Every finding on record at Elkhorn Health & Rehabilitation

Based on interview, record review, and a review of the facility policy, it was determined the facility failed to implement a person-centered care plan to ensure services were furnished to prevent accidents for one (1) of three (3) sampled residents (Resident #1). Review of Resident #1's record revealed he/she required assistance of two (2) staff members with toileting and bed mobility. Resident #1's care plan directed staff to encourage him/her to leave his/her bed in the lowest position when care was not being provided. Interviews with staff revealed they were trained to review resident care plans and to provide care as directed in each resident's plan of care. However, interview with staff that cared for Resident #1 during the night shift on 06/01/2020 revealed the resident's care plan was not reviewed and care had been provided by one (1) staff member. Resident #1's bed was also observed not to be in the lowest position, and he/she experienced a fall from the bed on 06/01/2020. The resident was transferred to the local hospital after the fall where he/she was diagnosed with [REDACTED]. The findings include: Review of the facility policy titled, Baseline Care Plan Assessment/Comprehensive Care Plans, not dated, revealed a resident's Comprehensive Care Plan would be finalized within seven (7) days of completion of the full Comprehensive MDS Assessment. The policy also stated the resident's care plan would expand on identified risks, goals, and interventions using the Person-Centered plan of care approach which included measureable objectives and timetables to meet the resident's medical, nursing, and physical functioning needs. Interview with the Director of Nursing on 07/23/2020 at 2:15 PM revealed the facility had no policy related to the State Registered Nurse Aide (SRNA) care plans in the facility; however, she stated SRNA care plans were developed from information obtained from the Comprehensive Care Plan, and staff were directed to provide care as outlined in the plan of care. Review of Resident #1's record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1's admission Minimum Data Set Assessment ((MDS) dated [DATE] revealed he/she required extensive assistance of two (2) staff members for transfers, bed mobility, and toileting. Staff assessed Resident #1 to be incontinent of bowel and bladder and the resident's Brief Interview for Mental Status (BIMS) score was 00, which indicated he/she was not interviewable and cognitively impaired. Review of Resident #1's comprehensive and SRNA care plan, Bedside Kardex Report, dated 05/15/2020, revealed he/she required two (2) staff members to provide incontinence care and to assist with bed mobility. The care plan also revealed Resident #1 was at risk for falls and staff were to encourage the resident to leave the bed in the lowest position when care was not being provided. Review of Resident #1's incident report dated 06/01/2020 at 5:00 AM revealed staff heard a loud bang and found the resident in the floor beside his/her bed, in a right lateral position. The report also indicated Resident #1's head was touching his/her nightstand and the bed height was elevated. Resident #1 also had a small laceration and hematoma to the left eyebrow and a hematoma to his/her right forehead. Continued review of the report revealed Resident #1 was transferred to a local hospital for further evaluation and treatment. Review of Resident #1's hospital record revealed the resident arrived at a local hospital on [DATE], at approximately 6:59 AM to be evaluated in the emergency room (ER) after a fall. Further review of the record revealed after diagnostic tests were completed, Resident #1 was diagnosed with [REDACTED]. Interview with State Registered Nurse Aide (SRNA) #3 on 07/21/2020 at 11:50 AM and SRNA #2 on 07/22/2020 at 4:50 PM revealed at approximately 5:00 AM on 06/01/2020, they were at the nurses' station and heard a loud noise. The SRNAs entered Resident #1's room and observed the resident lying on the floor on his/her right side and his/her head was touching a nightstand. The SRNAs stated Resident #1's bed height was not in the lowest position; however, the SRNAs stated it should have been. Per the SRNAs, staff had been trained to review resident care plans and to provide care as directed in each resident's plan of care. SRNA #2 and SRNA #3 also stated staff had been trained to ensure residents' bed levels were kept at the lowest level after care was provided to assist in preventing accidents in the facility. Interview with Licensed Practical Nurse (LPN) #1 on 07/22/2020 at 4:00 PM revealed she was assigned to care for Resident #1 on 06/01/2020, when the resident experienced a fall in the facility. LPN #1 stated Resident #1 was observed on the floor, on his/her right side, and raised areas were observed to both sides of his/her forehead. LPN #1 stated staff had been trained to review each resident's plan of care and that care provided in the facility should be directed from the care plans. The LPN also stated staff had been trained to ensure bed levels for residents in the facility were kept at the lowest level after care was provided, to assist in the prevention of accidents in the facility. LPN #1 also stated nurses made rounds during each shift to ensure care plans were followed and beds were in the lowest position as required. A post exit interview with State Registered Nurse Aide (SRNA) #1 on 07/27/2020 at 10:40 AM revealed she was assigned to care for Resident #1 on 06/01/2020 when the fall occurred. SRNA #1 stated that even though she had been trained to review resident care plans for information on how to care for facility residents, she had failed to review Resident #1's care plan as required. SRNA #1 also stated she was the only staff member that provided care to the resident before the fall occurred, and was not aware that the resident's care plan indicated he/she required the assistance of two (2) staff members for bed mobility/incontinence care. Per the SRNA, she had repositioned the resident and provided incontinence care for Resident #1 earlier in the shift prior to the resident's fall. SRNA #1 also stated she had been trained to ensure residents' beds were kept in the lowest position after care was provided, and stated she had placed the resident's bed in the lowest position the last time she was in the resident's room. SRNA #1 was unsure why Resident #1's bed was in an elevated height position when he/she experienced a fall from the bed on 06/01/2020. Interview with MDS Coordinator #1 on 07/23/2020 at 10:15 AM revealed she had included the intervention that staff were to encourage Resident #1 to keep his/her bed at the lowest position because that was a standard intervention she added to care plans in the facility. The MDS Coordinator stated all staff had been trained to ensure the beds for all residents in the facility were kept at the lowest level in height, for the safety of the residents. She also stated Resident #1 required the assistance of two (2) staff members as outlined in his/her care plan and staff were expected to implement resident care plans when care was provided in the facility. Interview with the DON on 07/23/2020 at 2:15 PM revealed staff had been trained to review and follow resident care plans before care was provided to residents in the facility. The DON also stated staff had been trained to ensure resident beds were left in the lowest height position after care was provided, to assist in the prevention of accidents in the facility. The DON investigated Resident #1's fall that occurred on 06/01/2020 and determined his/her bed was left in an elevated position during the shift on 06/01/2020; however, she was unable to determine why. The DON stated staff should have ensured Resident #1's care plan was followed related to the number of staff required to provide assistance and his/her bed should have been in the lowest position when care was not being provided. The DON also acknowledged if Resident #1's bed had been in the lowest height position as required, the amount of injuries the resident sustained [REDACTED].

