs for licensed staff per the Facility Assessment Tool on three (3) days out of twenty-nine (29) in the month (1st, 2nd, and the 16th). However, due to staff call ins and no call no shows of licensed staff, the facility failed to provide coverage to replace staff the facility had scheduled on five (5) out of twenty-nine (29) days in the month (1st, 2nd, 8th, 16th and the 23rd). Although the facility failed to schedule their assessed staffing needs on the 1st, 2nd and 16th, they did not replace the staff that were call ins and no call no shows bringing the staffing down lower. Review of the twenty-four (24) hour Daily Assignment Sheets for the month of February 2020, revealed the facility failed to schedule the number of staff to meet their assessed staffing needs for SRNAs per the Facility Assessment Tool on ten (10) days out of twenty-nine (29) in the month (1st, 7th, 13th, 14th, 15th, 16th, 22nd, 23rd, 28th, and the 29th). However, due to staff call ins and no call no shows of SRNAs, the facility failed to provide coverage to replace staff the facility had scheduled on twenty-four (24) out of twenty-nine (29) days in the month (1st, 2nd, 3rd, 6th, 7th, 8th, 9th, 10th, 12th, 13th, 14th, 15th, 16th, 17th, 19th, 20th, 21st, 22nd, 23rd, 24th, 26th, 27th, 28th and the 29th). Review of the twenty-four (24) hour Daily Assignment Sheets for the month of March 2020, revealed the facility failed to schedule the number of staff to meet their assessed staffing needs for licensed staff per the Facility Assessment Tool on two (2) days out of thirty-one (31) in the month (8th and the 22nd). However, due to staff call ins and no call no shows of licensed staff, the facility failed to provide coverage to replace staff the facility had scheduled on two (2) out of thirty-one (31) days in the month (8th, and the 22nd). Review of the twenty-four (24) hour Daily Assignment Sheets for the month of March 2020, revealed the facility failed to schedule the number of staff to meet their assessed staffing needs for SRNAs per the Facility Assessment Tool on ten (10) days out of thirty-one (31) in the month (6th, 7th, 8th, 14th, 19th, 21st, 22nd, 26th, 27th, and the 29th). However, due to staff call ins and no call no shows of SRNAs, the facility failed to provide coverage to replace staff the facility had scheduled on eighteen (18) out of thirty-one (31) days in the month (3rd, 5th, 6th, 7th, 8th, 14th, 16th, 17th, 18th, 19th, 20th, 21st, 22nd, 24th, 26th, 27th, 28th and the 29th). Review of the twenty-four (24) hour Daily Assignment Sheets for the month of April 2020, revealed the facility did not schedule the number of staff to meet their assessed staffing needs for licensed staff per the Facility Assessment Tool on three (3) days out of thirty (30) days in the month (5th, 19th, and the 26th). However, due to staff call ins and no call no shows of licensed staff, the facility failed to provide coverage to replace staff the facility had scheduled on five (5) out of thirty (30) days in the month (5th, 12th, 18th, 19th, and the 26th). Review of the twenty-four (24) hour Daily Assignment Sheets for the month of April 2020, revealed the facility failed to schedule the number of staff to meet their assessed staffing needs for SRNAs per the Facility Assessment Tool on eleven (11) days out of thirty (30) days in the month (1st 3rd, 4th, 5th, 6th, 13th, 16th, 17th, 18th, 23rd, and the 25th). However, due to staff call ins and no call no shows of SRNAs, the facility failed to provide coverage to replace staff the facility had scheduled on twenty-two (22) out of thirty (30) days in the month (1st, 2nd, 3rd, 4th, 5th, 6th, 9th, 10th, 12th, 13th, 16th, 17th, 18th, 20th, 21st, 23rd, 24th, 25th, 26th, 27th, 29th, and the 30th). Review of the twenty-four (24) hour Daily Assignment Sheets for the month of May 2020, revealed the facility failed to schedule the number of staff to meet their assessed staffing needs for licensed staff per the Facility Assessment Tool on nine (9) days out of thirty-one (31) in the month (3rd, 7th, 10th, 13th, 16th, 17th, 24th, 30th, and the 31st). However, due to staff call ins and no call no shows of licensed staff, the facility failed to provide coverage to replace staff the facility had scheduled on nine (9) out of thirty-one (31) days in the month (3rd, 7th, 10th, 13th, 16th, 17th, 24th, 30th, and the 31st). Review of the twenty-four (24) hour Daily Assignment Sheets for the month of May 2020, revealed the facility failed to schedule the number of staff to meet their assessed staffing needs for SRNAs per the Facility Assessment Tool on nine (9) days out of thirty-one (31) in the month (7th, 8th, 9th, 22nd, 24th, 28th, 29th, 30th, and the 31st). However, due to staff call ins and no call no shows of SRNAs, the facility failed to provide coverage to replace staff the facility had scheduled on nineteen (19) out of thirty-one (31) days in the month (1st, 2nd, 3rd, 7th, 8th, 9th, 10th, 13th, 14th, 16th, 17th, 18th, 22nd, 23rd, 24th, 28th, 29th, 30th, and the 31st). Review of the twenty-four (24) hour Daily Assignment Sheets for the month of June 2020 from the 1st to the 26th, revealed the facility did not schedule the number of staff to meet their assessed staffing needs for licensed staff per the Facility Assessment Tool on six (6) days out of twenty-six (26) in the month (6th, 7th, 13th, 14th, 20th, and the 22nd). However, due to staff call ins and no call no shows of licensed staff, the facility failed to provide coverage to replace staff the facility had scheduled on seven (7) out of twenty-six (26) days in the month (6th, 7th, 13th, 14th, 19th, 20th, and the 22nd). Review of the twenty-four (24) hour Daily Assignment Sheets for the month of June 2020 from the 1st to the 26th, revealed the facility failed to schedule the number of staff to meet their assessed staffing needs for SRNAs per the Facility Assessment Tool on four (4) days out of twenty-six (26) in the month (15th, 20th, 21st, and the 26th). However, due to staff call ins and no call no shows of SRNAs, the facility failed to provide coverage to replace staff the facility had scheduled on nine (9) out of twenty-six (26) days in the month (6th, 7th, 9th, 13th, 15th, 19th, 20th, 21st, and the 26th). Observation on 05/28/2020 at 4:54 PM revealed on A Wing Unit there was one (1) Licensed Practical Nurse (LPN), a Kentucky Medication Aide (KMA) on the medication cart passing medications, and two (2) SRNAs present on the floor. B Wing Unit observation at 5:08 PM revealed one LPN, and one KMA until 7:00 PM, three (3) SRNAs, and one Personal Care Aide (PCA). Interview with PCA #1, on 05/28/2020 at 6:05 PM revealed as a PCA she was not allowed to assist residents with meals so she was only able to help pass trays and help obtain things from the kitchen for residents. Interview with LPN #8, who worked second shift A Wing Unit, on 05/28/2020 at 6:30 PM revealed the staffing the past few months had not been the greatest. She stated often times she would have to jump in and help the SRNAs to get their assigned duties completed, which took her away from her duties as a nurse. Observation on 06/21/2020 at 3:25 PM revealed on the A Wing Unit there was one (1) LPN, a KMA, and three (3) SRNAs. On the B Wing Unit there was a Charge Nurse, who was responsible for the entire building from 7:00 AM until 7:00 PM, a LPN, and three (3) SRNAs. Observation and review of the facility's Posted Daily Staffing dated for Sunday 06/21/2020 for a total census of 80 revealed for the 7:00 AM to 3:00 PM shift there was a total of ten (10) staff with one (1) RN, two (2) LPNs, and seven (7) SRNAs; for 3:00 PM to 11:00 PM shift there was a total of ten (10) staff members with one (1) LPN and nine (9) SRNAs; for the 11:00 PM to 7:00 AM shift there was four (4) total staff with two (2) LPNs and two (2) SRNAs. Interview with SRNA #16 on 06/23/2020 at 11:05 AM, who worked the shift of 7:00 AM to 3:00 PM on 06/21/2020, revealed she was the only SRNA working on the A Wing Unit as someone had not showed up for that shift. She stated there was a float aide who worked between A Wing and B Wing to help with meals. However the float aide was on light duty and could not help with turning and repositioning residents. She stated there was a nurse and a KMA; however, they could rarely help with providing care as they were passing medications and doing assessments. She stated management was aware of the shortage and failed to help, they only sent out a text message to see if anyone would come in to help. She stated no one responded and she had to work the whole shift as the only aide and it was very difficult. Further interview revealed she was able to assist residents with eating but it took nearly twice as long. She stated there was a float who came and helped her; however, there were twelve (12) residents that required assistance with eating, not counting the residents that needed frequent cueing or prompting to eat. She stated during the day breakfast and lunch took almost two hours to pass and assist with residents and, normally with four (4) SRNAs they could get through the meal in one (1) hour. Interview on 05/28/2020 at 6:13 PM with Resident #10 revealed he/she has had to wait a very long time for the call light in the past when he/she was first admitted . He/She stated luckily he/she was able to do most things on his/her own and did not utilize the call light very much. Resident #10 stated he/she did not think they (the facility) had enough help. Interview on 05/29/2020 at 3:52 PM with Resident #9 revealed the staff were very pleasant and kind but at times it took a while for them to answer the call light. He/She stated at times he/she would attempt to do things on his/her own like transferring back into the bed because it seemed as though staff would not come to assist after pushing the call light. Continued interview revealed it was a common occurrence for the staff to take a long time to answer the call light. Interview on 05/29/2020 at 3:47 PM with Resident #7 revealed he/she felt like there wasn't enough staff to care for him/her. Resident #7 stated the staff could take up to forty-five (45) minutes to an one (1) hour until someone came to assist him/her. He/She stated it happened at all times of the day and it wasn't during certain times like in the morning or night. Interview on 05/29/2020 at 11:09 AM with SRNA #11 revealed that it was very hard for her to complete her assigned tasks. She stated that weekends were the worst for staffing. She stated that usually there were two SRNAs but one of the SRNAs was on light duty. SRNA#11 stated that when there were only two SRNAs, she stayed after her shift ended to catch up on charting. She stated that the administration offered gift cards for staff to pick up shifts that were understaffed; however, she had not received the promised gift cards which prevented her from picking up extra shifts. Interview on 05/31/2020 at 12:13 PM with SRNA #9 revealed she had resigned from the facility approximately 1 month ago. She stated that she resigned due to staffing. SRNA #9 stated that usually there would be two (2) SRNAs and one nurse per unit. She stated that she was unable to complete her assigned duties, such as showers and assisting with feeding, due to the low staffing. SRNA #9 stated she feared losing her license and could not risk working at the facility; stating she only worked for about two weeks. Further interview revealed when she was able to sit and assist residents with their meals and call lights would go off, she was not able to answer them for fear of leaving a resident alone while eating. SRNA #9 stated that the management would try to get people to come in and help by offering incentives, but they never followed through with those incentives so no one would pick up shifts. She stated that management would be at the facility but would not assist in delivering meal trays or assisting residents with meals. Further interview revealed she would let management know that it was almost impossible to work short. She stated they told her to do the best she could and they were working on getting more staff members. SRNA #9 stated she had attempted to call corporate office to alert them and they ignored her concerns. The SRNA stated she was verbally reprimanded for going over management's authority. Interview on 06/01/2020 at 11:03 AM with SRNA #18 revealed she had been employed at the facility for approximately six (6) years. She stated that there was not enough staff for her to complete her assigned tasks such as showers and documentation. SRNA #18 stated that usually there were two (2) SRNAs on each hall which was not adequate staffing to complete tasks such as assisting giving shower/baths and feeding residents that needed assistance with meals. She stated assisting with meals took much longer and she felt that residents were not being assisted as they needed with their meals. Interview on 06/01/2020 at 1:25 PM with SRNA #11 revealed the facility was often short staffed. She stated that Sundays was when the SRNAs attempted to catch up on showers and other assigned tasks; however, the facility was most always short staffed on the weekends as well so it was nearly impossible to catch up. She further stated that it was harder to assist residents with their meals since they now had to dine in their rooms. Interview on 06/16/2020 at 1:45 PM with SRNA #2 revealed the facility was very short staffed on the weekends. She stated that if staff called in or didn't show up they did very little to find coverage and if none was found then they worked short staffed. The SRNA stated on a recent Sunday, she was the only SRNA with a nurse and a KMA on the floor during day shift. She stated during this shift she was the only SRNA for up to forty (40) residents for at least five (5) hours until they were finally able to get another SRNA to come in and help her. SRNA #2 stated that meals were nearly impossible to complete with only one (1) SRNA. SRNA #2 stated that she literally had to go from resident to resident and it was not fair to the residents. Further interview revealed when the State Survey Agency (Surveyor) entered the building there were only two (2) SRNAs on the B Wing Unit for day shift, but when the Surveyors looked at the Daily Assignment Sheet, management added names to make it look like there was more staff than there really was and the Posted Daily Staffing was incorrect as well. She further stated it was hard to get to all of the residents that required assistance with meals. Interview on 06/16/2020 at 11:05 AM with SRNA #16 revealed the facility was frequently understaffed. She stated that management did not help pass meal trays when they were short on the floor, even when management was aware they were short or had multiple call ins. She stated that it could take up to two (2) hours to finish assisting residents with meals. SRNA #16 stated that when SRNAs did not show up for a shift, the Administrator or DON sent a message through an app to all employees that they were short, but if no one was willing to pick up the shift, they would end up working many shifts very short due to not finding coverage for people who called in or didn't show up. Interview on 06/22/2020 at 8:38 AM with SRNA #5 revealed she was a Kentucky Medication Aide (KMA) and was responsible for helping administer medications to the residents throughout the day. She stated she usually worked on Unit B and that there were twelve (12) residents who required assistance with eating/feeding on that unit. She stated that typically there was one (1) SRNA and one (1) nurse on the hall with one (1) SRNA assigned to float between Unit A and Unit B. SRNA/KMA #5 stated that she was unable to assist with breakfast due to morning medication pass. She stated that she had not observed management assisting with passing trays and assisting residents that needed assistance with eating. Interview on 06/23/2020 at 8:14 AM, with SRNA #17 revealed she was a float meaning she was not assigned to a particular unit. She stated she was the float due to her light duty restrictions. She stated that the facility was often short staffed, especially on weekends. SRNA #17 stated that it was hard to get other employees to pick up shifts, as they were so exhausted from working short staffed. She stated that management offered incentives for people to pick up shifts, but they have never followed through on the incentives such as gift cards. SRNA #17 stated this was also a reason why staff did not pick up because they knew they would not receive the incentives they were promised. She stated she did not feel they had enough staff to assist all the residents with their meals as required. Interview on 06/23/2020 at 2:12 PM with LPN #6 revealed she had been employed at the facility for approximately four (4) months. She stated that staffing was horrible. LPN #6 stated that usually there were only two (2) SRNAs on each unit. She stated that with only two (2) SRNAs, it was difficult to ensure that each resident received the care they deserved. The LPN stated that management tried to get additional staff in to help but staff were reluctant to pick up extra shifts. She stated management would send out a text message when they were in need of staff but if no one responded then nothing else was done and they would work short staffed. LPN #6 stated she would try to assist with meals when she was finished with the medication administration, but she didn't feel residents were getting the assistance they required. Interview on 06/24/2020 at 3:00 PM with LPN #3 revealed that on a typical shift there was one (1) nurse and two (2) SRNAs per unit. She stated that it was difficult to ensure all duties were completed including showers and assistance with meals. She stated that it was difficult to keep staff due to working short staffed. LPN #3 stated no one wanted to pick up shifts because staff were worn out. She stated the Director of Nursing (DON) and Unit Managers often had to work the units when they couldn't find licensed coverage. An interview was conducted with the DON and the Administrator on 06/04/2020 at 4:07 PM. Per the interview, the Administrator stated that the staff turnover rate had been really bad the past few months and that in March 2020 the staff turnover rate was 60% and they attempted to do exit interviews but many staff quit and did not show back up to work. Further interview revealed they assumed since COVID19 became an issue, people did not want to work during these times. They stated that during day and evening shifts they would utilize a KMA and a nurse for a unit and if there was no KMA then they would attempt to have two (2) nurses. Continued interview with the Administrator revealed he thought the DON was scheduling the 24 hour facility staffing to match the Facility Assessment Tool and that in the Facility Assessment Tool, it indicated there were five (5) additional Administrative Licensed Staff that could perform direct care duties, that were available to add to the total on the twenty-four (24) hours Daily Assignment Sheet. He stated these management staff included the DON, Minimum Data Set Nurse, Infection Control Nurse, Unit Managers, and Supervisors. Further interview revealed they were available to assist with direct resident care; however, this would only be when they were available from their other duties. However, he stated these management staff were not present in the evening after their shift, nor were they present over the weekends to aid in care. Continued interview with the DON and Administrator on 06/25/2020 at 11:40 AM revealed the DON was responsible for creating the schedule and the daily staffing sheets. They stated the staffing sheets were updated when there was a call in. They stated they attempted to find coverage when there was a call in. The DON said she did not realize she was not scheduling enough staff to meet the assessed need based on the Facility Assessment Tool. She stated if there was no one to work the floor and they absolutely could not find coverage, then management would work the floor to ensure staffing was covered to care for the residents. However, there was no documented evidence management covered staffing to reach the assessed staffing needs per their Facility Assessment Tool. Continued interview revealed there was no effective system in place to ensure there was the needed/assessed coverage after a staff member calls in or there were no call no shows other than sending out a text to all staff indicating a need for staff to come in due to a shortage. Interview with the Regional DON/Administrator on 06/25/2020 at 10:24 AM revealed she was unaware the Facility Assessment indicated a greater number of staff needed than the facility truly required. She stated she expected the residents to receive the care and assistance they had been assessed to receive. She stated she was there to look into the problems that were identified and to try to fix them. The facility provided an acceptable credible Allegation of Compliance (AoC) on 06/13/2020 that alleged removal of the immediate Jeopardy (IJ) on 06/13/2020. Review of the AoC revealed the facility implemented the following: 1. On 06/05/2020 The Vice President (VP) of Compliance arrived and immediately met with the Administrator and Director of Nursing (DON) to determine the root cause of the deficiencies. They reviewed all policies related to the IJs received and determined the root cause of the deficient practice. On 06/05/2020 the DON recommended Registered Dietician (RD) review for Residents #2, #3, #4, #5, #6, #7, #8, #9, and #11. On 06/06/2020 the VP of Compliance in-serviced the DON and Administrator on the Change in Resident's Condition or Status policy and the Nutrition Unplanned Weight Loss Policy. 2. On 06/05/2020, the Medical Director was contacted by the Administrator and DON. They discussed with him his role in the QA process, which will allow all residents identified with any significant or severe weight loss, to be clinically evaluated in a timely manner. They discussed that his involvement will aid facility nursing staff in setting interventions as necessary to avoid any future trending weight loss in an attempt to improve the overall quality of care. 3. On 06/06/2020 and 06/07/2020 the DON, Administrator and VP Compliance worked on developing an abatement plan. 4. The DON notified the Physician and Power of Attorney (POA) of weight loss on 06/05/2020 for Residents #2 and #3 and on 06/06/2020 for Residents #4, #5, #6, #7, and #8. On 06/06/2020, the POA for Resident #9 and the Physician for Resident #11 were notified. On 06/07/2020, the Physician for Resident #9 and the POA for Resident #11 were notified. 5. On 06/07/2020 the VP of Compliance reviewed the Administrator and DON Job Descriptions and provided an in-service on the proper way to conduct NAR meetings and the importance of having them weekly. They also reviewed how to pull the Weight Exception report from Point Click Care (PCC) so that all residents with significant and severe weight loss can be reviewed. 6. The DON and Licensed Practical Nurse (LPN) Unit Manager ensured that all residents directly involved in the deficient practice were reweighed, significant/severe weight loss identified, and the notifications were made to the Physicians, RD and POAs by 06/12/2020. 7. The residents directly involved in the deficient practice had their Care Plans and interventions reviewed by the DON and Regional Minimum Data Set (MDS) Coordinator from 06/06/2020 to 06/09/2020 to ensure that they were appropriate to prevent further weight loss. On 06/08/2020, the MDS Coordinator was in-serviced by the Regional MDS Coordinator on the Comprehensive Person-Centered Care Plans Policy. The DON met with the new RD on 06/09/2020 to discuss each resident affected to ensure interventions were in place to prevent further weight loss. 8. Residents directly involved in the deficient practice had their care plan reviewed by the Regional MDS (Minimum Data Set) Coordinator and/or DON and/or MDS Coordinator and updated to reflect more person-centered interventions related to severe/significant weight loss. Care Plan interventions were implemented by 06/12/2020. 9. On 06/10/2020, all residents were evaluated by the DON to determine the need for assistance with meals. A list of residents requiring feeding assistance was created by the DON and placed at the nurse's station. The DON educated the Unit Managers of their responsibility for maintaining and updating the list and ensuring the residents were receiving the feeding assistance needed by an assigned staff for each meal. 10. Weekly Nutritional at Risk (NAR) meetings have been scheduled. Administration will attend the weekly meetings to ensure that it is being conducted properly and consistently. The Administrator will pull the weight exception report weekly from PCC to ensure all residents with significant weight loss are being followed in the meetings as necessary. A NAR Meeting was held on 06/09/2020 and all recommendations by the RD were completed on 06/10/2020. The VP of Compliance attended the NAR meeting on 06/09/2020 to ensure it was carried out properly. If needed, the VP of Compliance will attend future meetings to ensure compliance. All new recommendations will be reviewed and approved by the Physicians, notifications of changes will be made to families/representatives, and Care Plans will be updated to reflect those changes by 06/12/2020. 11. On 06/08/2020 all the State Registered Nursing Assistants (SRNA) and Nurses were in-serviced by the DON on proper monitoring of resident weights, importance of making sure the Care Plans reflect any weight loss and/or interventions in place, ensuring that interventions are in place and being carried out for residents with weight loss, importance of notifying the RD and Physician of residents with significant/severe weight loss, providing meal assistance as necessary, and monitoring meal intakes. On 06/08/2020 the Licensed staff and SRNAs were also in-serviced by the DON on the binder that will be kept listing the residents requiring feeding assistance and the mealtime staff assignments. Policies reviewed during the in-service were the Nutrition Unplanned Weight Loss Policy and Weight Assessment and Intervention Policy. The DON included in the in-service to the Nurses and SRNAs education on utilizing the Kardex in PCC to access the residents' interventio (TRUNCATED)