Based on interview, record review, and review of the facility policy it was determined the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for one (1) of three (3) sampled residents (Resident #1). On 06/01/2020, at approximately 5:00 AM, staff heard a loud noise and when they went to investigate, they found Resident #1 on the floor beside his/her bed with the resident's head observed touching the nightstand. Staff stated Resident #1's bed was observed in an elevated position (approximately thigh level). Resident #1 was transferred to a local hospital where he/she was diagnosed with [REDACTED].#3 - #8), Right Hip and Right Pelvic fractures, Cervical Spine Fractures (C1 and C2), and fracture of his/her Right Outer Table Frontal Sinus (facial bone). Interviews with staff revealed they had been trained to ensure residents' beds were placed at the lowest position after care was provided, to assist in ensuring residents' safety in the facility. The findings include: Review of the facility policy titled, Accident and Incident Guidelines, not dated, revealed the facility policy did not address residents' bed heights in ensuring residents' safety after care was provided in the facility. However, an interview with the Director of Nursing on 07/23/2020 at 2:15 PM revealed all staff had been trained to ensure resident beds were left in the lowest position after care was provided to assist in ensuring the residents' safety and to aid in preventing accidents in the facility. Review of Resident #1's record revealed the facility admitted the resident on 05/15/2020 with [DIAGNOSES REDACTED]. Review of his/her admission Minimum Data Set Assessment ((MDS) dated [DATE] revealed Resident #1 required extensive assistance of two (2) staff members for bed mobility, toileting, and transfers. The resident was assessed to be incontinent of bowel and bladder and his/her Brief Interview for Mental Status (BIMS) score was 00, which indicated the resident was cognitively impaired and not interviewable. The assessment also revealed the resident had not experienced any previous falls in the facility. Review of Resident #1's Comprehensive Care Plan dated 05/20/2020 revealed staff determined that he/she was at risk for falls related to Confusion, Lack of Coordination, Weakness, Unsteady on his/her feet, and Unaware of Safety Needs. The care plan also indicated staff implemented staff to ensure the resident's call light was within reach and to encourage the resident to leave his/her bed in the lowest position when care was not being rendered on 05/27/2020. Review of an incident report dated 06/01/2020 at 5:00 AM revealed staff heard a loud bang and found Resident #1 on the floor beside his/her bed, in a right lateral position. The report also indicated the resident's head was touching his/her nightstand and the bed height was elevated. Resident #1 had a small laceration and hematoma to the left eyebrow and a hematoma to his/her right forehead. The incident report also indicated the facility identified that Resident #1's bed was in an elevated position when the fall occurred. Review of Resident #1's hospital record revealed Resident #1 was evaluated in a local hospital emergency room (ER) on 06/01/2020, at approximately 6:59 AM after he/she sustained a fall. The record also revealed after diagnostic tests were completed, Resident #1 was diagnosed with [REDACTED]. Interview with State Registered Nurse Aide (SRNA) #3 on 07/21/2020 at 11:50 AM and SRNA #2 on 07/22/2020 at 4:50 PM revealed at approximately 5:00 AM on 06/01/2020, they were at the nurses' station and heard a loud noise. The SRNAs stated they entered Resident #1's room and observed him/her lying on the floor on his/her right side and the resident's head was touching his/her nightstand. The SRNAs also stated the resident's bed was not in the highest position but not in the lowest position either. The SRNAs stated the resident's bed height was elevated to thigh level (SRNA #3 stated she was approximately five (5) feet tall), and the resident's head of bed was raised to approximately a forty-five (45) degree angle. Both staff members stated they had been trained to ensure residents' beds were in the lowest position after providing care to assist in preventing accidents in the facility. Interview with Licensed Practical Nurse (LPN) #1 on 07/22/2020 at 4:00 PM revealed she was assigned to care for Resident #1 when the fall occurred on 06/01/2020. LPN #1 assessed Resident #1 after the fall occurred and she observed the resident on the floor, on his/her right side, and raised areas were observed to both sides of the resident's forehead. Resident #1's bed was in the lowest position when the LPN entered his/her room, and she was not aware the resident's bed was in an elevated position when the fall occurred, until 06/02/2020 during the investigation conducted by Administrative staff at the facility. LPN #1 stated staff had been trained to ensure residents' beds were in the lowest position after care was provided to assist in ensuring residents' safety and preventing accidents in the facility. LPN #1 stated she had been in the resident's room approximately thirty (30) minutes earlier and his/her bed was in the lowest position. A post exit interview with State Registered Nurse Aide (SRNA) #1 on 07/27/2020 at 10:40 AM revealed she was assigned to care for Resident #1 when the fall occurred on 06/01/2020. She stated she had provided care to the resident at approximately 3:00 AM (unable to recall exact time) on 06/01/2020 and had placed Resident #1's bed in the lowest position before she exited the resident's room. SRNA #1 also stated she was the only staff member that provided care to the resident before the fall occurred. Interview with the DON on 07/23/2020 at 2:15 PM revealed staff had been trained to ensure residents' beds were left in the lowest height position after care was provided, to assist in ensuring accidents were prevented in the facility. The DON conducted an investigation of Resident #1's fall and determined his/her bed was left in an elevated position during the shift on 06/01/2020; however, she was unable to determine why Resident #1's bed was not left in the lowest position as required. However, the DON acknowledged if Resident #1's bed had been in the lowest height position as required, the amount of injuries the resident sustained [REDACTED].

Based on observation, interview, record review, and facility policy review it was determined the facility failed to treat one (1) of thirty-nine (39) sampled residents (Resident #28) with respect and dignity in a manner that promotes maintenance or enhancement of his or her quality of life. Observation on 03/09/2020 revealed State Registered Nurse Aide (SRNA) #5 standing over Resident #28 during the lunch meal feeding him/her lunch in the resident's room. The findings include: Interview with the Director of Nursing (DON) on 03/11/2020 at 11:00 AM revealed the facility did not have a policy in regard to staff feeding residents. Review of the medical record for Resident #28 revealed the resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, Section C, Cognitive Patterns, dated 01/12/2020, revealed the facility assessed the resident to be severely cognitively impaired and therefore a Brief Interview for Mental Status (BIMS) score could not be obtained. Further review of the MDS, Section G, Functional Status, revealed the resident required extensive assistance of one (1) person for eating. Review of the Comprehensive Plan of Care dated 07/05/2017 for Resident #28 revealed a focus area of Activities of Daily Living with an intervention that the resident was to be fed per staff. Observation of Resident #28 on 03/09/2020 at 1:03 PM revealed the resident lying in bed with the head of bed raised and SRNA #5 standing over the resident at bedside feeding the resident. Further observation revealed a chair in the room next to the resident's bed. Interview with SRNA #5 on 03/11/2020 at 5:01 PM revealed she should not have stood and fed the resident. The SRNA further revealed she was nervous with the surveyor in the room. The SRNA revealed she had been trained during orientation to not stand and feed residents. Interview with the DON on 03/11/2020 at 4:34 PM revealed the SRNA should not have been standing and feeding. The DON further revealed staff are educated during orientation on feeding residents. The DON also revealed she monitors residents being fed properly by making rounds and spot-checking and had not identified any concerns with residents being fed inappropriately.

Based on observation, interview, record review, and facility policy review it was determined the facility failed to complete an accurate assessment for one (1) of thirty-nine (39) sampled residents. Resident #53 had a urinary catheter; however, the facility failed to include the presence of the urinary catheter on the resident's Admission Minimum Data Set (MDS). The findings include: Interview on 03/11/2020 at 12:43 PM with the Director of Nursing (DON) revealed the facility did not have a policy related to the accuracy of the MDS but used the Resident Assessment Instrument (RAI) manual. The RAI manual under Steps for Assessment in Section H: Bladder and Bowel reads: 1. Examine the resident to note the presence of any urinary or bowel appliances. Furthermore under Coding Instructions: Check next to each appliance that was used at any time in the past 7 days. Section H, 100 Appliances includes indwelling catheter as an option to be selected if the resident has an indwelling catheter. Review of Resident #53's medical record revealed the facility admitted the resident on 02/03/2020 with [DIAGNOSES REDACTED]. Further review of the medical record revealed the resident was admitted with an indwelling urinary catheter (an appliance inserted from outside the body through the urethra into the bladder to allow emptying of the bladder). Review of Resident #53's Admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 10 indicating the resident had moderate cognitive impairment. Further review of the MDS revealed the resident was not marked on Section H as having an indwelling catheter, and was assessed to always be incontinent of bladder. Review of Resident #53's current Physician order [REDACTED]. Review of Resident #53's care plan, dated 02/10/2020, revealed the resident was care planned with a Focus of: the resident has an indwelling Foley catheter due to [DIAGNOSES REDACTED]. Observation on 03/08/2020 at 2:25 PM of Resident #53 revealed the resident was in bed with an indwelling catheter noted with yellow urine with no sediment in the tubing, and a dignity bag was in place. Observation on 03/11/2020 at 10:18 AM of catheter care for Resident #53 revealed no concerns. Interview with State Registered Nursing Assistants (SRNA) #1 and #2 who performed the catheter care revealed that the resident had the catheter ever since they have been here. Interview on 03/11/2020 at 10:47 AM with the MDS Coordinator revealed the resident was admitted to the facility from another facility. Per the MDS Coordinator, the resident was admitted with a Urinary Tract Infection, but she stated she did not remember if the resident had a catheter at that time. Upon reviewing the Indwelling Catheter Evaluation that was performed upon admission the MDS Coordinator agreed the resident must have had the catheter upon admission and that it should have been triggered on the MDS. Interview on 03/11/2020 at 4:17 PM with the Administrator revealed they had identified a concern with the accuracy of the MDS. The Administrator stated staff were making sure daily orders were put into the care plan.

Based on observation, interview, record review, and facility policy review it was determined the facility failed to update the care plan for one (1) of thirty-nine (39) sampled residents (Resident #8). Resident #8's gastrostomy tube ([DEVICE]) (a tube inserted through the belly that brings nutrition directly to the stomach) was removed on 08/01/2019; however, the facility failed to revise the resident's care plan and remove the use of the [DEVICE] for nutrition. The findings include: Review of a facility policy titled, Baseline Care Plan Assessment/Comprehensive Care Plans, not dated, revealed, As the resident remains in the Nursing Home, additional changes will be made to the comprehensive care plan based on the assessed needs of the resident . Further review of the policy revealed, The Comprehensive Care Plans will be reviewed and updated every quarter at a minimum. The facility may need to review the care plan more often based on changes in the resident's condition and/or newly developed health/psycho-social issues. Record review revealed the facility admitted Resident #8 on 06/13/2018 with [DIAGNOSES REDACTED]. Review of Resident #8's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident could not participate in the Brief Interview for Mental Status (BIMS) due to being rarely or seldom understood. Further review of the MDS revealed the resident was not marked as having a [DEVICE] under Section K. Review of Resident #8's Care Plan, dated 01/17/2020, revealed the resident was care planned with a Focus: The resident requires tube feeding (thru [DEVICE]) related to [DIAGNOSES REDACTED]. Review of Resident #8's Physician order [REDACTED]. The reason for the order was listed as the tube was discontinued and the resident no longer had a [DEVICE]. Observation of Resident #8 on 03/08/2020 at 2:22 PM revealed the resident was in bed lying on the right side with eyes open; attempted interview resulted in the resident not able to answer questions. No tube pump (equipment to administer feeding thru [DEVICE]) was present. Other observations on 03/09/2020 revealed no tube pump present. Interview on 03/11/2020 at 9:08 AM with Licensed Practical Nurse (LPN) #1 revealed the resident did not have a [DEVICE] and stated the resident had not had the tube in a while. Observation at this time revealed a small healed scar where the [DEVICE] had been. She further stated the resident eats well and received the house supplement and drinks well. Interview on 03/11/2020 at 9:25 AM with the MDS Coordinator revealed she reviews the care plans and updates them when the MDS is due and as needed. She further stated that the nursing staff can also update care plans. Per the MDS Coordinator, I actually reviewed (Resident #8's) care plan yesterday, but I missed the [DEVICE] feeding that was left on it. She further stated that the tube feeding should have been taken off of the care plan. Interview on 03/11/2020 at 4:21 PM with the Administrator revealed the care plan should have been updated after the [DEVICE] was removed.