Based on interview, record review, review of the Director of Nursing and Administrator's Job Descriptions, and review of the facility's policies, it was determined the facility failed to ensure it was administered in a manner to utilize it's resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. There was no documented evidence the facility's Administration ensured the facility's Nutrition (Impaired)/Unplanned Weight Loss - Clinical Protocol Policy; Weight Assessment and Intervention Policy; Weight Assessment and Intervention Policy, and Hydration-Clinical Protocol, were implemented. In addition, there was no documented evidence the Registered Dietician (RD), Physician/Provider, or resident representative were notified when there was a significant or severe weight loss or when residents did not meet their fluid requirements. This affected Residents #2, #3, #4, #5, #6, #7, #8, #9, and #11. (Refer to F-580, F-692, and F-865) In addition, there was no documented evidence the facility's Administration ensured the facility's Staffing Policy was implemented in order to provide sufficient numbers of nursing staff, including Registered Nurses (RN), Licensed Practical Nurses (LPN) and State Registered Nurse Aides (SRNA), to provide nursing care on a twenty-four (24) hour basis to assure residents were provided meal assistance as needed in order to maintain acceptable parameters of nutritional status and provide quality care. (Refer to F-725) These failures by Administration resulted in significant and/or severe weight losses for Residents #2, #3, #4, #5, #6, #7, #8, #9, and #11 and dehydration for Resident #9. The facility's failure to have an effective system in place to ensure it was administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) was identified on 06/04/2020, and determined to exist on 01/06/2020. The facility provided an acceptable credible Allegation of Compliance (AoC) on 06/13/2020 alleging removal of the Immediate Jeopardy on 06/13/2020. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on 06/13/2020, prior to exit on 06/26/2020, with remaining non-compliance at a Scope and Severity of an E while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the Job Description for Administrator, dated 2003, revealed the primary purpose of the Administrator is to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations to assure that the highest degree of quality care can be provided to the residents at all times. It is the Administrator's duty to develop and maintain written policies and procedures and professional standards of practice that govern the operation of the facility. The Administrator is responsible for making routine inspections of the facility to assure that established policies and procedures are being implemented and followed. Further, the Administrator is responsible for assisting department directors in the development, use, and implementation of departmental policies and procedures and professional standards of practice. In addition, the Administrator is responsible for evaluating and implementing recommendations from the facility's committees as necessary. Additionally, the Administrator is responsible for consulting with department directors concerning the operation of their departments to assist in eliminating/correcting problem areas, and/or improvement of services. Further, the Administrator is responsible for ensuring that an adequate number of appropriately trained licensed professional and non-licensed personnel are on duty at all times to meet the needs of the residents. Review of the Job Description for Director of Nursing Services, dated 2003, revealed the primary purpose of the Director of Nursing (DON) is to plan, organize, develop and direct the overall operation of the Nursing Service Department in accordance with current federal, state, and local standards, guidelines, and regulations, and as may be directed by the Administrator and the Medical Director, to ensure that the highest degree of quality care can be provided to the residents at all times. Further review revealed the DON's duties include: developing, maintaining, and periodically updating written policies and procedures that govern the day-to-day functions of the nursing department; making written and oral reports or recommendations to the Administrator, as necessary/required, concerning the operation of the nursing service department; developing methods for coordination of nursing services with other resident services to ensure the continuity of the resident's total regimen of care; developing, implementing, and maintaining an ongoing quality assurance program for the nursing service department; assisting the Quality Assessment and Assurance Committee in developing and implementing appropriate plans of action to correct identified deficiencies; assigning a sufficient number of licensed practical and/or registered nurses for each tour of duty to ensure quality care is maintained; assigning a sufficient number of certified nursing assistants for each tour of duty to ensure routine nursing care is provided to meet the daily nursing care needs of each resident; and monitoring absenteeism to ensure an adequate number of nursing care personnel are on duty at all times. 1. Review of the facility's Nutrition (Impaired)/Unplanned Weight Loss - Clinical Protocol Policy, revised September 2017, revealed staff will monitor and document the weight and dietary intake of residents in a format which permits comparisons over time. Continued review revealed staff will report to the Physician significant weight gains or losses or any abrupt or persistence change from baseline appetite or food intake. The Physician will review for medical causes of weight gains or losses before ordering interventions. For individuals with rapid weight gains or losses, staff will review for possible fluid and electrolyte imbalance as a cause and the Physician will identify medical conditions and medications that may be causing weight gain or loss. Staff and the Physician will identify pertinent interventions based on identified causes and overall condition, prognosis, and wishes. Staff and the Physician will review and consider existing dietary restrictions and modified consistency diets. Further review revealed Staff and the Physician will monitor nutritional status, and individual's response to interventions. Review of the facility Weight Assessment and Intervention Policy, revised December 2019, revealed the multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents. Continued review under the Section titled, Implementation of Weight Assessment, revealed the nursing staff will measure the resident's weight upon admission, the next day, and weekly for four (4) weeks thereafter. Any weight change of five percent (5%) or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will notify the Dietician by receipt of the resident's weights. The Dietician will review the Weight Record by the 15th of the month to follow individual weight trends over time. Negative trends will be evaluated by the treatment team whether or not the criteria for significant weight change has been met. Review of the facility's Hydration-Clinical Protocol, revised 09/2017, revealed the Physician and staff will help define the individual's current hydration status (fluid and electrolyte balance or imbalances). Staff will identify and report to the Physician individuals with signs and symptoms or lab test results that might reflect existing fluid and electrolyte imbalance. Further review revealed the Physician and staff will identify significant risk for subsequent fluid and electrolyte imbalance such as residents who are not eating or drinking well. Record review revealed there was no documented evidence residents' weights were obtained weekly x four (4) weeks for new admissions and monthly as per policy, nor were weights obtained as per physician's orders [REDACTED]. In addition, there was no documented evidence food and fluid intake was being monitored as evidenced by numerous meal intakes not being documented. Furthermore, staff failed to ensure RD recommendations were appropriately communicated to the physician, resulting in failure of the dietary recommendations to be implemented to help prevent further weight loss and maintain weight. Interview with the RD, on 06/01/2020 at 9:23 AM, revealed the facility failed to obtain weights as per policy and as ordered and therefore when completing her reviews, she sometimes had to refer to the last weight obtained, which may not be a recent weight. Per interview, after she requested weights for certain residents, staff failed to notify her when the weight was obtained and a significant weight loss had occurred. Further, she brought the missing weights to the attention to the Director of Nursing (DON) in January 2020; however, she did not see any improvement after she notified the DON. Interview with the DON, on 06/04/2020 at 4:20 PM, revealed she failed to act in January 2020, when the RD notified her the weights were not being obtained as per policy and as per orders. Per interview, she did not notify the Administrator of the RD's concerns, but she should have immediately intervened to identify and correct this issue. In addition, record review revealed Resident #9 did not meet his/her fluid requirements of 1250-1500 milliliters per day from 04/20/2020 through 05/15/2020; however, there was no documented evidence of monitoring the resident's fluid intake, performing hydration assessments or notification to the RD or Physician/Provider. On 05/15/2020, Resident #9 had a change in behavior and laboratory values were obtained revealing the resident's Blood Urea Nitrogen (BUN) level was 67 (High) indicating dehydration. Interview with the Advanced Registered Nurse Practitioner (ARNP), on 06/04/2020 at 10:20 AM, revealed if staff had informed her the resident was refusing food/fluid intake, the resident may not have required the intravenous fluids on 05/15/2020 related to the resident being severely dehydrated. Interview with the DON and the Administrator, on on 06/01/2020 at 11:20 AM, 06/02/2020 at 11:45 AM, and 06/04/2020 at 4:07 PM, revealed the Electronic Health System (Point Click Care) would trigger when a resident lost weight and show an alert; however, this was a fairly new system to the facility and they had recently identified that the system would only trigger weight loss within a thirty (30) day period from the beginning of the month to the end of the month. Therefore, if a weight was obtained after thirty (30) days from the last weight and inputted into the system, weight loss did not trigger. Per interview, they were relying on this system to monitor for weight loss; however, they did not know how to effectively utilize the system related to monitoring weights. Further interview with the Director of Nursing (DON), and the Administrator, revealed the Nutrition at Risk (NAR) meetings with the interdisciplinary team (IDT) were held weekly; however, since the COVID-19 pandemic, the last in person NAR meeting was held in March 2020. Per interview, this may have contributed to the facility's lack of identification of weight loss and failure to notify the Provider of weight loss. Additional interview with the DON and Administrator, revealed a Performance Improvement Plan (PIP) was put in place on 05/19/2020 when the facility identified the concern related to weights not being obtained. However, the DON and Administrator acknowledged even with the PIP in place, necessary weights were not obtained for some residents until Surveyor intervention. Per interview, the facility's failure to obtain weights as necessary was a systemic issue and there was not appropriate monitoring in place to prevent weight loss for residents. 2. Review of the facility's Staffing Policy, revised October 2017, revealed the facility is to provide sufficient numbers of staff with the skill and competency necessary to provide care and services for all residents in accordance with residents' care plans and the facility assessment. Further review revealed staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident's plan of care. The facility utilized the Facility Assessment Tool as a guide to ensure sufficient staff was available to residents within twenty-four (24) hours. However, staff interviews and review of the facility's, Twenty-four (24) hour, Daily Staffing Assignment sheets from 02/01/2020 to 06/13/2020, revealed numerous days in which the facility did not ensure there was the assessed number of licensed staff and State Registered Nurse Aides (SRNAs), as outlined in the Facility Assessment based on resident acuity to ensure residents' needs were met related to feeding assistance. Furthermore, review of the Daily Staffing Assignment sheets, revealed the facility failed to always provide required coverage when there were staff call ins and no call no shows, if coverage was not found then the staff would work short. Observation and record review revealed residents were not being assisted at meal times per the residents required assistance from their Minimum Data Set (MDS) Assessment for eating assistance. Interview with the Director of Nursing (DON), on 06/04/2020 at 4:07 PM, revealed it was her duty to plan, organize, develop and direct the overall operation of the Nursing Service Department. She stated she was ultimately responsible for ensuring sufficient nursing staff was available in order to provide care for residents as per their assessed needs; however, she admitted the facility was not meeting minimum requirements for staffing. Interview with the Administrator, on 06/04/2020 at 4:07 PM, revealed he was aware of the staffing issue and the facility had a turnover rate of 60 percent in March 2020. He stated he thought the DON was scheduling staff in accordance to the Facility Assessment Tool with five (5) additional Administrative Licensed Staff to perform direct care duties. However, there was no documented evidence management covered staffing to reach the assessed staffing needs per their Facility Assessment Tool. Further interview with the Administrator revealed it was his duty to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations to assure that the highest degree of quality care could be provided to the residents at all times. He stated it was also his job duty to ensure adequate staffing to meet the residents' needs. The facility provided an acceptable credible Allegation of Compliance (AoC) on 06/13/2020 that alleged removal of the immediate Jeopardy (IJ) on 06/13/2020. Review of the AoC revealed the facility implemented the following: 1. On 06/05/2020 The Vice President (VP) of Compliance arrived and immediately met with the Administrator and Director of Nursing (DON) to determine the root cause of the deficiencies. They reviewed all policies related to the IJs received and determined the root cause of the deficient practice. On 06/05/2020 the DON recommended Registered Dietician (RD) review for Residents #2, #3, #4, #5, #6, #7, #8, #9, and #11. On 06/06/2020 the VP of Compliance in-serviced the DON and Administrator on the Change in Resident's Condition or Status policy and the Nutrition Unplanned Weight Loss Policy. 2. On 06/05/2020, the Medical Director was contacted by the Administrator and DON. They discussed with him his role in the QA process, which will allow all residents identified with any significant or severe weight loss, to be clinically evaluated in a timely manner. They discussed that his involvement will aid facility nursing staff in setting interventions as necessary to avoid any future trending weight loss in an attempt to improve the overall quality of care. 3. On 06/06/2020 and 06/07/2020 the DON, Administrator and VP Compliance worked on developing an abatement plan. 4. The DON notified the Physician and Power of Attorney (POA) of weight loss on 06/05/2020 for Residents #2 and #3 and on 06/06/2020 for Residents #4, #5, #6, #7, and #8. On 06/06/2020, the POA for Resident #9 and the Physician for Resident #11 were notified. On 06/07/2020, the Physician for Resident #9 and the POA for Resident #11 were notified. 5. On 06/07/2020 the VP of Compliance reviewed the Administrator and DON Job Descriptions and provided an in-service on the proper way to conduct NAR meetings and the importance of having them weekly. They also reviewed how to pull the Weight Exception report from Point Click Care (PCC) so that all residents with significant and severe weight loss can be reviewed. 6. The DON and Licensed Practical Nurse (LPN) Unit Manager ensured that all residents directly involved in the deficient practice were reweighed, significant/severe weight loss identified, and the notifications were made to the Physicians, RD and POAs by 06/12/2020. 7. The residents directly involved in the deficient practice had their Care Plans and interventions reviewed by the DON and Regional Minimum Data Set (MDS) Coordinator from 06/06/2020 to 06/09/2020 to ensure that they were appropriate to prevent further weight loss. On 06/08/2020, the MDS Coordinator was in-serviced by the Regional MDS Coordinator on the Comprehensive Person-Centered Care Plans Policy. The DON met with the new RD on 06/09/2020 to discuss each resident affected to ensure interventions were in place to prevent further weight loss. 8. Residents directly involved in the deficient practice had their care plan reviewed by the Regional MDS (Minimum Data Set) Coordinator and/or DON and/or MDS Coordinator and updated to reflect more person-centered interventions related to severe/significant weight loss. Care Plan interventions were implemented by 06/12/2020. 9. On 06/10/2020, all residents were evaluated by the DON to determine the need for assistance with meals. A list of residents requiring feeding assistance was created by the DON and placed at the nurse's station. The DON educated the Unit Managers of their responsibility for maintaining and updating the list and ensuring the residents were receiving the feeding assistance needed by an assigned staff for each meal. 10. Weekly Nutritional at Risk (NAR) meetings have been scheduled. Administration will attend the weekly meetings to ensure that it is being conducted properly and consistently. The Administrator will pull the weight exception report weekly from PCC to ensure all residents with significant weight loss are being followed in the meetings as necessary. A NAR Meeting was held on 06/09/2020 and all recommendations by the RD were completed on 06/10/2020. The VP of Compliance attended the NAR meeting on 06/09/2020 to ensure it was carried out properly. If needed, the VP of Compliance will attend future meetings to ensure compliance. All new recommendations will be reviewed and approved by the Physicians, notifications of changes will be made to families/representatives, and Care Plans will be updated to reflect those changes by 06/12/2020. 11. On 06/08/2020 all the State Registered Nursing Assistants (SRNA) and Nurses were in-serviced by the DON on proper monitoring of resident weights, importance of making sure the Care Plans reflect any weight loss and/or interventions in place, ensuring that interventions are in place and being carried out for residents with weight loss, importance of notifying the RD and Physician of residents with significant/severe weight loss, providing meal assistance as necessary, and monitoring meal intakes. On 06/08/2020 the Licensed staff and SRNAs were also in-serviced by the DON on the binder that will be kept listing the residents requiring feeding assistance and the mealtime staff assignments. Policies reviewed during the in-service were the Nutrition Unplanned Weight Loss Policy and Weight Assessment and Intervention Policy. The DON included in the in-service to the Nurses and SRNAs education on utilizing the Kardex in PCC to access the residents' interventions so that they can properly implement them. One hundred percent (100%) of the Nurses and SRNAs attended the in-service. 12. On 06/09/2020 a Quality Assurance and Performance Improvement (QAPI) meeting was held consisting of the Administrator, DON, Social Service Director, Dietary Manager, MDS Coordinator, Admissions Coordinator, Activities Director, Unit Managers, RD and Housekeeping Director. At that meeting, the Interdisciplinary Team (IDT) received QAPI training and in-service on the QAPI policy by the VP of Compliance. The QAPI decided to meet daily Monday through Friday until the IJ was abated then weekly until Substantial Compliance is met. 13. The DON will conduct Monday through Friday audits of the residents' weights to ensure that any significant/severe weight losses have been identified and communicated to RD, POA and MD. 14. The DON, MDS Coordinator or Regional MDS Coordinator will review the Care Plans of new residents with significant/severe weight loss to ensure that they reflect more person-centered interventions related to severe/significant weight loss and Care Plan interventions were implemented. Any deficient practice found during the audits will be corrected immediately by the DON and education and/or corrective action implemented as appropriate. 15. The Administrator and DON will meet daily throughout the weekend until the abatement plan is accepted to address additional needs. All audit findings from the weekend will be carried over to the IDT meetings on the following Monday. 16. Required staffing levels were re-evaluated by the Administrator and a new Staff Level for the facility based on resident acuity was established and the Facility Assessment was updated on 06/10/2020. The State Survey Agency validated the implementation of the facility's AoC as follows: 1. Interview with VP of Compliance #1, on 06/16/2020 at 11:20 AM, revealed he met with the Administrator and DON on 06/05/2020 to determine the root cause of the deficiencies. He further stated they also reviewed all policies related to the IJs received. He revealed he went over the job duties with the Administrator and discussed the purpose of the QAPI. Interview with Administrator, on 06/26/2020 at 11:00 AM, revealed the VP of Compliance #1 met with him and the DON to go over the IJ tags, review the facility policies, discuss the Administrator's duties/responsibilities and discuss the role of QAPI. Interview with DON on 06/26/2020 at 11:00 AM revealed she received education provided by the VP of Compliance #1 regarding the policies. Review of education sign-in sheet revealed the DON and Administrator were in-serviced by the VP of Compliance #1 on 06/06/2020 of Residents Change of Condition Policy and Nutrition Unplanned Weight Loss Policy. Review of Change of Condition Forms revealed the RD's review and recommendations for Resident #2, #3, #4, #5, #6, #7, #8, #9 and #11 from 06/05/2020 to 06/07/2020. Interview with the RD on 06/25/2020 at 3:15 PM revealed he was informed by the DON of the residents who needed to be reviewed and he stated he reviewed and made recommendations. 2. Interview with Medical Director, on 06/25/2020 at 10:22 AM, revealed he was contacted by the Administrator and DON on 06/05/2020 to inform him of the deficient practice and his role in the QA process. 3. Review of the Meeting Minutes, dated 06/06/2020 and 06/07/2020, revealed the Administrator, VP of Compliance and DON met to develop an abatement plan. Interview with the Administrator/DON and VP of Compliance, on 06/26/2020 at 11:15 AM, revealed they met on 06/06/2020 and 06/07/2020 to develop and begin implementing an abatement plan of the IJ's. 4. Review of Progress notes for Residents #2, #3, #4, #5, #6, #7 #8, #9 and #11 revealed the Physicians and the POAs were all notified of residents' weight loss and recommendations. Interview with the DON, on 06/26/2020 at 11:25 AM, revealed she began notifying the Physicians and POAs of the residents on 06/05/2020 and all were notified by 06/07/2020. 5. Interview with the VP of Compliance #1, on 06/16/2020 at 11:00 AM, revealed she reviewed both the Administrator and DON job descriptions, provided in-service on the proper way to conduct a Nutritional At Risk meeting, the importance of having them weekly and how to pull and exception report from Point Click Care (PCC) so that all residents with significant/severe weight loss can be reviewed. Interview with DON and Administrator, on 06/26/2020 at 11:05 AM, revealed they received education related to their job description, was shown how to pull the exception report and how to conduct a NAR meeting weekly and the importance of their job duties. 6. Review of Residents #2, #3, #4, #5, #6, #7, #8 ,#9, and #11 Electronic Health Records (EHR) revealed, the residents were reweighed, any significant/severe weight loss that was identified was documented, and notifications were made to the Physicians, RD and POAs. Interview with Unit Manager #1, on 06/25/2020 at 11:40 AM, revealed she assisted with reweights of residents affected by the deficient practice. She stated notifications were made to their Physicians, the RD was made aware, as well as the POAs. Interview with DON, on 06/26/2020 at 11:45 AM, revealed all residents affected were reweighed, referrals were submitted to the RD, and she further stated the Physicians and POAs were also notified. 7. Review of Residents #2, #3, #4, #5, #6, #7, #8, #9, and #11 medical records revealed the DON and Regional MDS Coordinator reviewed each residents' Care Plan and ensured appropriate interventions were put into place to prevent further weight loss. Interview with DON, on 06/26/2020 at 11:45 AM, revealed new interventions were put into place to prevent further weight loss by her and the Regional MDS Coordinator. She stated supplements were ordered for some of the residents and on 06/09/2020 the new RD reviewed and made recommendations, which were added to the care plan. A new weight binder was developed and was being implemented and was in place for monitoring weights and being audited by the DON. Review of in-service sign in sheet dated 06/08/2020, revealed the MDS Coordinator was in-serviced by the Regional MDS Coordinator on the Comprehensive Person-Centered Care Plans Policy. Interview with MDS Coordinator, on 06/25/2020 at 2:30 PM, revealed she was in-serviced on the policy by the Regional MDS Coordinator on 06/08/2020. 8. Review of Residents #2, #3, #4, #5, #6, #7, #8, #9, and #11 Residents Person Centered Care Plans revealed new interventions were implemented related to severe/significant weight loss from 06/06/2020 to 06/12/2020. Interview with Regional MDS Coordinator, on 06/24/2020 at 11:20 AM, revealed she assisted with reviewing care plans for those residents affected, and new interventions were put into place. Interview with MDS Coordinator on 06/26/2020 at 12:00 AM revealed, she reviewed the care plans and worked with Regional MDS Coordinator and DON to implement new interventions to prevent further weight loss. She stated some of the residents were given supplements, and the POAs and Physicians were notified. 9. Review of the Daily Meal Assistance Audit and new meal assistance sheets revealed they were updated to reflect residents needing assistance with meals. The sheets were at each of the nurse's station with staff assignments at each meal for each resident requiring assistance with eating. Interview with DON, on 06/26/2020 at 10:15 AM, revealed she re-evaluated each resident to determine their need for assistance with meals and revealed she created a new meal assistance sheet, educated staff and the sheets were at each nurse's station. She further stated she was responsible for maintaining and updating the meal assistance sheet and ensuring it was accurate. Interview with Kentucky Medication Aid (KMA) #2, on 06/25/2020 at 08:10 AM, SRNA #17 on 06/25/2020 at 08:14 AM, Unit Manager #1 on 06/25/2020 at 11:15 AM, Unit Manager #2 on 06/25/2020 at 11:30AM, LPN #6 on 06/25/2020 at 2:12 PM, MDS Coordinator on 06/25/2020 at 2:38 PM, LPN #7 on 06/25/2020 at 3:00 PM, KMA #1 on 06/25/2020 at 3:05 PM, SRNA #2 on 06/25/2020 at 3:10 PM, SRNA #3 on 06/25/2020 at 3:20 PM, SRNA #5 on 03/25/2020 at 3:45 PM, and LPN #5 on 06/25/2020 at 4:15 PM, revealed there was a new meal assistance sheet located at each nurses station, staff was assigned to each resident requiring assistance for each meal and the DON was responsible for updating. 10. Review of the Weekly Nutritional at Risk (NAR) meeting held on 06/09/2020 revealed Administration attended and they reviewed the weight exception report pulled from PCC. The meeting was to ensure all residents with significant weight loss were being monitored. Further review revealed recommendations made by the RD on 06/10/2020. Review of the sign-in sheet revealed the VP of Compliance attended the meeting on 06/09/2020 to ensure it was carried out properly. Interview with the RD, on 06/25/2020 at 8:15 AM, revealed he attended the NAR meeting on 06/09/2020, the weight exception report was reviewed and recommendations were made to any resident affected. Interview with the VP of Compliance #1, on 06/16/2020 at 11:00 AM, revealed he ensured on 06/09/2020 that the NAR meeting was conducted properly and would attend and future meeting as needed. 11. Review of In-Service Sheets dated 06/08/2020 revealed CNAs and Licensed staff were educated by the DON on proper monitoring of resident weights, importance of making sure Care Plan reflects any weight loss and/or interventions in place, ensuring that interventions were in place and being carried out for residents with weight loss, the importance of notifying RD and Physician of residents with significant/severe weight loss, providing meal assistance as necessary, monitoring meal intakes and use of Kardex. Continued review revealed staff signatures indicating they had attended the education and understood the information in the education. Interview with KMA #2 on 06/25/2020 at 08:10 AM, SRNA #17 on 06/25/2020 at 08:14 AM, Unit Manager #1 on 06/25/2020 at 11:15 AM, Unit Manager #2 on 06/25/2020 at 11:30 AM, LPN #6 on 06/25/2020 at 2:12 PM, MDS Coordinator on 06/25/2020 at 2:38 PM, LPN #7 on 06/25/2020 at 3:00 PM, KMA #1 on 06/25/2020 at 3:05 PM, SRNA #2 on 06/25/2020 at 3:10 PM, SRNA #3 on 06/25/2020 at 3:20 PM, SRNA #5 on 06/25/2020 at 3:45 PM, and LPN #5 on 06/25/2020 at 4:15 PM, revealed the DON in-serviced them on 06/08/2020 regarding proper monitoring of resident weights, importance of making sure Care Plan reflects any weight loss and/or interventions in place, ensuring that interventions are in place and being carried out for residents with weight loss, importance of notifying RD and physician of residents with significant severe weight loss, providing meal assistance as necessary, monitoring meal intakes and use of Kardex. They revealed they understood the information in the edu (TRUNCATED)

Based on observation, interview, record review, and review of the facility's Policies, it was determined the facility failed to maintain a Quality Assurance and Performance Improvement (QAPI) Program that developed and implemented appropriate plans of action to correct quality deficiencies. This was evidenced by the facility's failure to systematically investigate and analyze to determine underlying causes of systemic concerns related to residents' nutritional/hydration status and implement corrective actions. Although the facility identified weights were not being obtained and a Performance Improvement Plan (PIP) was initiated 05/19/2020, the facility failed to implement their PIP as there was no documented evidence residents' weights were obtained as per the PIP. In addition, the facility failed to identify that residents had sustained significant and severe weight losses and/or dehydration. This lack of the QAPI Program oversight resulted in Resident #3 suffering a significant weight loss; Resident #9 suffering severe weight loss and dehydration; and Residents #2, #4, #5, #6, #7, #8, and #11 suffering severe weight loss. (Refer to F-580, F-641, F-656, F-657, F-725, and F-835) In addition, the facility failed to maintain a QAPI Program that developed and implemented appropriate plans of action to correct quality deficiencies as evidenced by repeat deficiencies from the Abbreviated Survey, concluded on 01/24/2020, at 42 CFR 483.12, F-604 and F-609, Freedom from Abuse, Neglect and Exploitation. The facility's failure to have an effective system in place to maintain a QAPI Program that developed and implemented appropriate plans of action to correct quality deficiencies caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) was identified on 06/04/2020, and determined to exist on 01/06/2020. The facility provided an acceptable credible Allegation of Compliance (AoC) on 06/13/2020 alleging removal of the Immediate Jeopardy on 06/13/2020. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on 06/13/2020, prior to exit on 06/26/2020, with remaining non-compliance at a Scope and Severity of an E while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's Quality Assurance and Performance Improvement (QAPI) Plan Policy, dated April 2014, revealed it is the policy of the facility to develop, implement, and maintain an ongoing, facility-wide QAPI Plan designated to monitor and evaluate the quality and safety of resident care, pursue methods to improve quality, and resolve identified problems. The objectives of QAPI are to provide a means to identify and resolve present and potential negative outcomes related to resident care and services; and provide a means to identify and resolve present and potential negative outcomes related to resident care and services. 1. Review of the facility's Nutrition (Impaired)/Unplanned Weight Loss - Clinical Protocol Policy, revised September 2017, revealed staff will monitor and document the weight and dietary intake of residents in a format which permits comparisons over time. Continued review revealed staff will report to the Physician significant weight gains or losses or any abrupt or persistence change from baseline appetite or food intake. The Physician will review for medical causes of weight gains or losses before ordering interventions. For individuals with rapid weight gains or losses, staff will review for possible fluid and electrolyte imbalance as a cause and the Physician will identify medical conditions and medications that may be causing weight gain or loss. Staff and the Physician will identify pertinent interventions based on identified causes and overall condition, prognosis, and wishes. Staff and the Physician will review and consider existing dietary restrictions and modified consistency diets. Further review revealed Staff and the Physician will monitor nutritional status, and individual's response to interventions. Review of the facility's Weight Assessment and Intervention Policy, revised December 2019, revealed the multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents. Continued review under the Section titled, Implementation of Weight Assessment, revealed the nursing staff will measure the resident's weight upon admission, the next day, and weekly for four (4) weeks thereafter. Any weight change of five percent (5%) or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will notify the Dietician by receipt of the resident's weights. The Dietician will review the Weight Record by the 15th of the month to follow individual weight trends over time. Negative trends will be evaluated by the treatment team whether or not the criteria for significant weight change has been met. Review of the facility's Hydration-Clinical Protocol, revised 09/2017, revealed the Physician and staff will help define the individual's current hydration status (fluid and electrolyte balance or imbalances). Staff will identify and report to the Physician individuals with signs and symptoms or lab test results that might reflect existing fluid and electrolyte imbalance. The Physician and staff will identify significant risk for subsequent fluid and electrolyte imbalance such as residents who are not eating or drinking well. Based on observation, interview, record review, and review of facility policies, it was determined the facility failed to systematically investigate and analyze to determine underlying causes of systemic concerns related to residents' nutritional/hydration status to ensure the development, implementation and evaluation of corrective actions to assure the facility's Nutrition and Hydration Policies were implemented. Further, the facility failed to develop an effective QAPI Plan and monitoring system and failed to ensure staff followed the facility's policies and procedures related to assessing, care planning, assisting with meals, and monitoring residents' nutritional/hydration status. These failures resulted in significant and severe weight loss and/or dehydration for residents. (Refer to F-692). Interview with the Registered Dietician (RD), on 06/04/2020 at 9:23 AM, revealed in January 2020 she informed the Director of Nursing (DON) that weights were not being obtained every week x four (4) weeks for new admissions, monthly or per the physician's orders [REDACTED]. Review of the QAPI Ad Hoc Committee Meeting Minutes, dated 05/19/2020, revealed the weight program was out of compliance and a Performance Improvement Plan (PIP) was indicated to obtain one hundred percent (100%) of the residents' weights weekly x four (4) weeks. Per the PIP, all residents were to be weighed using a Hoyer Lift (mechanical lift) with a compliance date set for 06/12/2020. However, record review revealed there was no documented evidence residents' weights were obtained as per the PIP. Per record review, Resident #9 was not weighed from 04/20/2020 until 05/27/2020; Resident #6 was not weighed from 04/13/2020 until 05/27/2020; Resident #8 was not weighted from 03/06/2020 until 05/28/2020; and Resident #11 was not weighted from 03/06/2020 until 06/01/2020. The residents were weighed per the State Survey Agency's (SSA)request. In addition, the PIP was not followed related to ensuring weights were obtained by the Hoyer Lift. Observations of weights being obtained on 06/03/2020, revealed Resident #2, Resident #9, Resident #4, Resident #8, Resident #7 and Resident #3, were weighed per the wheelchair scale. Additionally, during this Survey, it was identified there was no documented evidence the facility's Nutrition (Impaired)/Unplanned Weight Loss - Clinical Protocol Policy; Weight Assessment and Intervention Policy; Weight Assessment and Intervention Policy, and Hydration-Clinical Protocol, were implemented. Moreover, there was no documented evidence the Comprehensive Care Plans were developed or revised in order to promote sufficient food/fluid intake and promote weight gain or weight maintenance, nor were the Care Plans implemented related to necessary interventions to ensure residents' maintained acceptable parameters of nutritional status. Furthermore, there was no documented evidence the Registered Dietician (RD), Physician/Provider, or resident representative was notified when there was a significant or severe weight loss or when residents did not meet their fluid requirements. In addition, observation of the meal service revealed residents were not being assisted with meals as per their Minimum Data Set (MDS) Assessment. These failures resulted in Resident #3 suffering a significant weight loss; Resident # 9 suffering severe weight loss and dehydration; and Residents #2, #4, #5, #6, #7, #8, and #11 suffering severe weight losses. (Refer to F-580, F-656, F-657, and F-692) Interview with the Director of Nursing (DON) and Administrator, on 06/04/2020 at 4:20 PM, revealed the RD did notify the DON of the issue related to weights not being obtained. The DON stated at that time she did not alert the Administrator regarding this issue, nor did she intervene to identify the causative factors for the weights not being obtained. Further, the DON stated she was not comfortable with utilizing the Point Click Care (PCC) electronic health record that was newly implemented in February 2020, and she did not know how to pull the weight reports to review. Further, the DON and Administrator stated they relied on the PCC system to capture weight loss, but did not know how to correctly utilize the system. Per interview, they had recently identified the system only captured weight loss if it occurred within thirty (30) days, so if the weight loss had occurred over a two (2) month time frame the system would not alert them of the weight loss. Additional interview revealed a PIP was put in place on 05/19/2020 related to the concern of weights not being obtained. However, the DON and Administrator acknowledged even with the PIP in place, the required weights were not obtained for some residents until SSA intervention. Further, the PIP was not implemented related to weights being obtained per Hoyer Lift. Further, they acknowledged they were unaware of the significant and severe weight losses until during the survey, as prevention of weight loss was not part of the PIP Plan. Further interview with the Administrator, on 06/01/2020 at 2:47 PM, and on 06/04/2020 at 4:20 PM, revealed the facility held a QAPI Meeting at least quarterly and committee members included, but were not limited to the Administrator, DON, MDS Nurse, Social Services, RD, Advanced Registered Nurse Practitioner (ARNP), Dietary Manager, and Maintenance. He stated during the QAPI meetings held in January 2020 and March 2020, there were no issues identified related to weights being obtained or weight loss. Further interview revealed the purpose of QAPI was to provide a means to identify and resolve present and potential negative outcomes related to resident care and services. He stated through QAPI the facility was to place measures to correct the concerns identified and evaluate if the measures were effective. However, he stated the facility failed to identify weight loss as a concern when the PIP was placed on 05/19/2020. Further interview revealed the facility failed to develop appropriate plans of action to correct quality deficiencies related to ensuring weights were obtained as per policy, and ensuring interventions were in place to prevent weight loss. Continued interview revealed the Medical Director did not attend the quarterly QA meetings. Interview with the Medical Director, on 06/01/2020 at 1:34 PM, revealed he did not attend the QAPI meetings and was unaware there was a concern related to weights not being obtained. He stated he was also unaware the facility had implemented a PIP related to weights not being obtained. He further stated he had no idea there was a concern with several residents having significant or severe weight loss, but QAPI should have identified the weight loss concerns and implemented an action plan related to this as well. 2. Based on observation, interview, and record review, it was determined the facility failed to ensure residents were free from physical restraints imposed for the purposes of convenience. This was a repeat deficiency for the facility which was cited on 01/24/2020, for deficiencies related to an incident involving use of an unauthorized restraint when staff improperly restrained a resident in a wheelchair using a gait belt. 42 CFR 483.12 Freedom from Abuse, Neglect and Exploitation, F-604 was cited. Review of the facility's Policy titled, Use of Restraints, revised April 2017, revealed restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Per the policy, restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls. Continued review revealed when the use of restraints is indicated, the least restrictive alternative will be used for the least amount of time necessary, and the ongoing re-evaluation for the need for restraints will be documented. Further review of the policy revealed the definition of physical restraints was any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. Review of the facility's Plan of Correction (POC), with a compliance date of 02/14/2020, for F-604, revealed 100% of management staff, licensed nurses, Kentucky Medication Aides (KMA) and State Registered Nurse Aides (SRNA) were educated on the resident's right to be free from any manual method, physical or mechanical device, equipment or material, that is attached or adjacent to the resident's body; and cannot be removed easily by the resident; and restricts the resident's freedom of movement or normal access to the body. Per the POC, current residents would be reviewed and addressed to include Physician review. Residents would be assessed for restraints upon admission, readmission and quarterly. Restraints would only be used when the resident had a specific medical symptom that could not be addressed by a less restrictive intervention and a restraint was required to treat the medical symptom; protect the resident's safety; and help the resident attain the highest level of well being. All restraints were to be reviewed weekly x four (4) weeks to determine if there were any current orders that needed to be addressed. The Audit results would be taken to the QAPI meetings. During this Survey, it was identified the facility failed to ensure alternatives were attempted prior to use of a restraint; failed to ensure the restraint was used for the least amount of time; failed to have a systematic process for reduction of the restraint; and failed to implement interventions to prevent risks associated with the restraint. Additionally, the facility failed to ensure a Practitioner's order for the specific physical restraint identified the medical symptom and and how the restraint would treat the medical symptom and protect the safety of the resident. Moreover, the facility failed to ensure the physical restraint was used the least amount of time possible and there was ongoing supervision and monitoring while the restraint was in use. This affected four (4) of eighteen (18) sampled residents (Resident #3, #14, #15, and #16). Interview on 06/01/2020 at 3:00 PM with the Director of Nursing (DON) and the Administrator, revealed the POC was implemented related to education for management staff, licensed nurses, Kentucky Medication Aides (KMA) and State Registered Nurse Aides (SRNA) related to the facility's Use of Restraints Policy and the regulation, F-604, after the 01/24/2020 Survey. Further interview revealed all residents were assessed for restraint usage at that time to ensure the policy and regulation were being followed related to restraints. Continued interview revealed the DON and the Administrator did conduct audits weekly x four (4) weeks to determine if there were any current restraint orders that needed to be addressed to ensure restraints would only be used when the resident had a specific medical symptom that could not be addressed by a less restrictive intervention, and a restraint was required to treat the medical symptom. However, further interview revealed the audits stopped after the four (4) week interval as there were no further concerns identified. Continued interview revealed they were unaware there were further concerns related to restraint usage and documentation related to restraints until this survey. 3. Based on observation, interview, and record review, it was determined the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, are reported immediately, but not later than two (2) hours after the allegation is made if the events that cause the allegation involve abuse or result in serious bodily injury, to officials including the State Agency and Adult Protective Services in accordance with State Law for one (1) of eighteen (18) sampled residents, Resident #18. This was a repeat deficiency for the facility which was cited on 01/24/2020 for deficiencies related to an incident involving use of an unauthorized restraint. Staff improperly restrained a resident in a wheelchair using a gait belt, which was identified on 01/12/2020, but was not reported until 01/13/2020. 42 CFR 483.12 Freedom from Abuse, Neglect and Exploitation, F-609 was cited. Review of the facility's policy titled Abuse Investigation and Reporting, revised July 2017, revealed that all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source shall be promptly reported to local, state, and federal agencies as defined by current regulations. Further review revealed that all alleged violations of abuse, neglect, exploitation or mistreatment, including injuries of unknown source, will be reported immediately, but not later than two (2) hours if the alleged violation involves abuse or has resulted in serious bodily injury. Review of the facility's Plan of Correction (POC), with a compliance date of 02/14/2020, for F-609, revealed the Activities Assistant and 100% of management staff, licensed nurses, KMAs and SRNAs were educated on the importance of reporting in a timely manner as per regulation as well as the requirements set forth by the State of Kentucky and compliance reporting protocol. Per the POC, progress notes, skin assessments and incident reports would be monitored in daily stand up meeting, five (5) days a week. Any findings consistent with abuse would be reported to the appropriate regulatory agencies. All reportable incidents would be reviewed bi-weekly x four (4) weeks to determine if there were any inconsistencies that needed to be addressed for further review. The Audit findings would be taken to the QAPI meetings. During this Survey, staff interview and record review revealed on 06/23/2020 a deep purple bruise was observed on Resident #18's right breast. At the time of the initial observation, the origin of the injury was not observed, could not be explained by the resident, and the location and severity of the injury was suspicious. However, the bruise to Resident #18's breast was not reported to the State Survey Agency until 06/24/2020. (Refer to F-609) Observation of Resident #18's skin assessment performed on 06/24/2020 at 1:29 PM, completed by Licensed Practical Nurse (LPN) #1 and LPN #4, revealed a deep purple bruise to the right breast, extending into his/her armpit. The bruise measured 15.5 centimeters (cm) in length x 21 cm in width. Interview on 06/01/2020 at 3:00 PM with the Director of Nursing (DON) and the Administrator, revealed education was provided to the Activities Assistant and 100% of management staff, licensed nurses, KMAs and SRNAs on the importance of reporting allegations of abuse as well as injuries of unknown source in a timely manner as well as the requirements set forth by the State of Kentucky related to reporting protocol after the 01/24/2020 Survey. Continued interview revealed after the 01/24/2020 Survey, the interdisciplinary team monitored the progress notes, skin assessments and incident reports in the morning daily stand up meeting, five (5) days a week to ensure any findings consistent with abuse were reported to the appropriate regulatory agencies. Further, the POC was implemented related to ensuring all reportable incidents were reviewed bi-weekly x four (4) weeks to determine if there were any inconsistencies that needed to be addressed for further review. However, further interview revealed these audits stopped after the four (4) week interval, as there were no further concerns noted. Interview on 06/24/2020 at 1:49 PM, and 06/25/2020 at 10:18 AM, with the Director of Nursing (DON), revealed she was informed of Resident #18's bruise on 06/23/2020, and noted a deep purple bruise encompassing the entirety of Resident #18's right breast. Further interview revealed she felt certain the bruising to Resident #18's right breast was caused during a transfer and was not abuse. Interview on 06/25/2020 at 9:43 AM with the Administrator revealed he was notified of the bruising to Resident #18's right breast on 06/23/2020. He further stated he was sure the bruising to Resident #18's right breast was not the result of abuse, but was a result of him/her being transferred. Continued interview revealed he was aware that suspicions of abuse, including injuries of unknown origin, should be reported in two (2) hours. However, he stated he did not report the bruise as he felt certain that the bruise to Resident #18's right breast was a result of a transfer. Continued interview with the Administrator revealed he had been in his role as Administrator at the facility since October 2019. Per interview, once a problem was identified, education would be conducted with staff and audits would be conducted to assess if the plan of action was effective. Continued interview revealed the facility had conducted inservices and auditing when it was identified on the 01/24/2020 Survey that there was a concern related to restraints being applied without authorization and related to allegations of abuse not being reported timely. Further interview revealed it was again identified during this survey that there were concerns related to the use of restraints and failure to report an injury of unknown source timely. Per interview, it was his expectation that the QAPI Program correct identified deficiencies. The facility provided an acceptable credible Allegation of Compliance (AoC) on 06/13/2020 that alleged removal of the immediate Jeopardy (IJ) on 06/13/2020. Review of the AoC revealed the facility implemented the following: 1. On 06/05/2020 The Vice President (VP) of Compliance arrived and immediately met with the Administrator and Director of Nursing (DON) to determine the root cause of the deficiencies. They reviewed all policies related to the IJs received and determined the root cause of the deficient practice. On 06/05/2020 the DON recommended Registered Dietician (RD) review for Residents #2, #3, #4, #5, #6, #7, #8, #9, and #11. On 06/06/2020 the VP of Compliance in-serviced the DON and Administrator on the Change in Resident's Condition or Status policy and the Nutrition Unplanned Weight Loss Policy. 2. On 06/05/2020, the Medical Director was contacted by the Administrator and DON. They discussed with him his role in the QA process, which will allow all residents identified with any significant or severe weight loss, to be clinically evaluated in a timely manner. They discussed that his involvement will aid facility nursing staff in setting interventions as necessary to avoid any future trending weight loss in an attempt to improve the overall quality of care. 3. On 06/06/2020 and 06/07/2020 the DON, Administrator and VP Compliance worked on developing an abatement plan. 4. The DON notified the Physician and Power of Attorney (POA) of weight loss on 06/05/2020 for Residents #2 and #3 and on 06/06/2020 for Residents #4, #5, #6, #7, and #8. On 06/06/2020, the POA for Resident #9 and the Physician for Resident #11 were notified. On 06/07/2020, the Physician for Resident #9 and the POA for Resident #11 were notified. 5. On 06/07/2020 the VP of Compliance reviewed the Administrator and DON Job Descriptions and provided an in-service on the proper way to conduct NAR meetings and the importance of having them weekly. They also reviewed how to pull the Weight Exception report from Point Click Care (PCC) so that all residents with significant and severe weight loss can be reviewed. 6. The DON and Licensed Practical Nurse (LPN) Unit Manager ensured that all residents directly involved in the deficient practice were reweighed, significant/severe weight loss identified, and the notifications were made to the Physicians, RD and POAs by 06/12/2020. 7. The residents directly involved in the deficient practice had their Care Plans and interventions reviewed by the DON and Regional Minimum Data Set (MDS) Coordinator from 06/06/2020 to 06/09/2020 to ensure that they were appropriate to prevent further weight loss. On 06/08/2020, the MDS Coordinator was in-serviced by the Regional MDS Coordinator on the Comprehensive Person-Centered Care Plans Policy. The DON met with the new RD on 06/09/2020 to discuss each resident affected to ensure interventions were in place to prevent further weight loss. 8. Residents directly involved in the deficient practice had their care plan reviewed by the Regional MDS (Minimum Data Set) Coordinator and/or DON and/or MDS Coordinator and updated to reflect more person-centered interventions related to severe/significant weight loss. Care Plan interventions were implemented by 06/12/2020. 9. On 06/10/2020, all residents were evaluated by the DON to determine the need for assistance with meals. A list of residents requiring feeding assistance was created by the DON and placed at the nurse's station. The DON educated the Unit Managers of their responsibility for maintaining and updating the list and ensuring the residents were receiving the feeding assistance needed by an assigned staff for each meal. 10. Weekly Nutritional at Risk (NAR) meetings have been scheduled. Administration will attend the weekly meetings to ensure that it is being conducted properly and consistently. The Administrator will pull the weight exception report weekly from PCC to ensure all residents with significant weight loss are being followed in the meetings as necessary. A NAR Meeting was held on 06/09/2020 and all recommendations by the RD were completed on 06/10/2020. The VP of Compliance attended the NAR meeting on 06/09/2020 to ensure it was carried out properly. If needed, the VP of Compliance will attend future meetings to ensure compliance. All new recommendations will be reviewed and approved by the Physicians, notifications of changes will be made to families/representatives, and Care Plans will be updated to reflect those changes by 06/12/2020. 11. On 06/08/2020 all the State Registered Nursing Assistants (SRNA) and Nurses were in-serviced by the DON on proper monitoring of resident weights, importance of making sure the Care Plans reflect any weight loss and/or interventions in place, ensuring that interventions are in place and being carried out for residents with weight loss, importance of notifying the RD and Physician of residents with significant/severe weight loss, providing meal assistance as necessary, and monitoring meal intakes. On 06/08/2020 the Licensed staff and SRNAs were also in-serviced by the DON on the binder that will be kept listing the residents requiring feeding assistance and the mealtime staff assignments. Policies reviewed during the in-service were the Nutrition Unplanned Weight Loss Policy and Weight Assessment and Intervention Policy. The DON included in the in-service to the Nurses and SRNAs education on utilizing the Kardex in PCC to access the residents' interventions so that they can properly implement them. One hundred percent (100%) of the Nurses and SRNAs attended the in-service. 12. On 06/09/2020 a Quality Assurance and Performance Improvement (QAPI) meeting was held consisting of the Administrator, DON, Social Service Director, Dietary Manager, MDS Coordinator, Admissions Coordinator, Activities Director, Unit Managers, RD and Housekeeping Director. At that meeting, the Interdisciplinary Team (IDT) received QAPI training and in-service on the QAPI policy by the VP of Compliance. The QAPI decided to meet daily Monday through Friday until the IJ was abated then weekly until Substantial Compliance is met. 13. The DON will conduct Monday through Friday audits of the residents' weights to ensure that any significant/severe weight losses have been identified and communicated to RD, POA and MD. 14. The DON, MDS Coordinator or Regional MDS Coordinator will review the Care Plans of new residents with significant/severe weight loss to ensure that they reflect more person-centered interventions related to severe/significant weight loss and Care Plan interventions were implemented. Any deficient practice found during the audits will be corrected immediately by the DON and education and/or corrective action implemented as appropriate. 15. The Administrator and DON will meet daily throughout the weekend until the abatement plan is accepted to address additional needs. All audit findings from the weekend will be carried over to the IDT meetings on the following Monday. 16. Required staffing levels were re-evaluated by the Administrator and a new Staff Level for the facility based on resident acuity was established and the Facility Assessment was updated on 06/10/2020. The State Survey Agency validated the implementation of the facility's AoC as follows: 1. Interview with VP of Compliance #1, on 06/16/2020 at 11:20 AM, revealed he met with the Administrator and DON on 06/05/2020 to determine the root cause of the deficiencies. He further stated they also reviewed all policies related to the IJs received. He revealed he went over the job duties with the Administrator and discussed the purpose of the QAPI. Interview with Administrator, on 06/26/2020 at 11:00 AM, revealed the VP of Compliance #1 met with him and the DON to go over the IJ tags, review the facility policies, discuss the Administrator's duties/responsibilities and discuss the role of QAPI. Interview with DON on 06/26/2020 at 11:00 AM revealed she received education provided by the VP of Compliance #1 regarding the policies. Review of education sign-in sheet revealed the DON and Administrator were in-serviced by the VP of Compliance #1 on 06/06/2020 of Residents Change of Condition Policy and Nutrition Unplanned Weight Loss Policy. Review of Change of Condition Forms revealed the RD's review and recommendations for Resident #2, #3, #4, #5, #6, #7, #8, #9 and #11 from 06/05/2020 to 06/07/2020. Interview with the RD on 06/25/2020 at 3:15 PM revealed he was informed by the DON of the residents who needed to be reviewed and he stated he reviewed and made recommendations. 2. Interview with Medical Director, on 06/25/2020 at 10:22 AM, revealed he was contacted by the Administrator and DON on 06/05/2020 to inform him of the deficient practice and his role in the QA process. 3. Review of the Meeting Minutes, dated 06/06/2020 and 06/07/2020, revealed the Adm (TRUNCATED)