Based on observation, interview, and a review of facility policy it was determined the facility failed to ensure a resident who needs respiratory care was provided such care consistent with professional standards of practice for one (1) of thirty-nine (39) sampled Residents (Resident #82). A continuous positive airway pressure ([MEDICAL CONDITION]) mask assembly for Resident #82 was observed stored uncovered hanging on the bulletin board in the resident's room. The findings include: A review of the facility policy for [MEDICAL CONDITION] use titled, [MEDICAL CONDITION]/[MEDICAL CONDITION] Home System Use, undated, revealed the policy did not address the storage of the [MEDICAL CONDITION] machine or the [MEDICAL CONDITION] mask/equipment. A review of the medical record for Resident #82 revealed the facility admitted the resident on 11/23/2018 with [DIAGNOSES REDACTED]. A review of the plan of care developed for Resident #82 revealed the resident utilized the [MEDICAL CONDITION] machine from 10:00 PM to 6:00 AM for difficulty breathing and obstructive sleep apnea. Observations of Resident #82's [MEDICAL CONDITION] machine on 03/08/2020 at 2:25 PM, 03/09/2020 at 9:23 AM, and 03/11/2020 at 9:55 AM revealed the [MEDICAL CONDITION] mask apparatus was connected to the machine on a shelf by the resident's bed and the mask apparatus was hanging uncovered on a push pin on a bulletin board above the shelf. An interview with Licensed Practical Nurse (LPN) #2 on 03/11/2020 3:14 PM revealed the LPN was responsible for the care of Resident #82. According to the LPN she had placed the [MEDICAL CONDITION] on the resident at 10:00 PM and removed the [MEDICAL CONDITION] from the resident at 6:00 AM. Further interview with LPN #2 revealed she stored the [MEDICAL CONDITION] mask in a plastic bag and was not aware why the [MEDICAL CONDITION] was not stored in a plastic bag and was hanging on the resident's bulletin board uncovered. An interview with the Director of Nursing (DON) on 03/11/2020 at 10:21 AM revealed the facility did not have a policy addressing storage of the [MEDICAL CONDITION] equipment/mask. However, the DON stated nurses were responsible for cleaning, applying, removing, and placing the mask in a plastic bag for storage when the [MEDICAL CONDITION] was not in use. According to the DON, she made daily rounds to ensure resident equipment is stored correctly and had not identified any concerns with the storage of [MEDICAL CONDITION] masks.

Based on interview, record review, and review of facility policies, it was determined the facility failed to ensure one (1) of six (6) sampled residents (Resident #4) with limited mobility received appropriate services to maintain or improve mobility. On 03/06/18, Resident #4 was discharged from therapy services with recommendations for restorative nursing services to maintain range of motion and bed mobility. However, the facility failed to provide restorative nursing services for Resident #4. The findings include: A review of the facility policy titled Restorative Nursing Services, with a revision date of 05/01/11, revealed it was facility policy for residents to be evaluated for restorative nursing services and residents could be referred to Restorative Nursing Services by physical and occupational therapists. Further review revealed after conferencing with the interdisciplinary team, the Director of Nursing initiated restorative nursing programs to include range of motion and mobility programs. A review of the medical record for Resident #4 revealed the facility admitted the resident on 12/14/17 with a [DIAGNOSES REDACTED]. A review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 was assessed to require the assistance of one to two staff members for activities of daily living and was assessed to not have any limited range of motion. A review of an occupational therapy discharge summary dated 03/07/18 and a physical therapy discharge summary dated 03/09/18 revealed Resident #4 was discharged from therapy on 03/06/18 with recommendations for the resident to participate in the restorative nursing program for active and passive range of motion and bed mobility to ensure the resident maintained his/her current level of functioning and did not decline. However, there was no evidence the facility initiated or provided restorative nursing services. An interview with the Director of Nursing (DON) on 03/15/18 at 11:45 AM revealed Resident #4 was not receiving restorative services because the DON was not aware that therapy staff recommended restorative nursing for the resident. According to the DON, she had not received a referral from Therapy for restorative nursing services for range of motion and bed mobility. Interview with the Physical Therapist (PT) on 03/15/18 at 10:15 AM and the Occupational Therapist (OT) on 03/15/18 at 10:20 AM revealed the therapists documented in the discharge summary that Resident #4 should receive restorative nursing for range of motion/bed mobility; however, the therapists did not send a referral to the DON because they believed the resident was being discharged .

Based on interview, record review, and a review of the facility's medication error policy, it was determined the facility failed to ensure one (1) of three (3) sampled residents (Resident #1) was free of significant medication errors. Resident #1 had a documented allergy to [MEDICATION NAME] (an antipsychotic medication); however, the facility administered the medication to the resident for three days, 10/27/17 through 10/30/17. The findings include: A review of the facility's policy titled Medication Errors, dated (MONTH) (YEAR), revealed the facility strived to ensure residents' health and safety were not jeopardized due to a medication error. Further review of the policy revealed if an error occurred frequently and required discontinuing the medication the error was significant. Review of the medical record for Resident #1 revealed the facility admitted the resident on 12/15/15. A review of the initial nursing assessment revealed the resident was assessed to have a drug allergy to [MEDICATION NAME]. Further review revealed [MEDICATION NAME] was listed on the resident's medical record as an allergy. Review of a handwritten order by the facility psychiatrist dated 10/27/17, revealed the psychiatrist prescribed [MEDICATION NAME] 2 milligrams twice daily for Resident #1. Further review revealed Licensed Practical Nurse (LPN) #2 transcribed the order and entered the medication on the facility's computerized Medication Administration Record [REDACTED] Review of Resident #1's MAR indicated [REDACTED]. Review of progress notes revealed LPN #1 contacted the psychiatrist on 10/30/17 at 3:00 PM, and the [MEDICATION NAME] medication was discontinued. Interview with LPN #1 on 01/30/18 at 4:00 PM, revealed she contacted the psychiatrist on 10/30/17, regarding [MEDICATION NAME] being listed as an allergy for Resident #1. LPN #1 stated the psychiatrist discontinued the medication. Interview with the Psychiatrist on 01/31/18 at 11:05 AM, revealed he evaluated Resident #1 on 10/27/17, reviewed the resident's medications, and did not feel the resident had a true allergy to [MEDICATION NAME]. He stated he discussed the medication with Resident #1 and made the decision to prescribe the medication. However, when he was contacted by the facility on 10/30/17, he discontinued the medication. Interview with the Director of Nursing (DON) on 01/31/18 at 1:00 PM revealed she was not aware of the medication error. According to the DON, staff should have reported the error and an incident report should have been completed.