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure a resident who entered the facility without limited range of motion (ROM) did not experience a reduction in range of motion. The facility failed to ensure a resident with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence, unless a reduction in mobility was demonstrably unavoidable for seven (7) of thirty (30) sampled residents with limited ROM (Residents #4, #7, #13, #11/37, #39, #16/42 and #44). Resident #4's Admission Minimum Data Set (MDS) Assessment, dated 03/26/2019, revealed the resident had no functional limitations in ROM for upper and lower bilateral extremities. Review of the most current Quarterly MDS, dated [DATE], Section G revealed the resident had functional limitations in ROM for lower bilateral extremities. Observation, on 10/02/2020, revealed Resident #4 had contractures of the lower bilateral extremities. Resident #7's most current Quarterly MDS Assessment, dated 07/01/2020, Section G, revealed the resident had functional limitations in ROM to bilateral upper extremities. Resident #13's most current Quarterly MDS Assessment, dated 07/01/2020, Section G, revealed the resident had functional limitations in ROM to bilateral lower extremities. Resident #11/37's most current Quarterly MDS Assessment, dated 08/04/2020, Section G, revealed the resident had functional limitations in ROM to one (1) upper extremity and one (1)lower extremity. Resident #39's Admission MDS Assessment, dated 07/29/2020, and most current Quarterly MDS Assessment, dated 08/30/2020, Section G, revealed the resident had no functional limitations in ROM. However, observations and interview with nursing and therapy staff revealed the resident had functional limitations in ROM to his/her right hand since admission to the facility. Resident #16/42's most current Quarterly MDS Assessment, dated 06/30/2020, Section G, revealed the resident had functional limitations in ROM to bilateral lower extremities. Resident #44's most current Quarterly MDS Assessment, dated 08/29/2020, Section G, revealed the resident had functional limitations in ROM to bilateral upper extremities. Substandard Quality of Care (SQC) was identified related to the facility's systemic failure to provide the nursing care needed to prevent a decline in functional status. The findings include: Review of the facility's policy titled, Restorative Nursing Services, dated July 2017, revealed residents would receive restorative nursing care as needed to help promote optimal safety and independence. Additionally, restorative nursing care consisted of nursing interventions that could or could not be accompanied by formalized rehabilitative services. Continued review revealed a restorative program could be started upon admission, during the course of the stay, or when discharged from rehabilitative care. Per policy, restorative goals and objectives were individualized, resident-centered, and outlined in the resident's Care Plan. Further, restorative goals could include, but were not limited to supporting and assisting the resident in: adjusting or adapting to changing abilities; developing, maintaining or strengthening physiological and psychological resources; maintaining dignity, independence and self-esteem; and participating in the development and implementation of the Care Plan. 1. Review of Resident #4's medical record revealed the facility admitted the resident, on 03/18/2019, with [DIAGNOSES REDACTED]. Review of Resident #4's Admission MDS Assessment, dated 03/26/2019, Section G, revealed the facility assessed the resident with no upper or lower extremity limited range in motion impairment for both sides. Review of Resident #4's Quarterly MDS Assessment, dated 12/22/2019, Section G, revealed the facility assessed the resident with no upper extremity limitation in range of motion; however, the facility identified an impairment for limitation in ROM in bilateral lower extremities including hip, knee, ankle and foot. Review of Resident #4's Annual MDS Assessment, dated 03/23/2020, Section G, revealed the facility assessed the resident with no upper extremity limitation in ROM; however, the facility identified an impairment for limitation in ROM in bilateral lower extremities, including hip, knee, ankle and foot. Review of Resident #4's Quarterly MDS Assessment, dated 06/18/2020, Section G, revealed the facility assessed the resident with no upper extremity limitation in ROM; however, the facility identified an impairment for limitation in ROM in bilateral lower extremities, including hip, knee, ankle and foot. Further review revealed the facility assessed the resident as having a Brief Interview of Mental Status (BIMS) score of three (3) out of fifteen (15) for cognitively impaired. Review of the facility's form titled, Nursing Assessment: Contracture Assessment, dated 03/18/2019, revealed Resident #4 was assessed upon admission with moderate ROM for hips, knees, and ankles. Review of Resident #4's Physician order [REDACTED]. Further review revealed there were no directions specified for the order. An additional Physical Therapy (PT) clarification order, dated 08/19/2020, stated do an evaluation only because the resident was not appropriate for skilled PT services and was to transition to a Hoyer (mechincal) lift for safe transfers. An additional order, dated 09/15/2020, stated PT and Occupational Therapy to evaluate and treat if indicated because of decreased mobility; and, PT clarification orders, dated 09/16/2020, stated the resident was to receive skilled PT services to address contractures utilizing total extension (TE) and total abduction (TA), neurological re-education, wheelchair management and orthotic training three (3) times per week for thirty (30) days. Further review revealed an order, dated 09/22/2020, for Occupational Therapy to evaluate and treat for eight (8) visits for thirty (30) days for wheelchair positioning. Review of Resident #4's CCP revealed a focus of the resident had limited physical mobility related to Dementia and decreased mobility to lower extremities, initiated 03/18/2019 with a revision date of 04/03/2019. The goal, with a target date of, 12/13/2020, was for the resident to remain free of complications related to immobility, including contractures, thrombus formation, skin-breakdown, and fall related injury through the next review date. Further review revealed the intervention, initiated 03/18/2019, was to provide gentle ROM as tolerated with daily care. Review of Resident #4's nurse aide care plan (Kardex), dated 09/30/2020, revealed resident care provided gentle ROM as tolerated with daily care. Review of Resident #4's Occupational Therapy Progress and Discharge Summary, dated 07/22/2020, revealed dates of service were 06/21/2020 to 07/22/2020. It stated the end goal status, as of 07/22/2020, not met due to joint misalignment which caused the resident to lean to the side, lying in bed. Further review revealed the resident had poor sitting balance in bed with increased right-side lean and bilateral knee contractures; these conditions required use of positioning devices in order to properly position the resident in bed. Per summary, the resident required these positioning devices to increase independence with self-feeding, and the resident required a maximum assist of two (2) for proper positioning. Review of Resident #4's Nurse's Note, dated 09/25/2020 at 12:09 PM, revealed staff was turning the resident and noticed he/she was not able to straighten his/her legs out in the bed, and they were contracted. The note stated staff would make family and therapy aware, and continue to monitor Resident #4. Observation of Resident #4, on 09/28/2020 at 8:30 AM, revealed the resident lying in bed with covers over the abdomen and the lower extremities. Additional observation, on 09/29/2020 at 8:30 AM and 12:00 PM, revealed Resident #4 lying with covers over the abdomen and the lower extremities. Interview with the Occupational Therapist/Director of Therapy, on 09/30/2020 at 2:53 PM, revealed Resident #4 did not receive ROM, and there was no restorative program at this time. However, she stated SRNA's could complete ROM during regular ADL care. Per interview, the resident was referred to therapy for PT and approval for one (1) session of Occupational Therapy due to insurance carrier approval. The OT stated residents were seen for assessment when referrals were made but re-visits for follow-up were not done after discharge from therapy services. Interview with SRNA #4, on 10/01/2020 at 1:05 PM, revealed she provided ROM care to Resident #4. However, she stated not all residents received ROM care. She stated Resident #4 moved from A Wing with leg contractures. SRNA #4 stated she tried to perform ROM with daily care for residents. Interview with SRNA #21, on 10/01/2020 at 1:28 PM , revealed she worked day shift on B Wing and performed ROM on all residents as part of daily care in the AM. She stated the Therapy Department had provided ROM training in the past as well as having a restorative program. She stated it was important to provide ROM to residents so they did not become stiff, feel pain, and become contracted. SRNA #21 stated ROM promoted strong muscles and prevented skin breakdown. Per interview, SRNA #21 stated, for Resident #4, she tried to provide daily ROM while dressing, getting in the wheelchair, and for leg contractures. Interview with Occupational Therapist (OT) #1, COTA #1, and the Physical Therapy Assistant (PTA) Rehabilitation Manager, on 10/01/2020 at 2:28 PM, revealed upon referral, Resident #4's insurance would not cover therapy. However, the insurance company wanted therapists to train staff to use ROM for four (4) visits only. They stated Resident #4's family did not want to cover the cost of therapy, and in July 2020, the facility received approval from the corporate office for therapy to treat Resident #4 without insurance payment. They stated, in September 2020, Resident #4 was referred to therapy, and the insurance would pay for PT and approval was pending for Occupational Therapy; Occupational Therapy did receive emergency permission for one (1) visit for positioning in the wheelchair. They stated therapy goals were to prevent further contractures, maintain skin integrity, and permit the resident to sit in a wheelchair and enjoy activities. Additional observation, on 10/02/2020 at 3:50 PM, of Resident #4 with the Certified Occupational Therapy Assistant (COTA) #1 and Occupational Therapist (OT) Director of Therapy revealed the resident was resting in bed, under the bed covers, lying on the right side, with knees bent into a fetal position. The COTA explained to the resident the need to examine the contractures and the resident was in agreement. Further observation revealed the resident was uncovered, and there were no lower extremity devices. The resident's knees were touching tightly together with feet resting side by side, and the resident was assisted to his/her back but could not maintain control and rolled back to the right hip; the COTA had to stabilize the resident on his/her back. Further observation revealed Resident #4 held tightly onto the OT Director's hand, displayed facial grimacing, began to sing hymns, and said repetitively I'm ready to go. Further observation revealed both knees were very large with [MEDICAL CONDITION] and warm to the touch, per COTA #1. The COTA began gently to relax the resident and try to extend the right leg; however, the resident stated it could not be extended; the left leg had less extension than the right leg. COTA #1 rocked Resident #4's hips and was able to place both her hands in between the resident's knees, placing a small cloth between the resident's knees. COTA and OT stated, during this obsrvation, the resident was severely contracted in his/her bilateral lower extremities. Interview with SRNA #3, on B wing, on 10/02/2020 at 10:00 AM, revealed she worked with Resident #4 on his/her contractures while providing daily care. She stated she tried to get Resident #4 up, provide ROM, and to get pressure off the legs. Interview with Registered Nurse (RN) #1 B Wing, on 10/02/2020 at 10:10 AM, revealed range of motion (ROM) was done by the aides, during the resident's daily care. RN #1 stated ROM should be on the resident's care plan. Interview on 10/02/2020 at 5:15 PM with State Registered Nurse Assistants (SRNA) #26 and #27; and, Kentucky Medication Aide (KMA) #10 Unit A, revealed Resident #4 had history of [MEDICAL CONDITION] and favors one side over the other. Further interview revealed Resident #4 had pain in his/her knees. However, he/she would not express feeling knee pain. They stated the resident did not walk by himself/herself however, he/she tried to strengthen out his/her legs. 2. Review of Resident 39's medical record revealed the facility admitted the resident, on 07/22/2020, with [DIAGNOSES REDACTED]. Additional review revealed the resident changed rooms, from Wing B to Wing A, on 08/02/2020, related to no longer requiring isolation. Review of Resident #39's Admission Nursing Assessment, dated 07/22/2020, revealed the resident had no contractures. Review of Resident #39's Occupational Therapy Plan of Care, dated 07/23/2020 through 08/07/2020, revealed therapy was needed because the resident required increased assistance with self-care tasks and increased assistance with transfers and ambulation. The plan stated, without therapy, the resident was at risk for increased assistance with self-care tasks. Additional review revealed the resident required maximum assistance with self-feeding, hygiene, dressing, grooming, bathing, toileting, and transfers. Continued review revealed the long-term goal was for the resident to intermittently require supervision or touch assistance to complete activities. Review of Resident #39's Provider Progress Note, dated 07/28/2020, revealed the resident moved all extremities. Review of Resident #39's OT Progress Note and Discharge Summary, dated 08/09/2020, revealed the anticipated goals were not met related to severe cognitive deficits requiring increased verbal and tactile cues with all self-care tasks. Additional review revealed caregiver education was provided on the need for verbal instructions with all activities due to the resident's severe dementia and increased fear of falling. Further, discharge plans and instructions were to discharge the resident to nursing staff; and the resident required twenty-four (24) hour maximum to dependent care. Review of Occupational Therapy notes from 07/23/2020 and 08/09/2020 revealed no documented evidence Resident #39 had functional limitation in ROM to the right upper extremity. Review of Resident #39's Comprehensive Care Plan (CCP), dated 07/23/2020, revealed the resident had an ADL self-care deficit related to needing assistance with them. The goal was the resident would remain free of body odor and appropriately dressed and groomed by staff. Interventions included nursing staff to ensure daily needs were met; turn and reposition, shift weight to enhance circulation, during care rounds; and total dependence on one (1) staff for eating. However, there was no documented evidence the facility implemented a Restorative Care regimen with interventions, services, or treatment to maintain current functional status or to prevent a decrease in function. (Refer to F-656) Review of Resident #39's Admission MDS Assessment, dated 07/29/2020, revealed the facility assessed the resident as having severely impaired cognitive skills for daily decision-making; and short and long term memory problems. Additionally, the facility assessed the resident as requiring extensive assistance of two (2) staff for bed mobility, transfer, locomotion, dressing, toileting, and personal hygiene. Continued review revealed eating required extensive assistance of one (1) staff. Per the MDS Assessment, ambulation did not occur. Further, the resident had no Functional Limitation in Range of Motion (ROM) to upper or lower extremities. Per the MDS Assessment, the resident received five (5) days of therapy for at least fifteen (15) minutes in the last seven (7) days. Review of Resident #39's Quarterly MDS Assessment, dated 08/30/2020, revealed the facility assessed the resident as having severely impaired cognitive skills for daily decision-making; and short and long term memory problems. Additionally, the facility assessed the resident as requiring total assistance of two (2) staff for bed mobility, transfer, locomotion, dressing, toileting, eating, and personal hygiene. Per the MDS Assessment, ambulation did not occur. Further, the resident had no functional limitation ROM to upper or lower extremities. Per the MDS Assessment, therapy ended on 08/07/2020, and the resident did not receive RNP. Review of Resident #39's Progress Notes, dated 08/01/2020 through 10/02/2020, revealed no documented evidence of Restorative Care interventions. Review of Resident #39's Treatment Administration Record (TAR), dated 08/01/2020 through 08/31/2020 and 09/01/2020 through 09/30/2020, revealed no documented evidence of treatment to the resident's right upper extremity. However, observations of Resident #39, on 09/28/2020 at 8:00 AM, revealed the resident's right hand was grossly [MEDICAL CONDITION] and while at rest his/her right hand fingers were folded down onto the palm. Resident #39 was not wearing any devices on his/her right hand. Additional observations of Resident #39, on 09/29/2020 at 1:30 PM, revealed the right hand was [MEDICAL CONDITION] and closed in a fist, with a wash cloth folded in half in the resident's right hand. Continued observations of Resident #39, on 09/30/2020 at 3:30 PM, revealed State Registered Nursing Assistant (SRNA) #22 placed a folded wash cloth into Resident #39's right hand. The resident's right hand was closed in a fist at rest, with the resident's right hand fingers folded down onto the palm. Interview with SRNA #22, on 09/30/2020 at 3:30 PM, revealed she had worked at the facility for fifteen (15) years and did not provide ROM to any resident, especially to residents with contractures. However, she would remove the wash cloth from Resident #39's right hand and move the resident's fingers off of the palm. Observations at this time revealed the right hand middle digit #3's ROM was severely limited and digit #3 could be raised off the palm enough to allow for a washcloth to be wiggled out, and digits #4 (ring finger) and #5 (pinky) also had limited ROM but could be extended off the palm and were not as severe as digit #3. Resident #39 grimaced and stated ouch, and pulled his/her hand away when SRNA #22 was moving the right hand and digits. Continued interview with SRNA #22 revealed she did not provide ROM to residents because it was painful for them and therapy provided it. Further, she stated she worked on A Wing, and when Resident #39 transferred from B Wing in August, he/she had the contracture to his/her right middle finger. Interview with SRNA #4, on 10/01/2020 at 3:45 PM, revealed she had worked on A Wing and recalled when Resident #39 resided on A Wing in July and August 2020. Additionally, she stated, on A Wing, Resident #39 did not have pain in the right hand or limited ROM to the right hand middle finger. Per interview, she recalled, on A Wing, Resident #39 was able to move all fingers without no concern, and the resident did not have a contracted right hand middle finger. Further, she did not recall the resident requiring a device or washcloth for the right hand. Observation of Resident #39, on 10/02/2020 at 4:30 PM, with Licensed Practical Nurse (LPN) #7, revealed the resident was resting in bed on his/her right side, the right hand was out of the covers and at rest; it was grossly [MEDICAL CONDITION] at the knuckles, closed in a fist, and had no device in it. Further observation and interview revealed LPN #7 was not able to perform ROM because the resident's right hand middle digit was folded down on the right hand palm and could not be lifted/raised from the resting position. LPN #7 was able to place her finger underneath the resident's right middle digit. LPN #7, stated the resident's right middle finger was contracted. Additional observations revealed the right hand digits, #4 and #5, had limited ROM. However, they could be lifted/raised off the resident's palm and extended. Further observation revealed the resident stated ouch and guarded his/her right hand by pulling away from LPN #7. Review of Resident #39's Monthly October 2020 physician's orders [REDACTED]. Further review revealed no active therapy orders or RNP related to functional limitations in ROM to the right upper extremity. Interview with the OT, on 10/01/2020 at 2:18 PM, revealed Resident #39 was previously seen when he/she was first admitted to the facility because of the overall need for assistance with self-care. Additionally, Resident #39 had severe Dementia and would scream out and cry because he/she was afraid to fall. Per interview, the resident was discharged from therapy to nursing care because the resident would not participate in therapy due to Dementia; however, when the resident was seen by OT, he/she had no limitations in ROM and no contractures. Continued interview revealed since the resident had been discharged from therapy, he/she was rarely out of bed, at most one (1) time a week. Further interview revealed she expected staff to assist Resident #39 with ROM to decrease the risk for decreased mobility and contractures, skin integrity concerns, and pain. Continued interview revealed Resident #39 should have been referred back to therapy because the resident had a decline in mobility and/or contractures. Per interview, she was not aware the resident's right hand was [MEDICAL CONDITION] and had limited ROM in the digits, with the middle finger folded down on the palm at rest. 3. Review of Resident #11/37's medical record revealed the facility admitted the resident, on 07/23/2015, with [DIAGNOSES REDACTED]. Review of Resident #11/37's Contracture Assessment, dated 07/23/2015, revealed the resident was assessed to have full ROM in both left and right wrists. This was the only documented contracture assessment provided by the facility. Review of Resident #11/37's CCP revealed a focus, with an initiation date of 11/02/2016, of resident had potential for pain and complications related to [MEDICAL CONDITION] to hand, history of septic arthritis, s/p surgery to right knee, and muscle spasms. On 07/29/2020, the resident was noted to have a right hand contracture. The goal stated the resident would be/remain free of complications related to arthritis (contractures, joint stiffness, swelling, or decline in mobility), with a target date of 10/27/2020. Interventions included: right knee immobilizer as needed for support while up to wheelchair or recliner, initiated on 05/30/2019; appointments with physician as scheduled, initiated 11/02/2016; give [MEDICATION NAME] as ordered by the physician, monitor and document for side effects, initiated on 11/02/2016; monitor healed surgical site daily on right knee, initiated on 01/31/2017; monitor/document/report to physician as needed signs and symptoms related to arthritis, joint pain, joint stiffness, usually worse on wakening, swelling, decline in mobility, decline in self care ability, contracture formation/joint shape changes, crepitus (creaking or clicking with joint movement), pain after exercise, or weight bearing, initiated on 11/02/2016; no range of motion to right lower extremity, initiated on 02/07/2016; and notify physician if swelling to right knee worsens, pain worsens or drainage occurs, initiated on 11/12/2016. However, there was no documented evidence the facility developed or implemented Restorative Care with interventions, services, or treatment to maintain the resident's current functional status or to prevent a decrease in function. Review of the Quarterly (MDS) Assessment, dated 08/04/2020, revealed the facility assessed the resident to have a BIMS score of four (4) out of fifteen (15) indicating severe cognitive impairment. Additionally, the facility assessed the resident as requiring total assistance of two (2) staff for bed mobility, transfers, and toilet use. Per the assessment, the resident had functional limitation in ROM to one (1) upper extremity and one (1) lower extremity. Continued review of the assessment, revealed the resident received five (5) days of Occupational Therapy at least fifteen (15) minutes a day within the last seven (7) days of the assessment. Review of Resident #11/37's Occupational Therapy Plan of Care, dated 07/29/2020 through 08/18/2020, revealed the resident was referred to OT services following increased pain, redness, and decreased movement noted to the right ring and the right little finger. The resident was noted to have increased redness to the right knuckles and top of hand. Per the plan of care, therapy was needed for decreased pain, decreased risk for further finger contractures, and increased ROM to the right digits; without therapy, the resident was at risk for increased severe pain and further noted contractures, with increased risk of skin integrity concerns. Per the plan of care, short-term goals were for the resident to increase fine motor coordination with contact guard assist in order to complete care tasks; to have decreased pain in right hand in order to perform object manipulation; to demonstrate donning/doffing of right resting hand splint improving the resident's minimal assistance in order to increase the resident's ability to manipulate objects; and, to improve the right little and ring finger to 0-90 degrees movement without pain. Further review revealed the long-term goal was for the caregiver to be able to assist the resident to complete the exercise program for right digit motion with contact guard assist and respond to tactile and verbal instructions/cues to properly apply the hand brace to decrease contractures. Review of Resident #11/37's Occupational Therapy Daily Treatment Note, dated 08/07/2020, revealed the resident was able to tolerate the use of the gel filled palm protector in order to decrease the risk of skin integrity concerns and increase ROM to the right hand. Continued review revealed therapy monitored the resident's right hand during the day and noted no skin irritation and redness to the hand with use of the palm protector. Review of Resident #11/37's Occupational Therapy Discharge Summary, dated 08/18/2020, revealed the resident's short-term goals were met; the resident demonstrated poor fine motor coordination of right hand with maximum assistance; moderate pain in the right hand; demonstrated donning/doffing of right hand gel palm protector with assistance; the long-term goal revealed the caregiver would be able to assist the resident to complete the exercise program for right digit (ROM) with contact guard assistance and tactile and verbal instructions/cues to decrease contractures and properly apply the hand brace. Per summary, skilled service provided at the start of care included slow passive range of motion, donn/doff of the gel palm protector, and staff education on the use of the gel palm protector. The resident was discharged to the care of nursing on 08/18/2020. Review of Resident #11/37's Order Summary Report of active orders for October 2020, revealed the resident had no active order for a gel palm protector device. Additional review revealed an order dated 08/18/2020 for resident to be discharged from Occupational Therapy Services on this date, for the palm protector program. Review of Resident #11/37's Progress Notes, dated 08/01/2020 through 09/30/2020, revealed no documented evidence of Restorative Care interventions being implemented. Observation of Resident #11/37, on 09/29/2020 at 10:32 AM, revealed the resident up in his/her wheelchair with his/her right hand closed with the fingers folded into his/her palm at rest on the wheelchair arm. Further observation of the resident's room revealed no gel palm protector device in the room. Interview and observation with Resident #11/37, on 10/02/2020 at 4:10 PM, revealed Occupational Therapy was providing ROM to the resident's right hand. The resident was seated in a wheelchair with no device noted to the right hand. The device was observed on the night stand to the far right side of bed; the resident was unable to get his/her wheelchair between the bed and the wall to access the device. Further observation revealed the resident's right hand was at rest on the right wheelchair arm with the ring and pinky fingers bent at rest and more abducted than the middle finger, and the resident could not straighten or extend the fingers for full ROM. The resident stated it hurt when the OT picked up his/her fingers, and he/she could not open these fingers; however, the resident was able to make a full fist with the right hand. The resident stated at times the right hand hurt and felt as though the nails were digging and cutting into his/her skin. OT acknowledged, during the observation, the resident's nails and finger had pressed on the palm, causing redness. OT stated the palm protector when worn, would also prevent skin impairment. Further observation revealed in the mid-palm of the resident's right hand, a red non-blanchable circular area the size of a pencil eraser with peeling edges throughout. Resident #11/37 stated he/she could not stand for the fingers to be pulled out and liked to wear the palm protector because it felt good and kept the nails from cutting his/her skin. The resident's palm protector was then applied by the OT. Interview with the OT, on 10/01/2020 at 2:25 PM, revealed Resident #11/37 was seen by Occupational Therapy about a month ago related to his/her right hand contracture. She stated she did not remember the resident having this contracture when she started as they just started seeing him/her related to the contracture at the end of July. Per interview, she stated therapy provided education to all nursing staff on application and removal of the palm protector device for the resident's right hand, stating there was instructional pictures provided on how to appropriately apply and remove the device placed at the nurse's station. She stated staff should be utilizing this for Resident #11/37 as he/she tolerated the device. Per interview, the OT stated she was not aware the resident had not been wearing the right hand palm protector per therapy's recommendations. Interview with SRNA #3, on 10/01/2020 at 3:24 PM, revealed she cared for Resident #11/37 frequently, and to her knowledge, Resident #11/37 had never had a palm protector for his/her hand. She stated she had noticed the resident's right hand balled up in a fist more frequently and thought nursing was aware of this. SRNA #3 stated there was no mention of a device on Resident #11/37's Kardex or instructions for device application. 4. Review of (TRUNCATED)

Based on observation, interview, record review, review of job descriptions, and review of the facility's policy, it was determined the facility failed to ensure the Governing Body, or designated persons functioning as a Governing Body, that was legally responsible for establishing and implementing policies regarding the management and operation of the facility, was responsible and accountable for the QAPI program, related to the facility's Acceptable Plan of Correction (POC), provided on 09/22/2020. The facility submitted a Plan of Correction for deficiencies, cited on 06/26/2020, alleging compliance on 09/25/2020. However, during a noncompliance revisit, conducted on 09/28/2020 through 10/08/2020, it was determined the facility failed to implement their plans of correction as described in the documents issued to the State Survey Agency for F-689, F-692, F-700, F-758, and F-865. The findings include: Review of the facility's policy, Quality Assurance and Performance Improvement (QAPI) Plan, revised 04/2014, revealed the facility shall develop, implement, and maintain an ongoing, facility-wide QAPI plan designed to monitor and evaluate the quality and safety of resident care, pursue methods to improve care quality, and resolve identified problems. The owner and/or Governing Board (body) of the facility shall be ultimately responsible for the QAPI program, and the Administrator was responsible for assuring the facility's QAPI Program complied with federal, state, and local regulatory requirements. Review of the Administrator's Job Description, undated, revealed the purpose of the Administrator's job was to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing facilities to assure the highest degree of quality of care could be provided to residents at all times. Continued review revealed the Administrator was to assist the Quality Assurance and Assessment Committee in developing and implementing appropriate plans of action to correct identified quality deficiencies. Review of the Compliance Officer's Job Description, undated, revealed the position's purpose was to provide direction and oversight of the operating organization's compliance and ethics program. Further review revealed the major duties and responsibilities of the position were to assist with overseeing and monitoring implementation of the compliance program. Review of the QAPI Meeting attendance sign-in sheets, revealed no documented evidence any member of the Governing Body (CEO, Compliance Officer, and/or Board of Director's member) attended. Interview with the Administrator and Regional Liaison, on 10/08/2020 at 3:23 PM, revealed they did not consider the Regional Staff members part of their Governing Body. They stated the Governing Body was the CEO of the facility and the Board of Director's members. Further interview revealed they were available as needed and corresponded with the Governing Body over the phone to relay information. The Administrator stated he was ultimately responsible for the actions that happened in the facility and to ensure the Plan of Correction was acted upon as to what the facility stated would occur. He stated, as the Administrator, he reported to the Governing Body, and the Governing Body was updated on the day-to-day operations in regard to the POC. Interview with the Vice-President of Compliance, on 10/08/2020 at 3:47 PM, revealed he was not considered part of the Governing Body. He stated his job duties were to provide support to the facility and provide any help where it was needed. He stated he had been helping with the facility's Plan of Correction and helping to collect audits and attend QAPI meetings to discuss findings. The Vice-President stated any issues identified with the audits would be corrected immediately.

Based on record review, staff interviews, review of the facility's policy, and review of the Administrator's Job Description, it was determined the Quality Assurance and Program Improvement (QAPI) committee failed to identify quality deficiencies, take actions aimed at performance improvement, track performance to ensure that improvements were realized and sustained related to citations of F-689, F-692, F-700, F-758, and F-865. This resulted in harm to five (5) of thirty (30) sampled residents (Resident #4/20, #7/23, #3/31, #34, and #11/37) related to the facility's failure to have an effective plan to self-identify quality of care concerns, and implement a plan, to prevent the worsening significant/severe weight loss for these residents. The facility provided an acceptable Plan of Correction (POC), on 09/22/2020. The POC stated the facility was in compliance, as of 09/25/2020. The findings include: Review of the facility's policy, Quality Assurance and Performance Improvement (QAPI) Plan, revised 04/2014, revealed the facility shall develop, implement, and maintain an ongoing, facility-wide QAPI plan, designed to monitor and evaluate the quality and safety of resident care, pursue methods to improve care quality, and resolve identified problems. Further review of the policy revealed the owner and/or Governing Board (Body) of the facility shall be ultimately responsible for the QAPI program, and the Administrator was responsible for assuring the facility's QAPI Program complies with federal, state, and local regulatory requirements. Review of the Administrator's Job Description, undated, revealed the purpose of the Administrator's job was to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing facilities to assure the highest degree of quality of care could be provided to residents at all times. Continued review revealed the Administrator was to assist the Quality Assurance and Assessment Committee in developing and implementing appropriate plans of action to correct identified quality deficiencies. 1. Review of the facility's Plan of Correction (POC) for F-689, signed by the Administrator on 09/21/2020, revealed the facility was cited F-689 with a completion date of 09/25/2020. Continued review revealed incident reports for the previous day would be reviewed Monday through Friday in the Clinical Meeting to ensure appropriate interventions were implemented and an updated plan of care was complete. In addition, review revealed audits would be performed to ensure that appropriate interventions were put into place timely, to reduce the risk of resident falls/accidents and care plans have been updated to reflect these interventions. Review of the audits for F-689 revealed the purpose of the audits were to review incident reports to ensure appropriate interventions have been put in place timely to reduce the risk or resident falls/accidents and that care plans have been updated to reflect the interventions. Review of a facility Audit, with dates ranging from 09/27/2020 through 10/02/2020, revealed Resident #5/2 had sustained a fall on 09/27/2020. The Audit stated Resident #5/2's Incident Report was reviewed and completed, ice was offered with neurological checks completed and the Comprehensive Care Plan (CCP) was updated. However, after review of the medical record, Resident #5/2 had three (3) falls within eleven (11) hours: on 09/27/2020 at 2:45 PM, on 09/27/2020 at 6:40 PM, and on 09/28/2020 at 2:00 AM. However, the Audit, which included dates 09/27/2020 through 10/02/2020, did not included two of the resident's falls, the fall on 09/27/2020 at 6:40 PM, and fall on 09/28/2020 at 2:00 AM. Additional review revealed the CCP was not revised on 09/27/2020 to include providing ice water, performing neurological checks, routine rounding, until 09/29/2020, two (2) days after the fall occurrences and the Audit, on 09/27/2020. Further, the Audit did not identify the CCP was not revised to reflect the bolsters, in use at the time of the fall occurrence on 09/27/2020. (Refer to F-689 and F-657) Interview with the Facility's Administrator, on 10/06/2020 at 4:54 PM revealed their audit did not identify Resident #5/2's CCP interventions were not in place. However, when he became aware they started, on 10/05/2020, a new process that required the DON be called 24/7 to update the care with new interventions. 2. Review of the facility's Plan of Correction (POC) for F-692, signed by the Administrator on 09/21/2020, revealed the facility was cited F-692, with a completion date of 09/25/2020. Continued review revealed the Director of Nursing (DON) would conduct an audit of five (5) resident charts weekly for four (4) weeks then five (5) resident charts biweekly for eight (8) weeks to ensure any significant/severe weight losses were identified and their Care Plans with significant/severe weight loss reflected a more person-centered interventions. Any deficient practice found during the audits would be corrected immediately by the DON and education and/or corrective action done as appropriate. Continued review revealed Significant/Severe weight loss would be reviewed in the weekly Nutritionally at Risk (NAR) meeting. Review of the facility's audits revealed the failed to identify resident's weights were not being obtained monthly per the facility's policy and their POC. Resident #3/31, #11/37, #4/20, #7/23, and #34 who were not weighed monthly and suffered significant and severe weight loss. Resident #3/31, #11/37, #4/20, #7/23, and #34 meal intakes were not complete and had omissions. The State Survey Agency identified Resident #4/20, #7/23, 3/31, #34, and #11/37 with significant/severe weight loss; however, only Resident #3/31 was identified in the NAR meeting on 09/10/2020 with weight loss. (Refer to F-692). Interview with the Regional Liaison on, 10/06/2020 at 4:54 PM, revealed it was the DON's responsibility to ensure the audits related to weights were complete and accurate. These audits would then be brought to QAPI for review and to see if any changes needed to be made to the current process. They stated the weights were obtained per their policy and the policy does not define a month; the audits were completed correctly with the weights that were available. 3. Review of the facility's Plan of Correction (POC) for F-700, signed by the Administrator on 09/21/2020, revealed the facility was cited F-700 with a completion date of 09/25/2020. Continued review revealed side rails would be removed from all resident beds, and the administrator would audit all resident beds one (1) time per week for twelve (12) weeks to ensure that no bed rails were on any of the resident beds. Review of the Audits for F-700, revealed bed rails were audited weekly starting 09/17/2020, 09/23/2020, and 09/30/2020, indicating there were no side rails present on any resident beds. However, observation, on 09/28/20 at 10:00 AM, revealed Resident #7/23's bed, in room [ROOM NUMBER], had a ¼-side rail on the left lower quadrant. This side rail was never observed to be in use. The ¼-side rail continued to be observed during the course of the survey, including, on 09/29/20 at 9:50 AM and again at 2:45 PM, on 09/30/20 at 3:10 PM, and, on 10/01/20 at 11:15 AM. The side rail remained on the bed until the State Survey Agency alerted the DON and Administrator, on 10/02/2020 at 6:00 PM. Interview with the facility's Administrator on 10/02/2020 at 5:58 PM, revealed he as well as others audited the whole building as thoroughly as they could, and this was his responsibility as the Administrator. He admitted their audit must have not worked, as there was still a bed that had a side rail present. 4. Review of the facility's Plan of Correction (POC) for F-758, signed by the Administrator on 09/21/2020, revealed the facility was cited F-758 with a completion date of 09/25/2020. Continued review revealed all licensed nursing staff were in-serviced regarding the facility's policy for the Use of [MEDICAL CONDITION] Drugs and Behavioral Assessment, Intervention, and Monitoring. Per the POC, the DON/Nurse Supervisor would complete random weekly audits of five (5) residents on [MEDICAL CONDITION] medications for four (4) consecutive weeks and then five (5) residents biweekly for eight (8) weeks to ensure that appropriate diagnosis, behavioral documentation and Gradual Dose reductions were clearly documented in the medical record. Review of the audits for F-758, revealed the purpose of the audits were to ensure [MEDICAL CONDITION] medications have a diagnosis, behavioral documentation, and Gradual Dose Reductions were documented appropriately. Resident #11/37 was audited on 09/14/2020 stating resident had the appropriate [DIAGNOSES REDACTED]. Record review revealed Resident #11/37 had on order for [MEDICATION NAME] 0.5 milligram (mg) every 24 hours as needed for anxiety starting on 08/05/2020 with no stop date. The Resident's [MEDICATION NAME] was discontinued on 08/14/2020, however, an active order for [MEDICATION NAME] 0.5 milligrams (mg) started on 08/14/2020, as needed with no stop date and no evidence of non-pharmacological interventions prior to use. Interview with the DON, on 10/06/2020 at 4:54 PM, revealed there was issues identified in the facility, regarding [MEDICAL CONDITION] drugs and PRN [MEDICAL CONDITION] drugs not having a stop date, which was noted when performing the audits. However, Resident #11/37 still failed to have a stop date for PRN [MEDICATION NAME], on 10/08/2020 at the time of exit. He stated this should have been corrected as soon as it was identified. 5. Review of the facility's Plan of Correction (POC) for F-865, signed by the Administrator on 09/21/2020, revealed the facility was cited F-865, with a completion date of 09/25/2020. Continued review revealed any deficient practice found by any of the audits would be corrected immediately by the DON or Assistant Director of Nursing (ADON) and education would be provided and/or corrective action by DON or ADON as appropriate. The audit findings would be reported in a monthly QAPI meeting for a minimum of three months. The Interdisciplinary Team (IDT) meeting would be held weekly until placed into compliance. Per the POC, during the IDT meeting, weights would be monitored as recorded from the previous day, if triggered weight loss was identified, recommendations were made by the Registered Dietician (RD), APRN/MD was notified, family was notified, and care plans were updated appropriately. Audits from the previous day were also discussed and any identified issues were addressed. The facility failed to identify any issues until the SSA brought it to their attention, however, with F-692 they failed to identify issues as they stated they obtained the weights on the residents monthly. Review of the audits above for deficiencies F-689, F-692, F-700, and F-758 revealed the facility failed to identify issues or concerns with their audits. Review of the document Staff In-service revealed on 09/11/2020, all staff were re-educated on all deficiencies cited on 06/26/2020: F-689 regarding how all falls and incidents would be reviewed Monday through Friday in the Clinical Meetings to ensure implementation of interventions and updating Care Plans. F-692 regarding weight assessment, interventions, ensuring interventions were in place and carried out for residents with weight loss, residents who have triggered for weight loss were added to the NAR, and monitoring meal intakes for adequate intake. F-700 regarding bed rail removal from all resident beds. F-758 regarding how licensed staff were educated on the Use of [MEDICAL CONDITION] Drugs, Behavioral Assessment, Intervention and Monitoring, and monitoring for behaviors and proper documentation related to [MEDICAL CONDITION] medications. F-865 regarding the Interdisciplinary Team (IDT) was in-serviced on the QAPI plan and the objectives of the plan pertaining to the structure and processes to correct identified quality and/or safety deficiencies, establish and implement plans to correct deficiencies and to monitor the effects of these action plans on resident outcome. The facility ensured education was reiterated on 09/11/2020; however, the facility failed to follow their policy's in regards to obtaining weights, ensuring PRN [MEDICAL CONDITION] medications had a stop date and documented non-pharmacological interventions prior to use, interventions implemented after falls, and no bed rails present in the facility. Interview with the Regional Liaison, on 10/06/2020 at 4:28 PM, revealed the IDT met monthly for the QAPI meetings, per the POC and reviewed the audits. She stated they have been holding Clinical Meetings every day, Monday through Friday, to ensure the audits were being completed and any identified issues were being corrected. She stated they felt as though they executed the POC, almost near perfectly. Continued interview revealed the IDT went over the audits in the QAPI meetings, she stated no real concerns were identified during these meetings. Interview with the DON, on 10/06/2020 at 4:28 PM, revealed it was his responsibility to collect the audits and ensure their completion. He stated he gathered them and skimmed them, and placed them into a binder to take to QAPI for review. Continued interview revealed he was aware there were issues with PRN [MEDICAL CONDITION] medications however, had not implemented a plan into action. He stated in regards to F-689 their audit failed related to timely interventions updated to the care plan. Interview the facility's Administrator, on 10/06/2020 at 4:28 PM, revealed he in-serviced all staff again over all deficiencies on 09/11/2020, and went over expectations of the QAPI process. He stated the DON was responsible for the audits, which included ensuring audits were completed, accurate and were brought to QAPI. He stated that as the Administrator he was responsible for ensuring the overall execution of the POC. He stated they did not identify any issues when audits were brought to QAPI.

Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to ensure each resident receives adequate supervision and assistive devices to prevent accidents for three (3) of eighteen (18) sampled residents (Residents #3, #13 and #17). The facility failed to implement the Falls and Fall Risk, Managing Policy, related to identifying the underlying cause of falls and implementing additional or different interventions to prevent falls. There was no documented evidence of a thorough investigation or root cause analysis to determine the causative factors related to falls. Additionally, there was no documented evidence the facility implemented additional interventions after a fall in order to prevent further falls of the same nature, resulting in residents sustaining further falls with injury. Resident #3 sustained eleven (11) falls in less than four (4) months from 01/31/2020 until 05/10/2020. However, the facility failed to determine the root cause, or failed to care plan and implement interventions to help prevent future falls. Of the eleven (11) falls, three (3) of the falls were from the bed. On 06/13/2020, Resident #3 sustained major injury after a fall from the bed, resulting in the resident being transferred to the hospital and receiving treatment of [REDACTED]. In addition, Resident #17 sustained nineteen (19) falls within a six (6) month period. However, the facility failed to determine the root cause, or care plan and implement interventions to help prevent future falls. Furthermore, Resident #13 sustained eight (8) falls within a one (1) month; however, the facility failed to determine the root cause, care plan and implement interventions to help prevent future falls. (Refer to F656 and F-657) The findings include: Review of the facility's Falls and Fall Risk, Managing, Policy, revised March 2018, revealed staff with the input of the Attending Physician will implement a resident centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk or with a history of falls. In conjunction with the Consultant Pharmacist and nursing staff, the Attending Physician will identify and adjust medications that may be associated with an increased risk of falling. If falling recurs despite initial interventions, staff will implement additional or different interventions or indicate why the current approach remains relevant. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable. Staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. If interventions have been successful in preventing falling, staff will continue the interventions or reconsider whether these measures are still needed if a problem that required the intervention has resolved. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. Review of the facility's policy titled Accidents and Supervision, revised 01/01/2020, revealed the residents' environment was to remain as free of accident hazards as is possible; and each resident was to receive adequate supervision and assistive devices to prevent accidents. This includes identifying hazard(s) and risk(s); evaluating and analyzing hazard(s) and risk(s); and implementing interventions to reduce hazard(s) and risk(s) Interview with the Director of Nursing (DON) on 06/26/2020 at 11:15 AM, revealed after a resident sustained [REDACTED]. Further interview revealed the DON logged each fall on the Fall Log in order to track the falls for each resident. Continued interview revealed falls were investigated during the Morning Meetings with the Interdisciplinary Team and the investigation consisted of a review of the Progress Note, Post Fall Review, and Incident Report. Per interview, the investigation was documented as Morning Meeting minutes. Further, the Morning Meeting minutes were not a part of the medical record. 1. Review of Resident #3's medical record revealed the facility originally admitted the resident on 05/28/2019 and readmitted the resident on 12/10/2019, with [DIAGNOSES REDACTED]. Review of Resident #3's Quarterly Minimum Data Set (MDS) Assessment, dated 12/16/2019, revealed the facility assessed the resident as having both short term and long term memory loss and as rarely understood. There was no Brief Interview for Mental Status (BIMS) conducted. Further review revealed the facility assessed the resident as requiring extensive physical assistance of one (1) person for bed mobility and transfers. Continued review revealed the resident had not sustained a fall prior to this MDS Assessment. Review of Resident #3's physician's orders [REDACTED]. Review of Resident #3's Fall Risk Evaluation, dated 01/31/2020, revealed a total score of five (5), indicating the resident was not at a high risk for falls. A score of ten (10) or greater should be considered high risk according to the Evaluation. A. Review of the Progress Note and Fall Tracking Log, dated 01/31/2020 at 7:55 PM, revealed Resident #3 sustained an unwitnessed fall and was found on the floor in another resident's room, lying on his/her stomach. No injuries were noted. However, there was no documented evidence of a thorough investigation related to this fall to include interviews with staff involved, and no documented evidence the facility determined the root cause of the fall or implemented interventions to prevent further falls of the same nature. A Post Fall Review or Incident Report was not submitted for review related to this fall. Review of the Morning Meeting minutes, dated 02/04/2020, revealed Resident #3 fell on [DATE] and the suggested intervention was to put the resident's name or picture by his/her door. However, observations throughout the survey, revealed there was no name or picture by the resident's door. B. Review of the Progress Note and Fall Tracking Log, dated 03/07/2020 at 5:40 AM, revealed the A Wing nurse reported to Resident #3's nurse that the resident was seen walking at the end of the hallway, attempted to sit back in the wheelchair, and fell on to the floor. Further review revealed a scratch was noted to the resident's left forearm and a band-aid was applied. Review of Resident #3's Fall Risk Evaluation, dated 03/07/2020, revealed a total score of nine (9) indicating the resident was not at a high risk for falls. However, the resident had sustained two (2) falls (01/31/2020 and 03/07/2020). A score of ten (10) or greater should be considered high risk according to the Evaluation. A Post Fall Review or Incident Report was not submitted for review related to this fall. Review of the Morning Meeting minutes, dated 03/09/2020, revealed Resident #3 fell on [DATE], and the suggested intervention was to consider rear anti-tip or anti-roll back to wheelchair; however, the resident already had active orders for the rear anti-tip bars. There was no documented evidence of a thorough investigation related to this fall to include interviews with staff involved, and no documented evidence the facility determined the root cause of the fall or implemented interventions to prevent further falls of the same nature. C. Review of the Progress Note and Fall Tracking Log, dated 03/11/2020 at 7:33 PM, revealed Resident #3 was found in his/her room lying on the floor on his/her right side. Further review revealed, the resident was awake and alert. Noted skin tear and bleeding to top of right arm measuring 4.0 centimeter (cm) by 2.75 cm. Noted bruising to the right elbow. Record review revealed there was no Post Fall Review, Incident Report or Morning Meeting minutes submitted for review related to this fall. In addition, there was no documented evidence of an investigation or root cause analysis related to this fall. Further, there was no documented evidence interventions were implemented to prevent further falls of the same nature. Review of Resident #3's Quarterly MDS Assessment, dated 03/16/2020, revealed the facility assessed the resident as having both short term and long term memory loss. There was no BIMS conducted. Further, the facility assessed the resident as requiring extensive physical assistance of two (2) persons for bed mobility and transfers. Continued review revealed the resident sustained [REDACTED]. Continued review revealed the resident required two (2) person physical assistance with bathing. There was no documented evidence of a CCP to address this resident's falls until 03/23/2020, although the resident sustained [REDACTED]. Review of the Comprehensive Care Plan (CCP) dated 03/23/2020, revealed the resident was at risk for falls related to anti-anxiety medications, anti-depressant medication, resident gets up out of chair unassisted, history of falls, mobility impairment, poor safety awareness, and unsteady gait. The Goal stated staff will manage factors that increase the resident's risk for falls, with a target date of 06/14/2020. Interventions dated 03/23/2020, included: assess the wheelchair to ensure it is the appropriate size; assess need for footrests; assess need to have wheelchair locked/unlocked for safety; assistance of one (1) to two (2) with transfers; bed in the lowest position while in bed; call light within reach and reminders to use it; keep environment free of clutter; rear anti tip bars to wheelchair; and, sensatec (alarm) to bed and wheelchair. In addition, the intervention initiated on 03/23/2020 for call light within reach and reminders to use call light were not appropriate interventions for this resident as the facility assessed the resident as severely cognitively impaired per the MDS assessment dated [DATE]. Record review revealed the resident continued to fall with no new interventions added to the CCP in an attempt to prevent further falls. Per the CCP, the following falls occurred: 03/29/2020, the resident was observed standing up with the lap buddy in hand and lost balance and fell to the right side, with no acute injuries noted; 04/04/2020, the resident was making several attempts to stand up with lap buddy in place, and redirection was unsuccessful. Resident fell to left side hitting head against the nurse's station door frame causing a skin tear to the right lower arm; 04/15/2020, the resident fell with minor injuries noted; 04/20/2020, unwitnessed fall; and the resident was observed on the floor with no injuries, and was in bed prior to the fall; 04/21/2020 unwitnessed fall, resident observed on floor next to bed, no injuries noted; 04/29/2020 unwitnessed fall, resident in bed prior to finding resident on the floor, no injury; 05/01/2020 fall in shower, skin tear noted; 05/10/2020 resident slid from wheelchair. D. Review of the Progress Note and Fall Tracking Log, dated 03/29/2020 at 7:37 PM, revealed Resident #3's alarm was sounding, and the resident was standing in front of the wheelchair, with lap buddy in hand; lost balance and fell to the floor on his/her right side. No injuries noted. A Post Fall Review, Incident Report, or Morning Meeting minutes were not submitted for review related to this fall. Record review revealed no documented evidence the facility completed an investigation, or conducted a root cause analysis related to this fall. In addition, there was no documented evidence the facility implemented additional interventions to prevent further falls of the same nature, or monitored the current interventions for effectiveness. E. Review of the Progress Note and Fall Tracking Log, dated 04/04/2020 at 9:40 AM, revealed Resident #3 was seated in the hallway in the wheelchair and repeatedly attempted to stand up. Alarm sounding, lap buddy in place. Staff redirected the resident several times and was unsuccessful. fell and hit left side of head on A Wing nurse's station door frame. Sustained a sin tear to the right lower arm measuring 8.0 cm by 0.5 cm which was cleansed with normal saline, and six (6) steri strips applied. Review of Resident #3's Fall Risk Evaluation, dated 04/04/2020, revealed a total score of nine (9) indicating the resident was not at high risk for falls. However, the resident had sustained five (5) falls since 01/31/2020. A score of ten (10) or greater should be considered high risk according to the Evaluation. A Post Fall Review or Incident Report was not submitted for review related to this fall. Review of the Morning Meeting minutes, dated 04/05/2020, revealed Resident #3 fell on [DATE] at 9:40 AM, and the suggested interventions were to alert therapy, and possible lap tray needed for positioning as the lap buddy had been discontinued. New physician's orders [REDACTED]. Further, there was no documented evidence of a thorough investigation related to the fall to include interviews with staff involved, nor was there documented evidence the facility determined the root cause of the fall. F. Review of Resident #3's Progress Note and Fall Tracking Log, dated 04/15/2020 at 12:45 AM, revealed staff was called to the resident's room via the resident's roommate. Resident #3 was found lying on the floor parallel to the bed and the wheelchair was behind him/her. Scab on right elbow wound reopened; bleeding some, and clotting well. A Post Fall Review or Incident Report was not submitted for review related to this fall. Review of the Morning Meeting minutes, dated 04/16/2020, revealed the resident was already close to the nurse's station, and the bed was in lowest position, Therapy was alerted to the fall, and the resident had the least restrictive restraint. However, there was no documented evidence Therapy was alerted regarding this fall and no documented evidence additional interventions were implemented to prevent further falls of the same nature. In addition, there was no documented evidence the facility completed a thorough investigation to include interviews with staff involved or determined the root cause of the fall. G. Review of the Fall Tracking Log, dated 04/20/2020, revealed Resident #3 was found on the floor with no injuries noted. There was no documented evidence of a Progress Note, Incident Report or Post Fall Review submitted for review related to this fall. Review of the Morning Meeting minutes, dated 04/21/2020, revealed the suggested interventions were to keep the environment free of clutter, and the bed in lowest position; however, these interventions were already care planned on 03/23/2020. Another suggestion was to monitor bed positioning; however, there was no documented evidence the intervention for monitoring the bed position was implemented or care planned. There was no documented evidence the facility completed a thorough investigation of the fall to include interviews with staff involved, or determined the root cause of the fall. H. Review of the Fall Tracking Log, dated 04/21/2020, revealed Resident #3 was found between the bed and the wall, lying on the floor on his/her buttocks with his/her head against the night stand. Further review revealed the alarm was sounding, and there was no reference to injury or non injury related to this fall. There was no documented evidence of a Progress Note, Post Fall Review or Incident Report submitted for review related to this fall. Review of Resident #3's Fall Risk Evaluation, dated 04/21/2020, revealed a total score of six (6) indicating the resident was not at high risk for falls. A score of ten (10) or greater should be considered high risk according to the Evaluation. However, the resident had sustained a total of eight (8) falls since 01/31/2020 and four (4) falls in the month of April 2020 at this point. Review of the Morning Meeting minutes, dated 04/22/2020, revealed Resident #3 fell from the bed, and the resident had increased episodes of falling from the bed. Suggested interventions included place bed to wall, monitor bed positioning, and sensatec alarm to bed. However, the sensatec alarm to bed was already a physician's orders [REDACTED]. In addition, there was no documented evidence the interventions for bed to wall, and monitor bed positioning were implemented or care planned. Observations of Resident #3's room throughout the survey, revealed the resident's bed was not up against the wall. Continued record review revealed there was no documented evidence of a thorough investigation related to the fall to include interviews with staff involved, or a root cause analysis. Further, there was no documented evidence of additional interventions implemented to prevent further falls, or a review of current interventions for effectiveness. I. Review of the Progress Note and Fall Tracking Log, dated 04/29/2020 at 8:00 AM, revealed Resident #3 attempted to get out of the bed on the left side and fell on the floor; his/her feet were facing the bathroom. Further, the fall was not witnessed, but the alarm was sounding. No visible injuries. There was no Post Fall Review or Incident Report submitted for review related to this fall. Review of the Morning Meeting minutes, dated 04/30/2020, revealed the resident self transferred out of bed. The suggested interventions included bed in lowest position, and pad on floor. However, the intervention for bed in low position was care planned on 03/23/2020. In addition, there was no documented evidence the intervention for mats or pads on the floor was care planned or implemented. Observations from 05/26/2020, through 06/26/2020, of Resident #3's room, revealed no mats or pads on the floor. There was no documented evidence of a thorough investigation or root cause analysis related to the fall. J. Review of the Progress Note and Fall Tracking Log, dated 05/01/20 at 4:38 PM, revealed Resident #3 was in the shower when the State Registered Nursing Assistant (SRNA) turned around to get body wash and the resident got up and fell between the shower wall and shower chair. The resident sustained [REDACTED]. However, per the MDS assessment dated [DATE], the resident was assessed to require two (2) person physical assistance with bathing. Record review revealed no documented evidence of a root cause analysis and no documented evidence the facility identified the resident was being assisted during the shower with one (1) staff instead of two (2) staff as required per the resident's Quarterly MDS assessment, dated 03/16/2020. Further, there was no documented evidence of a fall