Based on interview, record review, and a review of the facility's policy, it was determined the facility failed to notify the responsible party of a need to alter treatment for one (1) of three (3) sampled residents (Resident #1). On 10/27/17, Resident #1's physician prescribed the resident a new medication, [MEDICATION NAME] (an antipsychotic medication); however, the facility failed to notify the resident's responsible party of the change in the resident's treatment. The findings include: Review of the facility's policy titled Change in Condition Notification, dated (MONTH) 2014, revealed the responsible party would be notified of changes unless directed otherwise. Review of the medical record for Resident #1 revealed the resident was seen by the psychiatrist on 10/27/17, and the psychiatrist ordered [MEDICATION NAME] for the resident. Licensed Practical Nurse (LPN) #2 transcribed the order and made a late entry on a progress note dated 10/27/17 at 1:30 PM that stated the resident's attending physician and responsible party were notified of the medication order. However, on 01/31/18 at 10:00 AM, an interview with Family Member (FM) #1, Resident #1's responsible party, revealed FM #1 was not notified that the psychiatrist had prescribed [MEDICATION NAME] and, had she known, she would have refused for the medication to be given to the resident because Resident #1 was allergic to the medication. Interview with LPN #2 on 01/31/18 at 12:10 PM, revealed the LPN could not recall transcribing the order for [MEDICATION NAME] or documenting that she had notified the resident's responsible party. Interview with the Psychiatrist on 01/31/18 at 11:05 PM, revealed he evaluated Resident #1 on 10/27/17, reviewed the resident's medications, and did not feel the resident had a true allergy to [MEDICATION NAME]. He stated he had a discussion with Resident #1 about the medication, but did not discuss the medication with FM #1. Interview with the Director of Nursing (DON) on 01/31/18 at 1:00 PM, revealed the facility should have contacted Resident #1's responsible party about the medication change and the DON stated she was not aware that the family was not contacted.

Based on observation, interview, and facility policy review, it was determined the facility failed to store food in accordance with professional standards for food service safety. Observation during the initial tour of the kitchen on 12/05/17 at 9:15 AM, revealed a food item in a clear bag in the walk-in freezer that was opened, but not labeled with the date it had been opened or when it should be used by. The findings include: Review of the facility's policy titled Nutritional Services, dated 03/14/14, revealed refrigerator items should include the name of the item and a use by date. The policy stated frozen food items should be stored in a moisture-proof wrap or containers that were labeled and dated. Observation during the initial tour of the kitchen on 12/05/17 at 9:15 AM revealed an opened bag of food in the walk-in freezer that was not labeled with the date/time the food was opened or a use by date. An interview conducted with the Cook on 12/08/17 at 9:09 AM and the Dietary Manager on 12/08/17 at 9:30 AM revealed the facility's policy was to label opened food items with the date the item was opened and a use by date. The staff stated the use by date was three days after the item was opened. According to the cook, many residents ask for a cheeseburger and tater tots at the last minute and someone may have grabbed the item and did not take the time to label the item with the appropriate dates. The Dietary Manager also stated that someone probably had to grab something quickly and did not label the item.