investigation, or any Post Fall Review related to Resident #3's fall on 05/01/2020. Continued review revealed there was no documented evidence of additional interventions to prevent falls of the same nature or monitoring of current fall interventions. K. Review of the Progress Note and Fall Tracking Log, dated 05/10/2020 at 9:53 AM, revealed Resident #3 was up in the wheelchair in the hallway when he/she slipped out of the wheelchair to the floor. Further, no injuries were noted. There was no Incident Report or Post Fall Review submitted for review related to this fall. Review of the Morning Meeting minutes, dated 05/10/2020, revealed the suggested interventions included having Therapy alerted, bed positioning, get resident out of bed earlier, and bed could be moved to the wall to aide in prevention. Observations, throughout the survey 05/26/2020, through 06/26/2020, revealed the resident's bed was not against the wall. In addition, there was no documented evidence interventions were care planned or implemented related to the bed positioning, or to get the resident out of bed earlier or move the bed to the wall. Review of the Morning Meeting minutes, dated 05/11/2020, revealed suggested interventions included provide continued monitoring every thirty (30) minutes and every two (2) hours for toileting. Further review revealed Therapy was alerted of the fall. Per the minutes, anti-tip bars were in place, sensatec (alarm) was in place, and call light was within reach. However, there was no documented evidence these interventions were care planned or implemented related to monitoring every thirty (30) minutes and every two (2) hours for toileting, or to alert Therapy of falls. Record review revealed Resident #3 had not been referred to Therapy since he/she met his/her therapeutic goals on 02/13/2020, and was only referred on 05/12/2020 after he/she sustained nine (9) falls from 02/13/2020 to 05/12/2020. In addition, review of the Therapy Notes, revealed the referral was due to the resident's head positioning in the wheelchair and there was no documented evidence the referral addressed the resident's frequent falls. There was no documented evidence of an investigation to include interviews with staff involved related to the fall, root cause analysis or additional interventions implemented or care planned after the fall on 05/10/2020. Review of Resident #3's Quarterly MDS assessment, dated 06/11/2020, revealed the facility assessed the resident as having both short term and long term memory loss. Further, the facility assessed the resident as requiring total dependence of two (2) or more with bed mobility and transfers. Continued review revealed activity did not occur for walking and resident utilized a wheelchair. Per the MDS Assessment, the resident sustained [REDACTED]. However, this MDS Assessment was incorrect as the resident sustained [REDACTED]. (Refer to F-641). L. Review of the Nurse's Notes and Fall Tracking Log, dated 06/13/2020 at 12:33 AM, revealed Resident #3 was found in his/her room lying between his/her roommate's bed and the bathroom floor with blood under his/her head and lying on his/her left arm. A laceration was noted to the left side of the resident's forehead. Further review revealed the POA and Physician were notified. Nurse called 911 (Emergency Medical Services, EMS) for transport to the hospital. Review of Resident #3's Hospital's Nurse's Notes, dated 06/13/2020, revealed the resident presented to the emergency room with a C-collar on per EMS, and was noted to have a laceration to the left side of the forehead after an unwitnessed fall. Resident #3 received wound repair to the subcutaneous laceration to the forehead measuring 3.0 centimeters (cm) by 1.2 cm. Skin was closed with six (6) 5-0 Ethilon using interrupted sutures and dressed with a bandaid. Review of the Hospital's Discharge Summary, dated 06/13/2020, revealed the resident was diagnosed and treated for [REDACTED]. Attempted phone interview on 05/25/2020 at 4:33 PM, with SRNA #19, who was assigned to Resident #3 on 06/13/2019 at the time of the fall. However, the voice mail box had not been set up to allow a voicemail message to be left. Interview with LPN (Licensed Practical Nurse) #8, on 06/19/2020 at 4:15 PM, revealed Resident #3 had a history of [REDACTED]. She stated the resident had an alarm on the bed to alert staff that the resident was attempting to get out of bed, but most times it only sounded after the resident had sustained the fall. Per interview, the resident was frequently on the move and very restless, and due to this, he/she was kept close to the nurse's station and was observed frequently during the shift. Continued interview revealed she was the nurse assigned to Resident #3 on 06/13/2020 when he/she fell from the bed sustaining the laceration to the forehead. She stated the bed alarm sounded and alerted her to the fall. Per interview, she was unable to recall when the resident was last toileted prior to the fall or if there was a pad on the floor by the bed at the time of the fall. LPN #8 stated the resident was cognitively impaired and could not explain why he/she got out of the bed or how he/she fell . Further interview revealed the resident was transferred to the emergency room related to the laceration to his/her forehead. Review of the Morning Meeting minutes, dated 06/15/2020, revealed suggested interventions for Resident #3 included therapy ordering a dyn-ergo scoop chair (a chair designed to reduce the risk of falls for wheelchair users who propel themselves with their feet, and can help to increase independent mobility). Observation of Resident #3 on 06/25/2020 at 8:35 AM, revealed the resident was self propelling in the hallway in the scoop chair. However, there was no Post Fall Review, or Incident Report provided for review related to this fall, nor was there documented evidence of a thorough investigation to include a root cause analysis related to this fall. Further, the intervention for the dyn-ergo scoop chair was not care planned. M. Review of Resident #3's Progress Note, dated 06/18/2020 at 2:35 PM, revealed the resident was sitting on the front porch for activities in his/her wheel chair. Per the Note, the resident started pushing backward with his/her feet, causing the wheelchair to flip over. Further, the resident landed on the decorative rocks in front of the porch. Continued review revealed Resident #3 hit his/her head and sustained a laceration to the right side of his/her forehead. The ARNP was made aware and new orders were received to transfer the resident to the hospital to evaluate and treat. Review of the Hospital's Nurses Notes, dated 06/18/2020, revealed Resident #3 had intact sutures to the left side of the head from a prior fall last week. Skin tear noted to forehead from the fall today and complains of pain in forehead. Laceration to forehead measured 0.5 to 2.5 cm long, with no active bleeding. Review of the Hospital's Discharge Instructions, dated 06/18/2020, revealed the resident had a negative head and cervical spine computerized tomography (CT) scan. Interview with the Director of Nursing (DON), on 06/18/2020 at 3:36 PM, revealed earlier today she wheeled Resident #3 towards the front porch and then had SRNA #18 take the resident out to the porch for an activity and informed the SRNA she needed to watch the resident. However, interview with SRNA #18, on 06/19/2020 at 9:36 AM, revealed she was assisting another resident with visitation and ensuring they were maintaining social distancing and she was not assigned to Resident #3. Per interview, she just assisted Resident #3 out to the porch and left to go back inside the building. The SRNA stated she did not think to lock Resident #3's wheelchair brakes as the resident was outside with the Activities Assistant and she thought the resident would be monitored. Interview with the Activities Director and Activities Assistant, on 06/18/2020 at 3:59 PM, revealed earlier in the day when they were assisting residents out on the porch, they were only bringing out residents who were cognitively aware and did not need close monitoring. Per interview, this was because Activities staff was leaving the residents unattended in order to go back inside the building to gather more residents to bring outside to play bingo. Further, they were unaware Resident #3 was outside on the porch until they heard a staff member yell out for assistance. Continued interview revealed the Nurse Educator found the resident lying on his/her side in the shrubs and lava rocks. The Activities Director stated she would often times sit one on one (1:1) with Resident #3 as she was aware this resident required her full attention due to decreased safety awareness. She further stated staff should have made her aware when they brought Resident #3 out on the porch and she would have kept a close eye on the resident or would have asked staff to wait and let her bring the resident out later when she could ensure he/she was closely observed for safety. Further record review revealed there was no documented evidence the facility conducted an investigation or determined the root cause of the resident's fall off the porch. In addition, there was no documented evidence the facility identified the resident's wheelchair brakes were not locked while outside with activities staff as per the interview with SRNA #18, nor was it identified Resident #3 needed close observation when in activities as per the interview with the Activities Director and Activities Assistant, on 06/18/2020. There was no Fall Log, Incident Report, Post Fall Review or Morning Meeting minutes submitted for review related to this fall. Although Resident #3 sustained ten (10) falls after 03/23/2020, there was no documented evidence of new interventions care planned or implemented to prevent falls from 03/23/2020 until 06/16/2020, after the State Survey Agency Surveyor asked for documentation related to Resident #3's falls. Interview with the Director of Physical and Occupational Therapy, on 06/26/2020 at 8:37 AM, revealed she was an Occupational Therapist and was very familiar with Resident #3. Per interview, she remembered attempting many things in the past to help with fall prevention, such as wheelchairs, and positioning devices. She further stated the resident was just recently referred back to Therapy. Further interview revealed Resident #3 was very restless and would greatly benefit from a good restorative program where he/she could be walked frequently to help with the restlessness. Continued interview revealed after a resident sustains falls, depending on the nature of the falls and the frequency of the falls, the resident should be referred to Therapy to help identify the cause of the fall and to identify if the resident was in need of a different wheelchair or a positioning device for stability. However, further interview revealed this did not always happen. 2. Review of Resident #17's medical record revealed the facility admitted the resident on 01/22/2020 with [DIAGNOSES REDACTED]. Review of Resident #17's Admission MDS Assessment, dated 01/28/2020, revealed the facility assessed the resident as having a BIMS of eleven (11) out of fifteen (15), indicating moderate cognitive impairment. Continued review revealed the facility assessed the resident as requiring extensive assistance of two (2) persons with bed mobility, transfers, and ambulation assistance. Further, per the MDS Assessment the resident had sustained one (1) fall prior to admission to the facility Review of Resident #17's Comprehensive Care Plan (CCP), dated 01/22/2020, revealed a Focus of at risk for falls related to generalized weakness, history of falls and self-transfers. The Goal stated staff will manage factors that increase the resident's risk for fall, with a target date of 05/18/2020. Interventions included assistance of one to two (1-2) with transfers, dated 01/22/2020; call light within reach and remind to use it, dated 01/22/2020, and educate resident on the importance of using call bell and waiting for assistance, dated 01/27/2020. Record review revealed the resident continued to fall with no new intervention (TRUNCATED)

Based on interview, record review, review of facility policy, and review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, it was determined the facility failed to ensure services were provided in accordance with each resident's Comprehensive Care Plan for one (1) of nineteen (19) sampled residents (Resident #70). Resident #70's Comprehensive Care Plan initiated 01/12/16, revealed the resident required extensive assist of two (2) staff for transfers and toileting. However, on 03/28/18, per staff interviews, Resident #70's Care Plan was not implemented and the resident was transferred to the toilet with the assist of one (1) staff member and then was left on the toilet unsupervised. Resident #70 sustained a fall and subsequently was transferred to the Hospital emergency room (ER) on 03/28/18, and was diagnosed with [REDACTED]. (Refer to F-689) The findings include: Review of the facility's Care Plan Policy, undated, revealed an interdisciplinary care plan should be initiated on admission to address immediate needs and ensure resident safety. Review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, dated (MONTH) (YEAR), revealed the Comprehensive Care Plan is an interdisciplinary communication tool and must include measurable objectives and time frames and must describe the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Further review revealed the services provided or arranged must be consistent with each resident's written Plan of Care. Review of Resident #70's medical record revealed the facility admitted the resident on 01/12/16, with [DIAGNOSES REDACTED]. Review of the Comprehensive Care Plan, initiated 01/12/16, revealed Resident #70 had a problem of Impaired Cognition and Activities of Daily Living (ADL) self-care performance deficit related to Dementia, [MEDICAL CONDITIONS], and [MEDICAL CONDITION] Right Eye. The goal revealed the resident would be able to communicate basic needs and would improve level of function in ADLs through review date of 08/03/18. The interventions included the following: cue, reorient and supervise as needed; extensive assist of two (2) staff to transfer; and extensive assist of two (2) staff to toilet. Continued review of the Comprehensive Care Plan, initiated 01/12/16, revealed Resident #70 was at risk for falls related to psychoactive drug use; vision problems/[MEDICAL CONDITION]/[MEDICAL CONDITION] Right Eye/ [MEDICATION NAME] Degeneration; History of Falls; Muscle Weakness; and was known to self-transfer. The goal revealed the resident would follow safety precautions and voice understanding to decrease fall risk. The interventions included the following: dycem to top and bottom of wheelchair cushion to prevent sliding; and call light within reach and encourage to use the call light. Review of Resident #70's Quarter Minimum Data Set (MDS) Assessment, dated 01/28/18, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of thirteen (13) out of fifteen (15) which indicated the resident was cognitively intact. Additional review revealed the facility assessed the resident as always incontinent of bowel and bladder; and as having no falls. Continued review of the MDS Assessment, revealed the facility assessed the resident as ambulation did not occur; as having unsteady balance during moving from seated to standing position, moving on and off toilet and surface to surface transfers; and as requiring extensive assistance of two (2) for transfers and toileting. Review of Resident #70's Nursing Assistant Care Guide, dated 03/01/18 through 03/31/18, revealed the resident was at high risk for falls; required extensive assistance of two (2) staff and a gaitbelt for transfers; and required extensive assistance of one (1) staff for elimination/toileting. (The Comprehensive Care Plan in effect for (MONTH) (YEAR), revealed the resident required two (2) staff for toileting). Observation and interview with Resident #70, on 05/29/18 at 1:33 PM, revealed the resident was sitting in the wheelchair at bedside with a buckle seat belt attached across his/her lap. Resident #70 revealed he/she knew how to remove the seatbelt and demonstrated pulling the seatbelt apart and then putting it back together. Per interview, the seatbelt made him/her feel more secure since a fall occurrence three (3) to four (4) weeks ago. Resident #70 was unable to further elaborate on the details related to the fall. Further interview revealed his/her pain was not as bad as it was before surgery. Review of Resident #70's Nurse's Note, dated 03/28/18 at 4:40 PM, completed by Registered Nurse (RN) #1, revealed a Nursing Assistant reported the resident had an unwitnessed fall and was on the bathroom floor with head against door opposite of resident's room. The Note further stated the resident verbalized hitting his/her head on the door, and was complaining of severe pain in the lower back, and requested to lye down in bed. Per the Note, the resident was assisted to bed. A Nurse's Note entry, dated 03/28/18 at 4:55 PM, completed by RN #1, revealed the resident's Power of Attorney (POA) was notified of the fall and requested the resident be sent to the Hospital for evaluation. The Note stated, the physician was contacted and a verbal order was received to send the resident to the Hospital emergency room (ER) per family request secondary to a fall. A subsequent Nurse's Note entry, dated 03/28/18 at 5:20 PM, completed by RN #1, revealed the resident left the facility via ambulance. The Nurse's Note dated 03/28/18 at 10:05 PM, completed by RN #1, revealed the resident returned to the facility via ambulance with [DIAGNOSES REDACTED]. Review of Resident #70's Fall Resident Incident Report, completed by RN #1, revealed on 03/28/18 at 4:50 PM, an unwitnessed fall occurred and the resident was observed lying on his/her back in the bathroom floor with his/her head touching the opposite door, complaining of back pain. The resident stated he/she was trying to get off the toilet. Two (2) staff assisted the resident off the floor, status [REDACTED]. Per the Incident Report, the interim fall intervention was to educate all Nursing Assistants to refrain from leaving any resident alone in the bathroom. The Incident Report which was signed by the DON on 03/29/18, and the Administrator on 03/30/18, did not name which staff were involved in the incident. Review of Resident #70 Accident Circumstance Assessment, dated 03/28/18, unsigned, revealed the accident occurred on 03/28/18 at 4:50 PM, when the resident was self transferring from the toilet to the wheelchair in the bathroom. Further review revealed the preventative measure status [REDACTED]. Interview with RN #1, on 06/08/18 at 9:10 AM, revealed she had completed the Assessment. Review of Resident #70's Hospital Computed Tomography (CT) Lumbar Spine without contrast, Final Report, dated 03/28/18, revealed a [DIAGNOSES REDACTED]. Review of Resident #70's Hospital Discharge Summary, dated 03/29/18, revealed the resident was not a clear historian and had a fall from the standing position, hitting the back of his/her head on the floor with sudden aching pain at the base of the skull and lower back area. Further review revealed the resident was unable to independently dress, attend to toileting needs, transfer independently or maintain control of urinary and bowel functions. Continued review revealed discharge recommendations included to continue current [MEDICATION NAME] as needed for pain control, Physical Therapy (PT) evaluation and consider Orthopedic evaluation if pain could not be controlled. Per the Summary, the resident was not to bend, twist, or lift for 1 (one) week, and a follow up appointment was scheduled for 05/30/18 at 10:15 AM. Review of Resident #70's Orthopedic consult dated 05/10/18, revealed surgery was scheduled for a L2 Kyphoplasty (surgical filling of an injured or collapsed vertebrae which restores original shape and configuration and relieves pain from spinal compression) for 05/16/18. Review of Resident #70's Physician's Progress Note, dated 05/16/18, signed by a facility Physician, revealed the resident returned from having a Kyphoplasty today and reported the pain in his/her back was better. Post Survey phone interview on 06/08/18 at 9:00 AM, with State Registered Nursing Assistant (SRNA)#7, revealed she worked at the facility as Agency staff on 03/28/18, and on that date she was assigned to Resident #70. Per interview, she had reviewed Resident #70's Nursing Assistant Care Guide prior to providing care, and was aware the resident required the assist of two (2) staff for transfers and toileting, and was at risk for falls. Continued interview revealed she was aware Resident #70 would self transfer independently at times. Additional interview with SRNA #7, revealed the evening of 03/28/18 at about 4:30 PM, she found Resident #70 in the bathroom floor by the toilet and notified RN #1. Per interview, she did not touch Resident #70 until RN #1 assessed the resident, and then she (SRNA #7) and RN #1 transferred the resident from the floor to the wheelchair and from the wheelchair to the bed. SRNA #7 stated she did not assist Resident #70 to the toilet or leave the resident unattended in the restroom prior to finding the resident in the floor. SRNA #7 stated she was aware Resident #70 required assistance with transfers and toileting and should not be left alone in the restroom. Per interview, Resident #70 must have tried to transfer himself/herself independently onto the toilet from his/her wheelchair and sustained the fall. Post survey phone interview with SRNA #8, on 06/11/18 at 11:59 AM, revealed she was working with SRNA #7 the evening of 03/28/18. SRNA #8 stated she did not remember the exact time Resident #70 fell , but she did recall she and SRNA #7 were transporting residents to the shower room for the shower team prior to the fall. She stated as they passed Resident #70's room, he/she called out to SRNA #7, in the hallway, that he/she needed to go to the restroom. Per interview, SRNA #7 started towards Resident #70's room and SRNA #8 told her the resident was an assist of two (2) for transfers and toileting and she would help. SRNA #8 further stated, SRNA #7 informed her Resident #70 was assigned to her and she would take care of the resident and entered Resident #70's room and closed the door behind her. Per interview, she (SRNA #8) went to transport another resident into the shower room after SRNA #7 entered Resident #70's room. SRNA #7 stated less than five (5) minutes later when SRNA #8 entered the hallway she saw SRNA #7 sticking her head out of Resident #70's door. Per interview, SRNA #7 told her (SRNA #8) to go get the nurse because the resident fell . Continued interview with SRNA #8, revealed she alerted Licensed Practical Nurse (LPN) #3 on the hallway of the fall and then went to Resident #70's room. SRNA #8 stated the resident was sitting on the floor in front of the toilet and the wheelchair was in the resident's room near the bathroom door. SRNA #8 further stated she did not witness SRNA #7 transfer Resident #70 onto the toilet; however, SRNA #7 told her when she entered Resident #70's room, she had assisted the resident to the toilet and stepped out of the restroom to get a brief when the resident stood up unassisted and fell to the floor. Additional interview with SRNA #8, revealed RN #1 provided education to the SRNAs on the hallway on 03/28/18 related to not leaving the residents alone on the toilet after the incident. Per interview, SRNA #7 had worked at the facility multiple times prior to this fall incident and was familiar with Resident #70 and the facility's procedures. However, she stated SRNA #7 usually worked independently and was not partnered with a facility SRNA because she preferred to provide care for her assigned residents by herself. Post survey phone nterview with RN #1, on 06/08/18 at 9:10 AM, revealed she was assigned to Resident #70 on 03/28/18 and at approximately 4:50 PM on that date, a SRNA notified her Resident #70 had a fall and was in the floor. RN #1 stated she could not remember which SRNA notified her of this, but she immediately entered Resident #70's room. Per interview, she observed the resident sitting propped up against the bathroom door frame and he/she complained of lower back pain and asked to get off the floor. RN #1 stated she assessed the resident's vital signs and neurological status and after checking the resident's head and skin for obvious injuries, the resident was assisted from the floor to the wheelchair, and then to bed. Per interview, Resident #70 continued to complain of lower back pain after being assisted to bed and she administered pain medication. RN #1 stated she completed an Incident Report, and then called the family and physician to notify them of the fall. Per interview, the family did not answer her first call; however, called back and asked RN #1 to send the resident to the ER to be on the safe side since he/she was complaining of lower back pain. RN #1 stated the resident was then sent to the local Hospital ER for evaluation. Additional interview with RN #1, revealed a facility SRNA told her SRNA #7 had assisted Resident #70 to the toilet independently and then stepped out of the bathroom to gather supplies prior to the resident sustaining the fall. She stated she was unsure which facility SRNA had informed her of the resident being left on the toilet alone by SRNA #7. She further stated SRNAs were to provide care to each resident by following the individualized Nursing Assistant Care Guide located on the back of each resident's door. Per interview, the Nursing Assistant Care Guide specifically guides staff on the type of assistance required for transfers, toileting, eliminations needs, safety precautions and devices. RN #1 stated she did not show SRNA #7 where the Nursing Assistant Care Guides were located at the beginning of the shift on 03/28/18 because SRNA #7 had worked at the facility before. Continued interview with RN #1, revealed at the time of Resident #70's fall, the resident required assistance of two (2) staff for transfers and toileting which meant staff was to stay with the resident while the resident was on the toilet. Per interview, Resident #70 had a history of [REDACTED]. She stated she call the Director of Nursing (DON) after Resident #70 fell to make sure she had followed policy related to paperwork after the fall incident, and to find out if there was anything else she needed to do. RN #1 revealed the DON directed her to educate all SRNAs who were on duty at the time that no resident should ever be left unattended on the toilet in the restroom. Per interview, she gathered all the SRNAs at the nursing station and provided education related to supervising residents in the bathroom to maintain resident safety. She stated SRNA #7 was not present during the education and had already left the facility as she had stayed late to assist with care and her replacement SRNA had arrived. RN #1 further stated she did not obtain a written or verbal statement from SRNA #7 to find out what happened prior to her leaving the facility on 03/28/18. Per interview, it was important for staff to follow the care plan for the safety of the residents. Interview with the Minimum Data Set (MDS) Coordinator, LPN #5, on 05/31/18 at 08:13 PM, revealed she completed Resident #70's Quarterly MDS assessment dated [DATE] and the accompanying Comprehensive Care Plan. LPN stated Resident #70 was a fall risk and per the resident's Comprehensive Care Plan he/she required extensive assistance of two (2) staff for transfers and toileting and due to poor safety awareness would attempt to self transfer independently. Further interview revealed staff should always follow the Care Plan related to assistance needed with ADLs and supervision to ensure resident safety. Interview with the DON, on 05/31/18 at 8:33 PM, and post survey phone interview on 06/08/18 at 4:50 PM, revealed she was not in the building on 03/28/18 when Resident #70's fall occurred, but RN #1 called her after the fall and the resident was sent to the Hospital ER. The DON stated during her investigation of Resident #70's fall, she interviewed staff who were assigned to the unit on the evening of 03/28/18, including RN #1, LPN #3, SRNA #7, SRNA #8 and SRNA #9. The DON further stated interviews with staff revealed they did not witness SRNA #7 assist Resident #70 to the toilet. Further interview with the DON, revealed she interviewed SRNA #7 a few days after the incident, and SRNA #7 told her she assisted Resident #70 to the toilet by herself, and then left the bathroom and obtained a brief from the bedside drawer. The DON further stated SRNA #7 told her when she went back to the bathroom she found the resident on the floor, and then asked SRNA #8 to help. The DON stated, the Comprehensive Care Plan had interventions for two (2) staff to assist with transfers and toileting at the time of the fall. Per interview, the Nursing Assistant Care Guide which was a guide utilized by the SRNAs for providing care had instructions at the time of the fall for two (2) staff for transfers; and one (1) staff for toileting, meaning staff was to stay with the resident when he/she was on the toilet. The DON further stated SRNA #7 told her during the interview, she was aware Resident #70 required two (2) to assist with transfers and two (2) to assist with toileting and she was aware of the location of the resident's Nursing Assistant Care Guide posted in the resident's room and at the nurse's station. Additional interview with the DON, revealed the Care Plan was an important tool that provided communication to staff on how to provide individualized care for residents. Further interview revealed Resident #70 should not have been left alone on the toilet; and should have been supervised to prevent the fall and injury. Continued interview with the DON, revealed Resident #70's 03/28/18 fall was reviewed and discussed in the facility's weekly Quality Assurance (QA) meeting and the Root Cause was determined as failure to to follow the Care Plan related to toileting. Interview with the Administrator, on 05/31/18 at 9:02 PM, and post survey interview on 06/08/18 at 5:00 PM, revealed he was notified of Resident #70's fall on 03/29/18, but was not involved in the fall investigation. Per interview, RN #1 started the investigation on 03/28/18 by filling out the Fall Incident Report and the DON continued the investigation. The Administrator further stated he was told by the DON that SRNA #7 turned around to get a brief and Resident #70 fell from the toilet. He stated the resident was care planned for assist of two (2) to transfer and SRNA #7 effectively transferred the resident by herself, and then stepped away to get a brief and at that point the resident slid off of the commode. Per interview, the resident was at risk for falls and was care planned for assistance with toileting, and staff was expected to stay with the resident at all times in the bathroom. Further interview with the Administrator, revealed the Care Plan was based on an accurate assessment of the resident's needs, preferences and wishes and staff was expected to follow the Care Plan and provide care as necessary. He stated it was important to follow the Care Plan and provide assistance as care planned to ensure safety and to prevent injury or accident. Additional interview revealed Agency SRNAs were shown where Nursing Assistant Care Guides were located by the Charge Nurse and were teamed up with a regular staff member. Per interview, SRNA #7 was aware of where the Nursing Assistant Care Guides were located as she had worked at the facility prior to this incident. The Administrator revealed Resident #70's 03/28/18 fall was discussed in the facility's weekly QA meeting, and after discussion it was decided the root cause of the fall was SRNA #7 not following the Care Plan. .

Based on interview, record review, and review of facility policies, it was determined the facility failed to ensure each resident receives adequate supervision to prevent accidents for one (1) of nineteen (19) sampled residents (Resident #70). Resident #70 was assessed by the facility to be at risk for falls and to require the extensive assist of two (2) staff for transfers and toileting. However, staff interviews revealed on 03/28/18, the resident was transferred to the toilet with the assist of one (1) staff member and was left alone in the bathroom without supervision. Resident #70 sustained a fall and upon request of the resident's Power of Attorney (POA), the resident was transferred to the Hospital emergency room (ER) on 03/28/18 and was diagnosed with [REDACTED]. The facility failed to complete a thorough investigation as there was no documented evidence of interviews with staff or statements obtained from staff involved at the time of the incident and there was no documented evidence the facility did a root cause analysis of the fall. (Refer to F-659) The findings include: Review of the facility's Fall Prevention Policy, revised 07/31/17, revealed the facility's goal was to identify residents at high risk for falls, alert staff to risk, and to provide the safest environment for residents and assist them to function at their highest level. Further review, revealed a Fall Risk Assessment tool will be completed upon admission and readmission and interventions will be implemented and documented on the resident's care plan. Review of the facility's Accidents/Incidents Policy, undated, revealed the facility identifies each resident at risk for accidents and/or falls, and adequately plans and implements procedures to prevent accidents. Additional review revealed incidents or accidents take place not in the usual course of events, including but not limited to falls. Further review revealed an evaluation of the resident to identify potential risk factors will guide the development and implementation of an individualized care plan that is monitored and revised as necessary. Review of Resident #70's medical record revealed the facility admitted the resident on 01/12/16, with [DIAGNOSES REDACTED]. Review of the Comprehensive Care Plan, initiated 01/12/16, revealed the resident had a problem of Impaired Cognition and Activities of Daily Living (ADL) self-care performance deficit related to Dementia, [MEDICAL CONDITIONS], and [MEDICAL CONDITION] Right Eye. The goal stated the resident would be able to communicate basic needs and would improve level of function in ADLs through review date of 08/03/18. The interventions included: cue, reorient and supervise as needed; extensive assist of two (2) staff to transfer; and extensive assist of two (2) staff to toilet. Continued review of the Comprehensive Care Plan, initiated 01/12/16, revealed the resident was at risk for falls related to psychoactive drug use; vision problems/[MEDICAL CONDITION]/[MEDICAL CONDITION] Right Eye/ [MEDICATION NAME] Degeneration; History of Falls; Muscle Weakness; and was known to self-transfer. The goal stated the resident would follow safety precautions and voice understanding to decrease fall risk. The interventions included, but were not limited to: dycem to top and bottom of wheelchair cushion to prevent sliding; and call light within reach and encourage to use the call light. Review of Resident #70's Fall Risk Assessment, dated 01/25/18, revealed the resident scored nine (9). According to the scale, a score between eight (8) and fourteen (14) indicated indicated high risk for falls. Review of Resident #70's Quarter Minimum Data Set (MDS) Assessment, dated 01/28/18, revealed the facility assessed Resident #70 as having a Brief Interview for Mental Status (BIMS) score of thirteen (13) out of fifteen (15) indicating the resident was cognitively intact. Continued review revealed the facility assessed the resident as always incontinent of bowel and bladder; and as having no falls. Further review of the MDS Assessment, revealed the facility assessed the resident as ambulation did not occur; as having unsteady balance during moving from seated to standing position, moving on and off toilet and surface to surface transfers; and as requiring extensive assistance of two (2) for transfers and toileting. Review of the Nursing Assistant Care Guide, dated 03/01/18 through 03/31/18, revealed Resident #70 was a high fall risk; required extensive assistance of two (2) staff and a gaitbelt for transfers; and required extensive assistance of one (1) staff for elimination/toileting. However, the Comprehensive Care Plan in effect for (MONTH) (YEAR), revealed the resident required two (2) staff for toileting. Observation and interview with Resident #70, on 05/29/18 at 1:33 PM, revealed the resident was sitting in the wheelchair at bedside, with his/her feet on the wheelchair pedals and his/her arms resting at his/her side. The resident was observed to have a buckle seat belt attached across his/her lap. Resident #70 stated he/she knew how to remove the seatbelt and demonstrated pulling the seatbelt apart and then putting it back together. Resident further stated the seatbelt made him/her feel more secure since a fall occurrence three (3) to four (4) weeks ago. Resident #70 was unable to elaborate further on fall event details. Further interview revealed his/her pain control was not as bad as it was before surgery. Review of the Nurse's Note, dated 03/28/18 at 4:40 PM, completed by Registered Nurse (RN) #1, revealed a Nursing Assistant reported Resident #70 had an unwitnessed fall and was on the bathroom floor with head against door opposite of resident's room. Per the Note, the resident verbalized hitting his/her head on the door, and was complaining of severe pain in the lower back, and requested to lye down in bed. Further review revealed the resident was assisted to bed. Review of the POS [REDACTED]. Review of the Nurse's Note, dated 03/28/18 at 4:55 PM, completed by RN #1, revealed the resident's Power of Attorney (POA) was notified of the fall and requested the resident be sent to the Hospital for evaluation. Per the Note, the physician was contacted and a verbal order was received to send the resident to the Hospital emergency room (ER) per family request secondary to a fall. Review of the Nurse's Note, dated 03/28/18 at 5:20 PM, completed by RN #1, revealed the resident left the facility via ambulance. The Nurse's Note dated 03/28/18 at 10:05 PM, completed by RN #1, revealed the resident returned to the facility via ambulance with [DIAGNOSES REDACTED]. Review of Resident #70's Fall Resident Incident Report, completed by RN #1, revealed on 03/28/18 at 4:50 PM, an unwitnessed fall occurred and the resident was observed lying on his/her back in the bathroom floor with his/her head touching the opposite door and he/she was complaining of back pain. Per the Report, the resident stated he/she was trying to get off the toilet. Further review of the Report, revealed two (2) staff assisted the resident off the floor, status [REDACTED]. According to the Report, the interim fall intervention was to educate all Nursing Assistants to refrain from leaving any resident alone in the bathroom. The Incident Report which was signed by the DON on 03/29/18, and the Administrator on 03/30/18, did not name which staff were involved in the incident. Review of the Accident Circumstance Assessment, dated 03/28/18, unsigned, revealed the accident occurred on 03/28/18 at 4:50 PM, when Resident #70 was self transferring form the toilet to the wheelchair in the bathroom. Continued review revealed the preventative measure status [REDACTED]. Interview with RN #1, on 06/08/18 at 9:10 AM, revealed she had completed this Assessment. However, there was no further investigation submitted for review related to Resident #70's fall. There was no documented evidence of statements or interviews from staff involved or assigned to Resident #70 at the time of the fall on 03/28/18. Also, there was no documented evidence of a Root Cause Analysis for the fall. Review of the Hospital Computed Tomography (CT) Lumbar Spine without contrast, Final Report, dated 03/28/18, revealed a [DIAGNOSES REDACTED]. Review of the Hospital Discharge Summary, dated 03/29/18, revealed Resident #70 was not a clear historian and had a fall from the standing position, hitting the back of his/her head on the floor with sudden aching pain at the base of the skull and lower back area. Additional review revealed the resident was unable to independently dress, attend to toileting needs, transfer independently or maintain control of urinary and bowel functions. Further review revealed discharge recommendations included to continue current [MEDICATION NAME] as needed for pain control, Physical Therapy (PT) evaluation and consider Orthopedic evaluation if pain could not be controlled. Further review revealed the resident was not to bend, twist, or lift for 1 (one) week, and a follow up appointment was scheduled for 05/30/18 at 10:15 AM. Review of the Orthopedic consult dated 05/10/18, revealed surgery was scheduled for a L2 Kyphoplasty (surgical filling of an injured or collapsed vertebrae which restores original shape and configuration and relieves pain from spinal compression) for 05/16/18. Review of the Physician's Progress Note, dated 05/16/18, signed by a facility Physician, revealed Resident #70 returned from having a Kyphoplasty today and reported the pain in his/her back was better. Post Survey phone interview on 06/08/18 at 9:00 AM, with State Registered Nursing Assistant (SRNA)#7, revealed she worked at the facility as Agency staff on 03/28/18 and was assigned to Resident #70 on that date. She stated she had reviewed Resident #70's Nursing Assistant Care Guide before providing care, and was aware the resident required the assist of two (2) staff for transfers and toileting, and was a fall risk. Further interview revealed she was aware Resident #70 had poor safety awareness and would self transfer independently after removing the buckle seatbelt. SRNA stated Resident #70 had the buckle seat belt on correctly when she saw the resident earlier in the shift. Continued interview with SRNA #7, revealed the evening of 03/28/18 at about 4:30 PM, she found Resident #70 in the bathroom floor by the toilet and notified RN #1. She stated she did not touch Resident #70 until RN #1 assessed the resident, and then she (SRNA #7) and RN #1 transferred the resident from the floor to the wheelchair and from the wheelchair to the bed. SRNA #7 further stated she did not assist Resident #70 to the toilet or leave the resident unattended in the restroom prior to finding the resident in the floor. Per interview, a resident who required assistance with transfers and toileting and was a fall risk should not be left alone in the restroom. Additional interview with SRNA #7, revealed Resident #70 must have tried to transfer himself/herself independently onto the toilet from his/her wheelchair and sustained the fall. SRNA #7 stated she had written a statement for the staffing agency and the long term care facility related to Resident #70's fall event on 03/28/18 before she left the facility that evening. Post survey phone interview with SRNA #8, on 06/11/18 at 11:59 AM, revealed she was working with SRNA #7 on second shift the evening of 03/28/18. SRNA #8 stated she did not remember the exact time Resident #70 fell , but did recall that she and SRNA #7 were transporting residents to the shower room for the shower team prior to the fall. Per interview, as they passed Resident #70's room, he/she called out to SRNA #7, in the hallway, stating he/she needed to go to the restroom. SRNA #8 stated SRNA #7 started towards Resident #70's room and SRNA #8 told her the resident was an assist of two (2) for transfers and toileting and she would help. SRNA #8 stated SRNA #7 informed her Resident #70 was assigned to her and she would take care of the resident and entered Resident #70's room and closed the door behind her. SRNA #8 stated she (SRNA#8) went to transport another resident into the shower room after SRNA #7 entered Resident #70's room. Per interview, less than five (5) minutes later when SRNA #8 entered the hallway she saw SRNA #7 sticking her head out of Resident #70's door. SRNA #8 stated SRNA #7 told her to go get the nurse because the resident fell . Further interview with SRNA #8, revealed she alerted Licensed Practical Nurse (LPN) #3 on the hallway of the fall and then went to Resident #70's room. She stated the resident was sitting on the floor in front of the toilet and the wheelchair was in the resident's room near the bathroom door. SRNA #8 stated she did not witness SRNA #7 transfer Resident #70 onto the toilet; however, SRNA #7 told her when she entered Resident #70's room, she had assisted the resident to the toilet and stepped out of the restroom to get a brief when the resident stood up unassisted and fell to the floor. Continued interview with SRNA #8, revealed RN #1 provided education to the SRNAs on the hallway on 03/28/18 related to not leaving the residents alone on the toilet. However, she stated they did not have to sign that they had received the education. She further stated she had not been interviewed or had not written a statement related to the fall incident even though she was on the unit at the time of the fall. Additional interview with SRNA #8, revealed SRNA #7 had worked at the facility multiple times prior to this fall incident and was familiar with Resident #70 and the facility's procedures. However, she stated SRNA #7 usually worked independently and was not partnered with a facility SRNA preferring to provide care for her assigned residents by herself. Post survey phone interview with RN #1, on 06/08/18 at 9:10 AM, revealed she was assigned to Resident #70 on 03/28/18 and at approximately 4:50 PM on that date, a SRNA came to the nursing station and notified her Resident #70 had a fall. RN #1 stated she could not remember which SRNA notified her of this, but she immediately entered Resident #70's room and observed him/her sitting propped up against the bathroom door frame. Per interview, the resident complained of lower back pain and asked to get off the floor. RN #1 stated she assessed the resident's vital signs and neurological status and checked the resident's head and skin for obvious injuries, and then the resident was assisted from the floor to the wheelchair, and then to bed. RN #1 further stated Resident #70 continued to complain of lower back pain after being assisted to bed and she administered pain medication. Continued interview revealed she completed an Incident Report, and then called the family and physician. Per interview, the family did not answer her first call; however, called back and asked RN #1 to send Resident #70 to the ER to be on the safe side since the resident was complaining of lower back pain. RN #1 further stated the resident was then transferred to the local Hospital ER for evaluation. Further interview with RN #1, revealed a facility SRNA told her SRNA #7 had assisted Resident #70 to the toilet independently and then stepped out of the bathroom to gather supplies prior to the resident sustaining the fall. She further stated she was unsure which facility SRNA had informed her of the resident being left on the toilet alone by SRNA #7. Continued interview revealed nursing staff were to provide care to each resident by following the individualized Nursing Assistant Care Guide located on the back of each resident's door. Per interview, the Nursing Assistant Care Guide specifically guides staff on the type of assistance required for transfers, toileting, eliminations needs, safety precautions (such as high fall risk), and devices. RN #1 stated she did not show SRNA #7 where the Nursing Assistant Care Guide was located at the beginning of the shift on 03/28/18 because SRNA #7 had worked at the facility before. Additional interview with RN #1, revealed at the time of Resident #70's fall, the resident was Care Planned as requiring assistance of two (2) staff for transfers and assistance with toileting which meant staff was to stay with the resident while the resident was on the toilet. Per interview, Resident #70 had poor safety awareness and a history of self transferring. She stated she was a new graduate from nursing school and call the Director of Nursing (DON) after Resident #70 fell to make sure she had followed policy related to paperwork after the fall incident, and to find out if there was anything else she needed to do. RN #1 stated the DON directed her to educate all SRNAs who were on duty at the time that no resident should ever be left unattended on the toilet in the restroom. RN #1 stated she gathered all the SRNAs at the nursing station and provided education related to supervising residents in the bathroom to maintain resident safety; however, did not have staff sign to indicate they had received the education. She further stated SRNA #7 was not present during the education and had already left the facility as she had stayed late to assist with care and her replacement SRNA had arrived. RN #1 stated she did not obtain a written or verbal statement from SRNA #7 to find out the circumstances of Resident #70's fall prior to the SRNA leaving the facility on 03/28/18. Interview with the DON, on 05/31/18 at 8:33 PM, and post survey phone interview on 06/08/18 at 4:50 PM, revealed nursing staff informed her of any falls when she was in the building, and called her at home for any falls with related injuries when she was not in the facility. Additionally, she stated she reviewed all Fall Incident Reports Monday through Friday. The DON stated her responsibility in reviewing falls was to review the Fall Incident Reports, interview staff involved, get feedback from Therapy staff, and ensure the Root Cause of the fall was identified. She stated she then ensured appropriate new interventions were care planned and carried out after the fall in an attempt to prevent further falls. Continued interview with the DON, revealed she was not in the building on 03/28/18 when Resident #70's fall occurred, but RN #1 called her after the fall and the resident was sent to the Hospital ER. She stated during the phone call with RN #1, she instructed the nurse to educate all SRNAs on the hallway not to leave residents alone on the toilet. Further interview revealed during her investigation of Resident #70's fall, she interviewed staff who were assigned to the unit on the evening of 03/28/18, including RN #1, LPN #3, SRNA #7, SRNA #8 and SRNA #9. The DON stated interviews with staff revealed they did not witness SRNA #7 assist Resident #70 to the toilet. Additional interview with the DON, revealed when she interviewed SRNA #7 a few days after the incident, SRNA #7 told her she assisted Resident #70 to the toilet by herself, and then left the bathroom and obtained a brief from the bedside drawer. Per interview, SRNA #7 told the DON when she went back to the bathroom she found the Resident on the floor, and then asked SRNA #8 to help. The DON stated, the Comprehensive Care Plan had interventions for two (2) assist with transfers and toileting at the time of the fall. She further stated the Nursing Assistant Care Guide which was a guide utilized by the SRNAs for providing care had instructions at the time of the fall for two (2) staff for transfers; and one (1) staff for toileting which meant staff was to stay with the resident when he/she was on the toilet. Additional interview with the DON, revealed SRNA #7 told her during the interview, she was aware Resident #70 required two (2) to assist with transfers and two (2) to assist with toileting and was a fall risk because the resident's Nursing Assistant Care Guide was posted in the resident's room and at the nurse's station. Per interview, there was no excuse for SRNA #7 not to provide care as per the resident's Care Plan. Further interview with the DON, revealed Quality Assurance (QA) meetings were held each Tuesday and any falls since the previous meeting were reviewed by an interdisciplinary team (IDT) which included the DON, Therapy, Administrator, and department heads as needed. Per interview, the Root Cause of falls was determined during this meeting. She stated Resident #70's 03/28/18 fall was reviewed and discussed in the facility's weekly QA meeting and the Root Cause was determined as failure to to follow the Care Plan related to toileting. She stated Resident #70 should not have been left alone on the toilet and should have been supervised to prevent the fall. The DON stated the QA meeting discussions related to falls was not a part of the medical record and were therefore not submitted for review. Continued interview with the DON, revealed although she had conducted the investigation related to Resident #70's 03/28/18 fall, she failed to document interviews or obtain statements from staff who were assigned to Resident #70 at the time of the fall and staff who were on the unit at the time of the fall. She further stated she failed to ensure the Root Cause Analysis was documented with the investigation. The DON stated the QA team realized a need to provide more education to all nursing staff related to following resident Care Plans after Resident #70's fall. However, she stated every nurse and SRNA were not immediately educated related to ensuring resident's at risk for falls were not left on the toilet alone or educated related to following the Care Plan after Resident #70 sustained the fall on 03/28/18. She further stated she had not contacted SRNA #7's Agency Manager related to Resident #70's fall to inform her of SRNA #7's failure to follow the Care Plan resulting in the resident sustaining injury. Post survey interview with SRNA's Agency Staffing Manager, on 06/08/18 at 9:00 AM, revealed it was company policy for agency staff to write a statement in their own words related to any incidents/events that occurred in a facility in which they were involved including falls. Per interview, the Agency would then obtain a copy of the facility's Incident Report related to the incident. Further interview revealed there was not a document on file submitted by SRNA #7 related to the fall event on 03/28/18 at 4:50 PM for Resident #70. She stated if SRNA #7 was assigned to a resident at the time of the fall, she should have turned in a statement related to the fall in order for the agency to obtain a copy of the facility Incident Report to find out if the SRNA had followed protocol. Interview with the Administrator, on 05/31/18 at 9:02 PM, and post survey interview on 06/08/18 at 5:00 PM, revealed he was notified of falls by the DON. He stated he was notified of Resident #70's fall on 03/29/18, but was not involved in the fall investigation. The Administrator stated RN #1 started the investigation on 03/28/18 by filling out the Fall Incident Report and the DON continued the investigation. The Administrator stated he was told by the DON that SRNA #7 turned around to get a brief and Resident #70 fell from toilet. He stated the resident was care planned for assist of two (2) to transfer and SRNA #7 effectively transferred the resident by herself, but stepped away to get a brief and at that point the Resident slid off of the commode. He stated if a resident was at risk for falls and was care planned for assistance with toileting, staff was expected to stay with the resident at all times in the bathroom. Continued interview with the Administrator, revealed Agency SRNAs were shown where Nursing Assistant Care Guides were located by the Charge Nurse and were teamed up with a regular staff member. He stated SRNA #7 was aware of where the Nursing Assistant Care Guides were located as she had worked at the facility prior to this incident. Continued interview with the Administrator, revealed Resident #70's 03/28/18 fall was discussed in the facility's weekly QA meeting, and after discussion it was decided the Root Cause of the fall was SRNA #7 not following the Care Plan. He stated he was not aware there was no documented evidence of interviews or statements from staff who were working on Resident #70's unit at the time of the fall until the QA meeting to discuss the fall. He further stated the written investigation should have included staff interviews and statements. Additionally, he stated the written investigation did not indicate a Root Cause Analysis was completed related to the fall and this information should have been documented. Per interview, he was also dissatisfied with the Fall Incident Report and lack of information after Resident #70's fall as it was not thorough and did not include names of staff involved. The Administrator stated he was not sure if facility staff contacted the staffing Agency to make them aware there was an incident involving SRNA #7; however, the Agency should have been notified. Further interview revealed staff were educated related to following care plan on a regular basis, but were not specifically educated related to following the Care Plan or fall prevention measures such as not leaving a resident who was at risk for falls on the toilet unsupervised, after Resident #70 sustained the fall on 03/28/18.

Based on interview and record review, it was determined the facility failed to ensure the Comprehensive Plan of Care was followed for one (1) of seventeen (17) sampled residents (Resident #6). Resident #6 was care planned to be transferred per the Hoyer lift with assist of two (2) staff. However, on 04/23/14 two (2) Certified Nursing Assistants (CNAs) transferred Resident #6 using a "towel" method and the resident experienced a fall which resulted in a right Femur Fracture diagnosed in the hospital emergency room (ER) on 04/26/14. The findings include: Interview on 05/08/14 at 6:23 PM with the Director of Nursing (DON) revealed she indicated the facility had no policy for staff to follow residents' care plans; however, indicated she would expect staff to do so. Review of Resident #6's medical record revealed the facility readmitted the resident on 04/13/12, with [DIAGNOSES REDACTED]. Review of the Significant Change MDS Assessment, dated 02/10/14, revealed the facility assessed Resident #6 to be moderately cognitively impaired and to be totally dependent on staff for Activities of Daily Living (ADLs) and transfers. Review of the Comprehensive Care Area Assessments (CAAs), dated 02/11/14, revealed Resident #6 was to have a two (2) person assist with transfers. Review of Resident #6's Comprehensive Plan of Care, dated 11/13/13, revealed a care plan for risk for falls regarding: the resident not being aware of his/her safety needs; having a history of a [MEDICAL CONDITION] disorder; and having balance problems and a fall on 02/18/13. Continued review of this care plan revealed Resident #6 required a Hoyer (mechanical) lift for all transfers. Additionally, continued review of the Comprehensive Plan of Care revealed an ADL care plan which indicated Resident #6 was dependent on two (2) staff for transfers. Review of the CNA Care Plan for April, 2014, revealed under the section on Transfers, a mechanical lift/Hoyer and assist times two (2) were checked, but had been marked through. Continued review of the CNA Care Plan revealed the section on Transfers was revised on 04/26/14 and 04/27/14. Review of CNA #3's written statement dated 04/26/14, revealed she and CNA #13 were transferring Resident #6 from the bed to a geri-chair new to the resident. Further review of the written stated revealed CNA's #3 and #13 sat Resident #6 up on the side of the bed, placing a towel under his/her knees and proceeded to transfer Resident #6 to the geri-chair. Continued review of the statement revealed the geri-chair was not locked and the chair slid out from under the resident, causing the towel to slip and the CNAs assisted Resident #6 to the floor. Interview, on 05/08/14 at 3:20 PM, with CNA #3 revealed she was not aware of what Resident #6's care plan stated regarding how the resident was to be transferred. She indicated she did not know she was supposed to use a Hoyer lift with Resident #6. CNA #3 revealed she had been told to transfer Resident #6 using a "towel transfer" which she indicated she had not been formally trained by the facility to do. However, review of the resident's Comprehensive Care Plan and the CNA's Care Plan revealed a Hoyer lift was indicated prior to 04/26/14. There was no intervention for a "towel transfer" on either care plan. Continued interview with CNA #3 revealed on 04/23/14, she and CNA #13 were trying to transfer Resident #6 from the bed to the geri-chair using a towel under the resident's knees and lifting under resident's arms, the "towel transfer". She stated she and CNA #13 were both holding under Resident #6's arms and holding the ends of the towel to transfer the resident and during the transfer the geri-chair began to roll backwards because it was not locked. CNA #3 further stated she and CNA #13 had to lower Resident #6 to the floor on his/her knees. She reported Resident #6 complained of pain in the right knee when they got him/her up off the floor into the geri-chair. Additionally, she stated Resident #6 had a skin tear on his/her leg; but, did not remember which leg. Interview with CNA #13 was attempted per telephone contact on 05/08/14 at 9:53 am and again at 4:00 PM. No answer was received and the Surveyor was unable to leave a message either time as the voice mail indicated the voice mailbox had not been set-up. Interview, on 05/08/14 at 10:19 AM, with Licensed Practical Nurse (LPN) #1 revealed LPN #2 came to her on 04/23/14, and asked her to look at a skin tear on Resident #6's left lower leg. LPN #1 stated two (2) CNAs were present, CNA's #3 and #13, and informed her they had transferred the resident using the "towel method", the geri-chair had rolled and the resident hit his/her shin on the chair causing the skin tear. She stated the "towel method" transfer was one (1) staff person lifting a resident under his/her arms and another staff person lifting the resident's knees using a towel placed under the knees and then transferring the resident. She indicated she was not aware Resident #6 was still to be transferred per a Hoyer lift. LPN #1 stated staff transferred Resident #6 using the "towel method" because it was easier on the resident as he/she was afraid of the Hoyer lift. Interview with LPN #2 on 05/08/14 at 4:30 PM, revealed he had assessed Resident #6's skin tear on 04/23/14 after the "aides" told him about it. LPN #2 stated LPN #1, who was the Charge Nurse that day, spoke to the CNAs regarding how the skin tear occurred; however, he did not hear what she was told by the CNAs. He stated he heard on 04/24/14, when he came to work, Resident #6 had a fall associated with when he/she received the skin tear. LPN #2 stated CNAs had care plan access which contained residents' "lifting procedure", and indicated CNA #3 and CNA #13 should have followed Resident #6's care plan. Interview, on 05/08/14 at 5:40 PM, with CNA #11 and CNA #12 at 6:10 revealed they looked at residents' care plans to know how residents were to be transferred. CNA #11 indicated she used a Hoyer lift for residents if they were care planned for that and she had never used a "towel transfer and had never received training on how to perform it. CNA #12 stated if a resident's care plan stated to use a Hoyer lift, then she used the lift as per the care plan. Interview, on 05/08/14 at 6:23 PM, with the DON revealed she learned of Resident #6's skin tear to the left shin which occurred on 04/23/14, during the morning meeting on 04/24/14. The DON stated Resident #6 had been care planned for use of a Hoyer lift, however, had become "fearful" of the Hoyer lift. She stated therefore, the facility had started using a "towel" to transfer him/her with. However, she indicated the facility had no formal training for the staff on performing the "towel" transfer. The DON reported because of Resident #6's fear of the Hoyer lift she thought it had been discontinued in January. She indicated the intervention to transfer Resident #6's per the Hoyer lift should have been discontinued from the resident's Comprehensive Plan of Care.