Based on observation, interview, record review, and facility policy review, it was determined that the facility failed to provide the appropriate treatment and service for pressure sores for three (3) of eighteen (18) sampled residents (Resident #46, Resident #59, and Resident #239). Observation of a wound assessment for Resident #46 on 12/05/17 revealed the resident had an open area in the left gluteal fold. However, staff documented, and notified the resident's physician, that the resident had a boil and no treatment was ordered for the open area. In addition, staff failed to provide treatment to Resident #239's wounds as ordered by the physician. Further observation of Resident #59 revealed staff failed to provide wound treatment and failed to utilize a positioning device to treat/prevent further pressure ulcers as ordered by the resident's physician. The findings include: Review of the facility policy titled Prevention and Management of Wounds, undated, revealed residents would receive the appropriate care and treatment for [REDACTED]., and indicate the interventions on the care plan. 1. Review of the medical record for Resident #46 revealed the facility admitted the resident on 06/01/17, with [DIAGNOSES REDACTED]. Review of the most recent quarterly Minimum Data Set (MDS) assessment for Resident #46 dated 10/20/17 revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of twelve (12), which indicated the resident was interviewable. The MDS revealed the facility assessed the resident to be independent with all bed mobility, transfers, and toileting, and was continent of both bowel and bladder. The MDS also revealed that Resident #46 was at risk for skin breakdown but had no open areas. Review of Resident #46's care plan, with a revision date of 10/25/17, revealed staff were required to notify the physician of any changes in the resident's condition and for any new orders. Observation of a skin assessment for Resident #46 completed by Licensed Practical Nurse (LPN) #3 on 12/05/17 at 9:37 AM, revealed an open area that measured 6.3 centimeters (cm) long by 4.6 cm wide in the gluteal fold of the resident's left buttock. However, a review of the nurse's notes for Resident #46 dated 12/06/17 at 12:30 PM revealed LPN #3 documented that the resident had a hard, red raised area that was not open. In addition, a review of physician orders dated 12/06/17 at 10:51 AM revealed orders for an oral antibiotic to treat a boil to the back of the resident's left leg in the gluteal fold. Interview with Resident #46 on 12/05/17 at 9:40 AM revealed the open area in the gluteal fold had been there for three (3) to four (4) days; however, the resident had not told staff about the area. Interview with LPN #3 on 12/07/17 at 03:43 PM revealed she notified Advanced Practice Registered Nurse (APRN) #1 on 12/06/17 that the wound under Resident #46's left buttock was open. LPN stated she had mistakenly documented that the wound was not open. However, an interview with APRN #1 on 12/07/17 at 03:51 PM, revealed she was not notified that Resident #46's wound was open. APRN stated if she had been notified that it was open, she would have ordered wound care dressing. Interview conducted with the Director of Nursing (DON) on 12/07/17 at 1:01 PM, revealed she had completed another skin assessment and identified that the area in Resident #46's gluteal fold was a stage two (2) pressure area and should have been reported to the ARNP as such. The DON stated she had not previously identified any concerns with pressure ulcers not being accurately assessed. 2. Review of the medical record for Resident #239 revealed the facility readmitted the resident on 08/03/17, with [DIAGNOSES REDACTED]. Review of the physician's orders for Resident #239 revealed an order dated 12/01/17, for staff to clean the left heel with normal saline, pat the area dry, and apply Santyl ointment and a dry protective dressing. Resident #239 also had a physician order dated 12/01/17, for staff to clean the resident's right stump (amputated site) with normal saline, pat the area dry, and apply Santyl and a [MEDICATION NAME] dressing. Observation of wound care on 12/06/17 at 2:15 PM revealed Licensed Practical Nurse (LPN) #3 cleaned the wounds to Resident #239's left heel and right stump with normal saline and applied Santyl ointment to both areas as prescribed by the physician; however, LPN #3 applied [MEDICATION NAME] dressing to the left heel, instead of the right stump as ordered by the resident's physician. Further observation revealed LPN #3 applied a dry protective dressing to the right stump, instead of the left heel as prescribed by the resident's physician. Interview with LPN #3 on 12/07/17 at 2:30 PM revealed she reviewed Resident #239's physician orders prior to performing wound care, but got the dressings mixed up and applied the wrong dressings to the wounds. Interview with the Director of Nursing (DON) on 12/08/17 at 9:07 AM, revealed staff were required to pass a competency exam annually related to wound care and she monitored wound care. The DON stated she had not identified any concerns with wound care being provided according to physician orders. 3. A review of Resident #59's medical record revealed the facility admitted the resident on 10/06/17, with [DIAGNOSES REDACTED]. Review of Resident #59's Minimum Data Set (MDS) assessment, dated 10/13/17, revealed the resident had a Brief Interview for Mental Status (BIMS) score of twelve (12), and the resident was interviewable. The MDS also revealed the resident had a Suspected Deep Tissue Injury (SDTI). A review of Resident #59's physician orders dated 10/17/17 revealed an order for [REDACTED].#59 also had a physician order dated 12/02/17, to cleanse the SDTI to the right heel daily with soap and water or cleanse with normal saline, pat the area dry, and apply a dry protective dressing daily. Review of Resident #59's Care Plan dated 12/03/17, revealed the facility identified that the resident had a SDTI to the right heel and developed an intervention to provide treatment per physician orders, but did not develop an intervention specifically for a heels up cushion as an intervention to prevent/treat pressure ulcers. Subsequently, a review of Resident #59's Kardex (a guide that direct care staff uses to provide care) dated 12/05/17 revealed no interventions for the resident to utilize a pressure-relieving device for the heels. Observation of Resident #59 on 12/05/17 at 11:12 AM revealed the resident was in bed on his/her back. The resident's right heel did not have a dressing as ordered by the resident's physician and the resident was not utilizing a device to float the resident's heels. Resident #59's right heel was dark purple. Interview with the resident revealed the resident had pain in the right heel. Resident #59 also stated that sometimes staff put a pillow under his/her legs, and staff did something to his/her right heel. Continued observation of Resident #59 on 12/05/17 at 12:01 PM revealed the resident continued to lie on his/her back, with no dressing to the right heel and no device in place to keep the pressure off the resident's heels. Observation of Resident #59 on 12/06/17 at 9:48 AM, and on 12/07/17 at 9:30 AM and 2:32 PM, revealed the resident's right heel had a dressing covering the heel; however, the resident's heels were not floated off the bed to relieve pressure. Interview with State Registered Nursing Assistant (SRNA) #1 on 12/07/17 at 2:24 PM revealed she was aware that Resident #59 required the use of a pillow to keep the resident's heels off the bed; however, the resident's family often removed the pillow. Interview with Resident #59's family (Family Member #1) on 12/08/17 at 11:39 AM, revealed when he arrived at the facility every morning, the resident often did not have a positioning device or dressing to the right heel. Family Member #1 stated the resident often rubbed his/her heel on the bed, resulting in the dressing coming off. He stated he tried to ensure the resident had a positioning device and did not remove the resident's pillow/positioning device because he realized it was important to relieve pressure from the resident's heels.

Based on observation, interview, record review, and a review of the facility's policy, it was determined that the facility failed to develop a care plan for one (1) of eighteen (18) residents (Resident #59). Resident #59 had an unstageable pressure ulcer, a Suspected Deep Tissue Injury (SDTI), with physician orders for a heels up cushion (positioning device that is placed under the lower legs to keep pressure off the heels), and treatment to the right heel. The facility failed to develop care plan interventions for the physician-ordered treatments. Subsequently, observation on 12/05/17 and 12/06/17 revealed the physician-ordered treatments were not being provided. The findings include: Review of the facility policy titled Prevention and Management of Wounds, undated, revealed residents would receive the appropriate care and treatment for [REDACTED]. According to the policy, the wound interventions were indicated on the resident's care plan and the Certified Nursing Assistant care plan (Kardex) was updated as needed. A review of Resident #59's medical record revealed the facility admitted the resident on 10/06/17, with [DIAGNOSES REDACTED]. Review of Resident #59's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was interviewable and had a Suspected Deep Tissue Injury (SDTI). A review of Resident #59's physician orders dated 10/17/17 revealed an order for [REDACTED].#59 also had a physician order dated 12/02/17, to cleanse the SDTI to the right heel daily with soap and water or cleanse with normal saline, pat the area dry, and apply a dry protective dressing daily. Review of Resident #59's Care Plan dated 12/03/17 revealed the facility identified that the resident had a SDTI to the right heel and developed an intervention to provide treatment per physician orders, but did not develop an intervention specifically for a heels up cushion as an intervention to prevent/treat pressure ulcers. Subsequently, a review of Resident #59's Kardex (a guide that direct care staff uses to provide care) dated 12/05/17, revealed no interventions for the resident to utilize a pressure-relieving device for the heels. Observation of Resident #59 on 12/05/17 at 11:12 AM revealed the resident was in bed on his/her back. The resident was not utilizing a device to float the resident's heels. Resident #59's right heel was dark purple. Interview with the resident revealed the resident had pain in the right heel. Resident #59 also stated that sometimes staff puts a pillow under his/her legs. Continued observation of Resident #59 on 12/05/17 at 12:01 PM, 12/06/17 at 9:48 AM, and on 12/07/17 at 9:30 AM and 2:32 PM, revealed the resident continued to lie in bed with no device in place to keep the pressure off the resident's heels. Interview with Registered Nurse (RN) #1 on 12/08/17 at 10:16 AM revealed she completed Resident #59's initial assessment and remembered the resident had a pink area to the heel. RN #1 revealed the facility's procedure was to enter care plan interventions into a computer system. RN #1 stated the computer system was new when she entered the resident's care plan so she also completed a paper copy of the resident's care plan. However, RN #1 did not remember what interventions were implemented for Resident #59. Interview with State Registered Nursing Assistant (SRNA) #1 on 12/07/17 at 2:24 PM and with SRNA #2 on 12/07/17 at 3:45 PM revealed they were aware that Resident #59 required the use of a pillow to relieve pressure from the resident's heels, but stated the resident's family often removed the pillow. The SRNAs stated residents' care needs were listed on a Kardex and in a computer system. However, the SRNAs were unable to access the computer system and were unable to produce a Kardex that listed an intervention for a heels up cushion.