Based on interview, record review, and review of the facility's Plan of Correction (POC) it was determined the facility failed to implement the POC which was developed to address the findings of the Recertification Survey conducted 05/06/14 through 05/08/14. The Recertification Survey determined the facility failed to ensure interventions on the Comprehensive Care Plan were implemented related to transferring a resident with a Hoyer lift. Staff was utilizing a "towel" method, instead of the Hoyer lift, which resulted in a resident fall with injury. Review of the facility's Plan of Correction (POC) revealed inservice education was provided to all staff regarding transfers and following the Comprehensive Care Plan. However, interview and record review revealed the facility failed to implement the POC. The findings include: Review of the facility's POC, dated and signed by the Administrator on 06/13/14, with an alleged compliance date of 06/13/14, revealed inservice education was conducted by the Director of Nurse (DON) and Physical Therapy (PT) on 05/19/14, 05/20/14 and 05/22/14 regarding utilizing the lifting technique indicated on the Comprehensive Care Plan. The POC revealed the DON educated Minimum Data Set (MDS) Nurses regarding changes in the procedure for care plans on 05/28/14. Continued review of the POC revealed the DON provided inservice education to all Registered Nurses (RNs), Licensed Practical Nurses (LPNs), Kentucky Medication Aides (KMAs), and State Registered Nursing Assistants (SRNAs) regarding following the Comprehensive Care Plan on 06/09/14, 06/10/14, 06/11/14, and 06/12/14. The POC stated "all nursing staff attended the training". However, review of the facility's care plan inservice attendance record compared to the facility's master employee list revealed twenty-four (24) of one hundred and five (105) nursing employee's had not received the education on following the care plan. Interview on 06/26/14 with SRNA #18 at 11:15 AM, with SRNA #17 at 11:26 AM, with SRNA #20 at 11:50 AM, SRNA #21 at 2:35 PM, with SRNA/KMA #19 at 12:31 PM, with LPN #5 at 1:05 PM, and with LPN #7 at 3:30 PM, revealed they had not received the care plan inservice education provided by the DON as per the POC. Interview with the DON on 06/25/14 at 3:00 PM and on 06/26/14 at 12:40 PM, revealed she "thought" all the nursing staff had attended the care plan inservice education. The DON indicated she did not have a system in place to track and ensure all nursing staff received the care plan inservice education per the POC, but should have had a system. Interview with the Administrator on 06/25/14 at 1:00 PM and on 06/26/14 at 2:25 PM, revealed he had taken "the word" of the employees assigned to ensure the education was provided as per the POC; however, should have "done more checking" and not just relied on the employees' word. He stated the facility should have had a system in place to assure education was completed and to monitor for any issues.

Based on observation, interview, record review and review of the facility's Accident/Incident Report form and policy, it was determined the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for one (1) of seventeen (17) sampled residents (Resident #6). Resident #6 was assessed by the facility to require the assistance of two (2) staff for transfers per the Minimum Data Set (MDS) assessment dated [DATE]. Review of the Comprehensive Plan of Care revealed Resident #6 was to be transferred per Hoyer lift. On 04/23/14, two (2) Certified Nursing Assistants (CNAs) attempted to transfer Resident #6 without the use of the Hoyer lift and the resident sustained [REDACTED].#6's fall to the licensed nurse as per the facility's policy. Therefore, Resident #6 was not assessed by the licensed nurse after the fall and the resident continued to complain of right leg pain. On 04/26/14, Resident #6 was sent to the emergency room (ER) and diagnosed with [REDACTED]. In addition, the facility failed to ensure the residents' environment remained free of accident hazards as evidenced by missing toilet bolt covers in three (3) resident bathrooms. The findings include: 1. Review of the facility's, "Fall Assessment and Prevention" Policy, undated, revealed it was the policy of the facility to facilitate an interdisciplinary approach to care planning to prevent injuries, to appropriately monitor and assess a resident's status following a fall, and to accelerate the plan of care to address factors related to the incident. The Policy stated a "potential for injury" care plan would be initiated, when appropriate, based on the results of the Resident Fall Assessment. According to the Policy, an interdisciplinary care plan was to be individualized to reflect the specific needs and risk factors of the resident. Continued review of the Policy revealed all staff providing care to the resident were to be familiar with the care plan and the interventions necessary to provide for the resident's safety. The Policy indicated if a resident sustained [REDACTED]. Further review revealed a licensed nurse was to immediately assess the resident after a fall and document the assessment and actions taken in the resident's medical record. Review of Resident #6's medical record revealed the facility admitted the resident on 08/03/10, and re-admitted [DATE], with [DIAGNOSES REDACTED]. Review of the Significant Change MDS Assessment, dated 02/10/14, revealed the facility assessed Resident #6 as having a Brief Interview for Mental Status (BIMS) of an eight (8) out of fifteen (15), indicating the resident was moderately impaired in cognition. Continued review of the MDS Assessment revealed Resident #6 was totally dependent on two (2) staff for transfers. Review of the Comprehensive Care Area Assessments (CAAs) dated 02/11/14, revealed Resident #6 was totally dependent on staff with ADLs and required total staff assist times two (2) with transfers. Further review of the CAAs revealed Resident #6 was to be "transferred with two (2) person assist" and would "proceed to" care plan. Review of the Comprehensive Plan of Care, initiated 11/13/13, revealed Resident #6 had a care plan for at risk for falls related to the resident being unaware of safety needs, having a balance problem, seizure disorder and history of a fall on 02/18/13. Continued review of the care plan revealed Resident #6 was to be transferred with a Hoyer (mechanical) lift for all transfers. Continued review of the Comprehensive Plan of Care revealed a care plan for Resident #6's Activity of Daily Living (ADL) self-care deficit in regards to his/her [DIAGNOSES REDACTED]. Review of the interventions for the ADL care plan revealed Resident #6 was totally dependent of staff for transferring, two (2) person assist with transfers. Review of the CNA Care Plan, dated April 2014, revealed under the "transfer section", mechanical lift/Hoyer and assist times two (2) were checked. However, continued review revealed these transfer interventions were marked through with a line and there was no documented evidence of a date to indicate when the interventions were discontinued. Further review revealed the Transfer Section was revised on 04/26/14 and 04/27/14. Review of the facility's Accident/Incident Report form, undated, revealed on 04/23/14 at 5:15 PM, Licensed Practical Nurse (LPN) #2 had reported to LPN #1 that CNA #3 and CNA #13 told him they were getting Resident #6 out of bed when the geri-chair "slipped out from under aids due to lock not locking". Continued review of the Accident/Incident Report form revealed Resident #6 "hit" his/her shin on the "metal bar on side of chair, knees buckled". Further review of the Accident/Incident Report form revealed no documented evidence Resident #6 had experienced a fall. Review of the Nurse's Notes, dated 04/23/14 at 5:15 PM, revealed Resident #6 was up in his/her geri-chair and the CNAs had reported when transferring the resident the geri-chair "slipped behind" him/her. Review of the Note revealed this had "caused" Resident #6 to "scrape" his/her shin on the "metal part" of the geri-chair. The Note revealed Resident #6 had a 1.0 centimeter (cm) by 0.1 cm skin tear to the lower left shin area which was cleansed by Licensed Practical Nurse (LPN) #2 and a steri-strip applied to the skin tear. Continued review of the Note revealed Resident #6 complained of pain in his/her leg and Tylenol (a non-narcotic pain reliever) was administered and the nurse would continue to monitor. There was no documented evidence of which leg Resident #6 complained of pain in. Review of the Note revealed Resident #6 was taken to the dining room "for dinner". Continued review of the Nurse's Notes revealed a Note timed 5:45 PM, which stated Resident #6 was taken back to his/her room as requested because of complaints of pain and the resident "immediately" closed his/her eyes and stated he/she just wanted "to rest". Interview on 05/08/14 at 3:20 PM with CNA #3, revealed she and CNA #13, had been transferring Resident #6 on 04/23/14 with the use of a towel under his/her knees. She stated she and CNA #13 each held the ends of the towel and Resident #6's arms to transfer the resident to the geri-chair. CNA #3 stated the geri-chair was not locked in place and rolled backwards and they had to "assist" Resident #6 to the floor on his/her knees. She stated they then lifted the resident and assisted him/her to the geri-chair. CNA #3 stated she had not been trained on how to perform a "towel transfer"; however, that was how she was told to get Resident #6 up. However, review of the CNA Care Plan revealed a Hoyer lift was indicated as the method for transfer for Resident #6, prior to 04/26/14. CNA #3 stated she knew a fall was anytime a resident went to the floor assisted or not. She stated she knew the CNAs were to go get a nurse before moving a resident after a fall. CNA #3 indicated they were in "just such a spur of the moment" and did not think to get the nurse as per the policy. She stated she did not know what Resident #6's care plan said regarding how he/she was to be transferred, and indicated she did not know she was supposed to be getting the resident up with a Hoyer lift. CNA #3 reported Resident #6 had a skin tear on his/her leg; however, could not recall which leg. She stated Resident #6 complained of pain to his/her right knee after they got him/her in the geri-chair. According to CNA #3, they transported Resident #6 in the geri-chair to the dining room for dinner where he/she continued to complain of right knee pain. CNA #3 stated they told LPN #1 and LPN #2 that Resident #6 was in pain, had a skin tear and they had assisted him/her to the floor. She stated they did not say "fall" when telling the nurses of assisting Resident #6 to the floor. Continued interview with CNA #3 reported the nurses did not ask any questions in regards to the fall after they explained the incident to them. She stated she did not work on 04/24/14, did return to work on 04/25/14 and Resident #6 complained of his/her right knee hurting and "moaning" all of her shift. Interview on 05/08/14 at 10:19 AM, with LPN #1 revealed on 04/23/14, LPN #2 came to her and asked her to go to Resident #6's room because the resident had a skin tear on his/her left leg. She stated she went to Resident #6's room and CNA #3 and another CNA, CNA #13, told her they were transferring the resident from the bed to the geri-chair using the "towel method" and the geri-chair "rolled back to the wall". LPN #1 stated the CNAs told her Resident #6's "knees buckled" and one (1) of them "grabbed" the geri-chair and they put the resident in the geri-chair. She stated the CNAs did not "say" Resident #6 "fell to the floor". According to LPN #1, the "towel method" involved one (1) person getting "under the arms" of a resident and the other person lifting the resident's knees with a towel and they transferred the resident that way. LPN #1 stated a fall was considered "anytime a person's body" went to the floor, except if it was the bottom of the person's feet which touched the floor. She indicated she "charted" what she had been told by the CNAs "at the time", in Resident #6's medical record. Additional interview on 05/08/14 at 10:30 AM, with LPN #1 revealed "at no time" had the CNAs reported to her Resident #6 was assisted to the floor. She stated on 04/26/14 at 3:00 PM was the first time she had heard anything about Resident #6 being assisted to the floor on 04/23/14. LPN #1 stated CNA #3 wrote a statement on 04/26/14 regarding Resident #6 being assisted to the floor on his/her knees. She stated CNA #3 and CNA #13 stated "it was miscommunication between themselves and me". LPN #1 indicated she had re-educated the CNAs on the protocol for falls to included notifying the nurse so an assessment could be performed; however, did not have "them sign anything". Interview on 05/08/14 at 4:30 PM with LPN #2, revealed on 04/23/14 the "aides" came and got him to "check out" a skin tear "they had". He stated he thought it was after dinner and that was all the "aides" had told him about. He reported he told the Charge Nurse, LPN #1 who talked to the CNAs "about what happened" to cause the skin tear and he did not hear what the "aides" told the Charge Nurse. Continued interview with LPN #2 revealed he worked the "next day", 04/24/14 he thought, and that was when he "heard there was a fall" associated with the skin tear. He stated he was not certain who had told him; but, indicated he was told CNA #13, who had assisted with the transfer and had informed Resident #6's family the resident had "fallen". According to LPN #2, he had never used "a towel lift" or seen it used; however, knew it involved a towel under the knees and under the arms" and then lift. LPN #2 indicated the CNAs had access to the care plan which had each resident's "lifting procedure" on it and they should follow it. Interview on 05/07/14 at 5:50 PM with LPN #5, revealed she had worked on 04/24/14, 04/25/14 and 04/26/14, on the 3:00 PM to 11:00 PM shift. She stated on 04/25/14, she asked CNA #3 what had happened to Resident #6 on 04/23/14. LPN #5 stated CNA #3 told her when she and CNA #13 transferred Resident #6 from the bed to a "new" geri-chair that was not locked which rolled and the "towel" they were using for the transfer "slipped" and they assisted the resident to the floor. She stated CNA #3 reported Resident #6 obtained the skin tear at that time also. According to LPN #5, she asked CNA #3 if she realized assisting the resident to the floor was considered a fall. She stated CNA #3 said "yes, she knew it was a fall"; however, had not reported the fall to LPN #1. LPN #5 told CNA #3 to write a statement as to what happened on 04/23/14, which she indicated CNA #3 had done. Review of CNA #3's written statement dated 04/26/14, revealed she and CNA #13 were transferring Resident #6 from the bed to a geri-chair, which was new to the resident. Review of the written statement revealed CNA #3 and CNA #13 sat Resident #6 up on the side of the bed, placed a towel under his/her knees and proceeded to transfer the resident to the geri-chair. Continued review of the written statement revealed the geri-chair was not locked and the chair slid out from under the resident causing the towel to slip and the CNAs had to assist Resident #6 to the floor. Interview with CNA #13 was attempted per phone contact on 05/08/14 at 9:53 AM and 4:00 PM; however, no answer was received and a message cound not be left as the recording indicated the voice mailbox had not been set-up. Continued interview on 05/07/14 at 5:50 PM with LPN #5, revealed on 04/26/14 she had spoken to LPN #1, who also had worked on 04/23/14, and asked her what had happened to Resident #6 that day (04/23/14). LPN #5 stated LPN #1 told her Resident #6 had received a skin tear to his/her left shin during a transfer and she (LPN #1) had completed an Incident Report on 04/23/14 in regards to the skin tear. According to LPN #5, LPN #1 reported LPN #2 had performed the treatment on Resident #6's skin tear. She stated she informed LPN #1 what CNA #3 had reported to her regarding Resident #6 sustaining a fall during the transfer. Review of a Nurse's Note dated 04/24/14 at 3:00 AM, revealed Resident #6 complained of pain to his/her right leg and there was "edema" in the right knee. However, Resident #6 refused pain medication. Review of a Nurse's Note dated 04/24/14 at 7:10 AM, revealed a "late entry" for 3:00 AM, which stated Resident #6's right knee was "edematous" with "+3" (significant) "edema" noted. Continued review of the 04/24/14 Nurse's Notes revealed at 10:30 AM, the nurse documented the Advanced Practice Registered Nurse (APRN) was notified of the skin tear on Resident #6's left lower extremity and approved of the treatment. Review of the Note revealed the APRN was also notified of the right knee pain Resident #6 was having, no new orders were received and the nurse documented the APRN was to "look at" the resident's knee on her next visit. Review of the 4/24/14 "late entry" timed 7:15 AM, revealed Resident #6 complained of right knee pain and the knee was swollen, with no redness or warmth noted. Continued review of the "late entry" Note revealed Tylenol was administered and the nurse would continue to monitor. The "late entry" Note revealed at 1:30 PM, Resident #6 complained of right knee pain and Tylenol was administered. Further review of the "late entry" Note revealed at 3:00 PM, Resident #6's daughter was notified related to the resident's complaints of right knee pain and that "PRN" (as necessary) pain medications were being administered to "control" the pain. The "late entry" Note indicated the resident's daughter was "agreeable" with "all". Interview on 05/07/14 at 5:50 PM with LPN #5, revealed she received in report on 04/24/14 information regarding Resident #6 having a skin tear on his/her left shin which occurred during a transfer on 04/23/14. LPN #5 stated she did not have to administer any PRN pain medication to Resident #6 on 04/24/14. LPN #5 reported one (1) of Resident #6's daughters had inquired what had happened the "night before" and she informed the daughter she had not worked on 04/23/14. Review of a 04/25/14 Nurse's Note, timed 8:00 AM, revealed Resident #6 complained of right leg pain and PRN Tylenol and the nurse would continue to monitor. At 9:20 AM, the nurse documented Resident #6 was "resting in bed" with no signs and symptoms of "distress" noted. Review of the 04/25/14 Nurse's Note, timed 7:00 PM, revealed Resident #6's family was "concerned" about the "edema" and "warmth" in his/her right knee. Continued review of the Note revealed the family was requesting an x-ray and the Physician was notified of the request. Continued interview with LPN #5,m on 05/07/14 at 5:50 PM revealed on 04/25/14, during shift report, she was told Resident #6 had "swelling" in his/her right knee and "yelled out" in pain during the previous shift and Tylenol had been administered. LPN #5 reported she believed Resident #6's pain was addressed with the APRN; however, could not recall how she knew this information. Continued interview with LPN #5, revealed Resident #6 had experienced "some" swelling in his/her right knee "a few months back" and therefore, no one "really thought too much about it". She stated she assessed Resident #6 after shift report on 04/25/14, and found swelling and warmth to the resident's right knee. LPN #5 stated she asked the medication technician (med tech) to administer Tylenol to Resident #6 during the next medication pass. She stated one (1) of Resident #6's sons and another daughter were visiting on the evening of 04/25/14, and made reference to the resident having "a lot of pain" in his/her knee and they had been told he/she had been "dropped". LPN #5 stated she told Resident #6's son and daughter there was no documentation of the resident sustaining a fall and stated she reminded them of his/her right knee "swelling in January from fluid on the knee". She reported she told them "fluid on the knee" was painful and she could ask the Physician for an order for [REDACTED].#5 stated Resident #6's son told her it would be okay to ask the Physician the next morning for an x-ray of the knee. Review of the Nurse's Note dated 04/26/14 at 10:40 AM, revealed the nurse spoke with the APRN regarding the fax to the Physician related to Resident #6's family's concern about his/her right knee edema and warm to touch and request for an x-ray. Continued review of the Note revealed a new order was received for a "venous doppler" (ultrasound) of Resident #6's right leg secondary to warm to touch and edema. Resident #6's Power of Attorney (POA) was notified of this information per the nurse's documentation. Interview on 05/08/14 at 4:05 PM with Licensed Practical Nurse Applicant (LPNA) #4 revealed she was the Charge Nurse on 04/26/14 and had spoken to the APRN about the fax to the Physician for an x-ray of Resident #6's right knee and about the family's concerns. She stated the APRN ordered a "venous doppler" instead of an x-ray, as she (LPNA) thought Resident #6's right knee edema might have been related to a Deep Vein Thrombosis (DVT), a blood clot. LPNA #4 stated she called the portable x-ray company and gave them the order for the "venous doppler". According to LPNA #4, the portable x-ray company called back and said they could not come to do the ordered "doppler" until 04/28/14. Continued review of the 04/26/14 Nurse's Notes revealed at 11:20 AM, Resident #6 continued to complain of right leg pain and PRN Tylenol was given. Review of the Nurse's Note dated 04/26/14 at 1:00 PM, revealed Resident #6's POA called "upset/crying" and stated her sister had told her the night "after" the skin tear incident happened, she was at the facility when an "aide" told her Resident #6 was "dropped" when the geri-chair "slid" and his/her right leg "buckled" at that time. The Note revealed Resident #6's POA was "demanding" an x-ray be performed of the resident's right leg. Continued review of the Note revealed the POA informed the nurse: there was "neglect" going on in the facility; the "aides" should not have "dropped" Resident #6; and the "aides" should have been "less worried about that chair". The nurse documented in the Note she told Resident #6's POA she "got no report of" the resident "being dropped" and had read through the medical record and there was nothing charted. Further review revealed a Note timed 1:29 PM, which revealed the nurse had notified the facility's Social Worker (SW) regarding what the POA had said and the SW was to call the POA. Review of a Note timed 1:40 PM, revealed the SW called the nurse back and informed her the family wanted an x-ray. Continued interview on 05/08/14 at 4:05 PM with Licensed Practical Nurse Applicant (LPNA) #4 revealed Resident #6's POA called her on 04/26/14, "crying and upset" and told her another daughter had visited the resident 04/24/14. Continued interview with LPNA #4 revealed Resident #6's POA reported the daughter who visited on 04/24/14, was told by a CNA the resident was "dropped" on 04/23/14 when he/she obtained the skin tear. LPNA #4 stated she called the facility's Social Worker (SW) on 04/26/14 and informed her of what Resident #6's POA had told her regarding being upset because the "aides were neglecting" the resident. Review of the 04/26/14 Nurse's Note at 2:30 PM revealed the nurse notified the Physician regarding the POA's request for an x-ray and received a new order for an x-ray of Resident #6's right knee. Further interview on 05/08/14 at 4:05 PM with LPNA #4 revealed she had "paged" the Physician at 2:30 PM and the Physician returned her call and ordered the x-ray. Review of the Nurse's Note dated 04/26/14 timed 4:30 PM, revealed a nurse documented Resident #6's right knee remained "swollen and warm to touch" and he/she had complaints of pain to the right leg. Continued review of the Note at 4:30 PM, revealed Resident #6 did not want to be moved or repositioned. Review of the Note timed 5:30 PM, revealed Resident #6 was "yelling in pain when transferred to geri-chair" and the nurse attempted to give Tylenol which the resident "spit out". Review of the Nurse's Note timed 6:00 PM revealed the portable x-ray company was at the facility to perform the x-ray and Resident #6 had "refused dinner and fluids". Review of the Note timed 6:45 PM, revealed the nurse noted the x-ray report had been received and revealed an "acute nondisplaced femoral fracture". Further review of the Nurse's Notes revealed at 7:10 PM, the Physician was notified; a Note at 8:00 PM revealed the nurse noted the Physician called back and she went over the x-ray report with him. Continued review of the 8:00 PM Note revealed the nurse documented the Physician ordered Resident #6 sent to the ER. Review of the Nurse's Note timed 8:30 PM revealed Resident #6 was sent to the ER via ambulance. Review of the Hospital ER Physician Documentation, dated 04/26/14, revealed Resident #6 was diagnosed with [REDACTED]. Continued review of the ER Physician Documentation revealed Resident #6 was discharged back to the facility on [DATE] at 9:58 PM in stable condition with narcotic pain medication ordered. Further interview on 05/07/14 at 5:50 PM with LPN #5, revealed on 04/26/14 she informed LPN #1 they needed to call the Director of Nursing (DON) and see what needed to be done. She stated the DON was called between 3:30 PM and 4:00 PM, everything she had learned was reported to the DON. LPN #5 stated the DON talked to LPN #1 and was also going to talk to the day shift nurse, LPNA #4 to "see how the family was that day". LPN #5 indicated she should have "done something" on 04/25/14 after learning of Resident #6's fall, such as, contacting the Physician; however, did not feel she had enough information at that time. Interview on 05/08/14 at 6:23 PM with the DON, revealed she knew an incident occurred on 04/23/14 during a transfer of Resident #6 when he/she sustained a skin tear to the left shin which she had learned about during morning meeting on 04/24/14. She stated she and a day shift LPN went and assessed Resident #6's skin tear and right knee for bruising and swelling. She reported they also reviewed Resident #6's medical record which revealed Resident #6 had experienced pain and swelling in the right knee in January, 2014. The DON stated at that time they thought they just had a "bump and buckle of the knee", nothing more because of having the same problem in January. Continued interview with the DON revealed on 04/24/14, the APRN was notified of Resident #6's right knee being swollen, warm to touch and painful. She stated LPN #5 should have contacted the Physician on 04/25/14 after she learned of Resident #6's fall; however, had not contacted anyone including herself until 04/26/14. The DON stated she should also have been contacted on 04/25/14 so she could investigate and re-educate as necessary. She stated the facility had training for staff on transfers including the use of gait belts and Hoyer lifts. The DON reported Resident #6 had been a Hoyer lift, but became "fearful" of the lift and the facility had initiated transferring him/her with a "towel". According to the DON, she thought the Hoyer lift had been discontinued in January because the resident "feared it". However, she indicated the facility had no formal training for CNAs to determine they could safely transfer residents using the "towel" method. She stated "new aides" were trained on the "towel" method by their co-workers. The DON stated Resident #6's Comprehensive Plan of Care should have been revised to discontinue the Hoyer lift and add the "towel" transfer method. The DON stated she expected the staff to follow the Care Plans. Record review revealed the Hoyer lift was listed as an intervention on the Comprehensive Care Plan and the CNA Care Plan prior to 04/26/14. 2. Observation of the facility on 05/08/14 at 11:10 AM, revealed there were no bolt covers on the toilets in room 18, room 37, and room 44. Interview with the Maintenance Supervisor on 05/08/14 at 3:20 PM, revealed bolts should be covered on the toilets. He stated it was his responsibility to ensure the toilet bolt covers were in place. The Maintenance Supervisor stated he had a log for repairs; however he had not been "keeping up with it". Interview with the Administrator on 05/08/14 at 3:35 PM, revealed maintenance was responsible for checking areas regarding the bolts on the toilets to ensure residents were safe using the bathroom. The Administrator stated he expected everyone in the facility to be responsible for the upkeep and report to him when they noticed areas of concern. Further interview with the Administrator revealed the missing bolt covers placed residents at risk, as not having the bolts covered, could cause a skin tear or cut. The Administrator revealed "ultimately" it was his responsibility to ensure all fixtures were safe for residents.