Based on interview, record review, and review of the facility's quality assurance policy, it was determined the facility failed to have an effective quality assurance program to implement an appropriate plan of action to correct identified quality deficiencies. A review of a facility plan of correction revealed the facility alleged compliance with the reporting requirements for allegations of abuse, neglect, injuries of unknown source, and misappropriation of resident property effective 08/28/17. The facility alleged that a Quality Assurance/Performance Improvement (QAPI) plan was initiated and the facility was reviewing all allegations to ensure they were reported in accordance with the regulations; however, the plan had not been finalized and the facility failed to report the findings of three investigations of misappropriation of resident property from 09/02/17 to 09/26/17 (refer to F225). The findings include: A review of Statements of Deficiencies (SODs) issued to the facility revealed on 08/02/17, an SOD was issued to the facility due to failure to report an allegation of an injury of unknown origin. A review of the facility's plan of correction revealed on 08/04/17 the facility established a Quality Assurance/Performance Improvement (QAPI) project for failure to report allegations. The plan of correction stated allegations were reviewed daily by the Interdisciplinary Team (IDT) and weekly during QAPI meetings to ensure compliance. The facility alleged compliance with the reporting requirements effective 08/28/17. An interview with the Administrator on 09/26/17 at 5:05 PM revealed the facility developed a Quality Assurance/Performance Improvement (QAPI) plan as a result of the deficient practice cited on 08/02/17. The plan had not been finalized as alleged in the facility's plan of correction; however, the facility had been monitoring investigations daily to ensure timely reporting. Review of allegations of misappropriation of resident property revealed the facility reported investigations were initiated when Resident #3 had a cell phone charger missing on 09/02/17, Resident #4 had a compact disc missing on 09/02/17, and when Resident A had twenty-five (25) quarters missing on 09/18/17. However, there was no evidence the facility reported the results of the investigations for these incidents to the state survey agency. A review of the quality assurance audit completed by the facility for allegations in August and September 2017 revealed no evidence the facility had identified that the final results of investigations for Residents #3, #4, and A had not been reported to the state survey agency as required. An interview with the Administrator on 09/26/17 at 5:05 PM revealed she and the IDT reviewed allegations daily and she was not aware the investigation findings for Residents #3, #4, and A had not been reported as required.

Based on interview, record review, and a review of the facility's abuse policy, it was determined the facility failed to report the results of three (3) of four (4) investigations of misappropriation of resident property to the state survey agency within five working days of the incidents. The facility reported allegations related to misappropriation of Resident #3's cell phone charger, Resident #4's compact disc, and Resident A's twenty-five (25) quarters. There was no evidence the facility reported the results of the investigations for these incidents to the state survey agency. The findings include: A review of the facility's policy titled Abuse, Neglect Exploitation, Mistreatment and Misappropriation of Resident Property, dated May 2017, revealed the follow-up results of all investigations were required to be reported to the state survey agency within five working days of the incident. 1. A review of an investigation completed by the facility for Resident #3 dated 09/08/17 revealed the facility had investigated an allegation of misappropriation of property that was reported by the resident's family on 09/02/17, alleging a phone charger was missing. According to the allegation, the facility reported the allegation to the state survey agency on 09/02/17 as required. However, there was no evidence the facility reported the final investigation results to the state survey agency. 2. A review of an investigation completed by the facility for Resident #4 dated 09/08/17 revealed the facility investigated an allegation of misappropriation of resident property that was reported by Resident #4 on 09/02/17, alleging that a compact disc was missing. According to the allegation, the facility initially reported the allegation to the state survey agency on 09/02/17 and conducted an investigation as required. However, there was no evidence the facility reported the final investigation results to the state survey agency. 3. A review of an investigation completed for Resident A by the facility dated 09/25/17 revealed the facility investigated an allegation that 25 quarters were misappropriated from Resident A on 09/18/17. The facility conducted an investigation of the allegation; however, there was no evidence the facility reported the final results of the investigation to the state survey agency. An interview with the Director of Nursing (DON), who was the facility Abuse Coordinator, on 09/26/17 at 4:25 PM revealed she initially reported the allegations for Residents #3, #4, and A and completed the summaries of the investigations within five working days as required. According to the DON, a facsimile transmission confirmation report was usually attached to the investigation as evidence that the investigation results were sent to the state survey agency; however, there was no confirmation that the investigations for Residents #3, #4, and A were sent to the state survey agency. The DON stated she thought the investigation results were faxed to the state survey agency and did not know why the reports were not provided.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure one (1) of three (3) residents remained in the facility and was not discharged . The facility issued a discharge notice to Resident #1 on 07/28/17, which stated the resident was endangering the health of other residents by putting wipes in the toilet, resulting in overflowing toilets. However, review of the resident's medical record and interview with staff revealed no evidence Resident #1 had put wipes or any other items in a toilet. The findings include: Review of the facility's policy titled Transfer/Discharges, dated 05/01/11, revealed a resident could be discharged from the facility if the discharge was necessary for the resident's welfare and the resident's needs could not be met in the facility, the safety of other residents and employees was endangered, or the health of residents and employees in the facility would otherwise be endangered. Review of Resident #1's medical recorded revealed the facility admitted the resident on 04/15/16, with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fifteen (15), indicating the resident was cognitively intact. Review of a 30 Day Discharge Notice, dated 07/28/17, revealed the facility issued a discharge notice to Resident #1 because the facility suspected Resident #1 was sabotaging the sewer pipe system with wipes clogging up the sewer system and causing toilet overflow in that area of the building. This discharge is necessary for the health of individuals in the facility who are endangered with potential harm for falls and infections control issues. The discharge notice stated the resident was scheduled to be discharged on [DATE]. Interview with Resident #1 on 08/16/17 at 2:04 PM, revealed the facility accused the resident of putting wipes in the toilet and causing the sewer system to overflow. The resident stated he/she was continent and did not require the use of wipes and did not put wipes in a toilet. Further interview revealed the facility issued the resident a thirty (30) day discharge notice stating the resident would be discharged from the facility on 08/28/17. Interview with the Administrator on 08/16/17 at 5:45 PM revealed Certified Nursing Assistant (CNA) #1 told her that Resident #1 was witnessed throwing wipes in his/her toilet causing the sewer system to overflow. She stated she felt it was a safety hazard for other residents and felt that the resident should have been discharged from the facility. Therefore, she along with the DON gave the resident a thirty (30) day discharge notice on 07/28/17. However, interview with Certified Nursing Assistant (CNA) #1 on 08/16/17 at 2:58 PM, revealed the CNA stated she had never witnessed Resident #1 put wipes in a toilet. Further interviews with CNA #1 on 08/16/17 at 2:58 PM, CNA #2 at 4:47 PM, and CNA #3 at 5:04 PM, revealed they had not witnessed Resident #1 put wipes in a toilet, causing the sewer system to overflow. They stated they had witnessed toilets overflow in different resident rooms throughout the facility. Further interviews revealed the sewer system had backed up on 08/14/17; however, it was not due to anything placed in resident toilets. Interview with the Social Services Director (SSD) on 08/16/17 at 3:53 PM revealed she had not witnessed Resident #1 throw anything into a toilet causing the sewer system to overflow. Interview with Licensed Practical Nurse (LPN) #1 on 08/16/17 at 4:27 PM revealed she had not witnessed Resident #1 throwing wipes or anything else in the toilet. Interview with the Maintenance Director on 08/16/17 at 4:37 PM, revealed he had found numerous items in the sewer system that had contributed to causing the system to back up. In addition to finding wipes, the Maintenance Director stated he had also found paper towels, gloves, and plastic bags in the sewer lines. Further interview revealed he had not witnessed Resident #1 or any other resident put anything in the toilets to cause overflow. Interview with the Director of Nursing (DON) on 08/16/17 at 5:22 PM, revealed she had not witnessed Resident #1 throw anything in the toilet, but felt that Resident #1 had put wipes in the toilet causing them to overflow. The DON stated the facility issued Resident #1 a thirty (30) day discharge notice on 07/28/17, because they felt the resident was putting other residents at risk for falls and infections because the sewer was overflowing into their rooms, even though there was no evidence Resident #1 was attempting to cause the toilets to overflow.

Based on interview, record review, and a review of the facility abuse policy it was determined the facility failed to immediately report and failed to investigate an injury of unknown source (fractured left arm) for one (1) of three (3) sampled residents (Resident #1). The findings include: A review of the facility's policy titled Abuse Prevention, dated 02/14/14, revealed the Shift Supervisor was responsible for immediate initiation of the reporting process. Further review of the policy revealed the Administrator and the Director of Nursing were responsible for investigation and reporting allegations of abuse to required state agencies. Review of the closed medical record for Resident #1 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #1's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed the resident to have severely impaired cognition. A review of a facility incident report dated 06/18/17 (the day after Resident #1 was diagnosed with [REDACTED].#1 completed a witness statement that stated Resident #1's daughter reported that Resident #1's hand appeared swollen. According to the witness statement, LPN #1 assessed the resident's hand to be slightly swollen, but completed range of motion without difficulty, and the resident had no signs or symptoms of pain or discomfort. According to the witness statement, Advanced Practice Registered Nurse (APRN) #1 ordered an x-ray of Resident #1's left forearm. Further review of Resident #1's medical record revealed the order to obtain an x-ray of the resident's arm was written on 06/16/17 at 6:40 PM and an x-ray was obtained on 06/17/17 at 3:00 AM. The facility received the x-ray results at 7:00 AM that stated Resident #1 had a questionable fracture. The facility repeated the x-ray of Resident #1's arm and received the results at 3:00 PM on 06/17/17 that confirmed the resident had a left radial neck fracture (a [MEDICAL CONDITION] forearm bone near the elbow). An interview with Resident #1's Family Member on 08/02/17 at 6:45 PM revealed on 06/16/17, the family member notified a facility nurse that the resident's arm was swollen, discolored, and warm to touch. The family member stated an x-ray of Resident #1's arm was ordered. An interview with LPN #1 on 08/01/17 at 1:00 PM, revealed Resident #1's family member asked the APRN to check the resident's arm on 06/16/17. LPN #1 further stated she assessed Resident #1's arm and documented the assessment on a witness statement and the APRN wrote an order for [REDACTED].>An interview with LPN #4 on 08/02/17 at 11:45 AM, revealed he received Resident #1's x-ray results on the morning of 06/17/17 that stated Resident #1 had a possible [MEDICAL CONDITION] arm. LPN #4 stated he notified the APRN and the Director of Nursing (DON) of the x-ray results. An interview with the DON on 08/02/17 at 11:20 AM revealed she did not conduct an investigation of the injury of unknown origin or report the injury to the state survey agency. Even though an investigation into the cause of the fracture was not conducted, the DON stated she felt the fracture was pathological (a bone fracture caused by disease that led to weakness of the bone structure such as [MEDICAL CONDITION], cancer, infection, etc.). The DON further stated she was not aware of the current regulation for reporting injuries of unknown source. An interview with the Administrator on 08/02/17 at 12:45 PM, revealed the DON notified the Administrator regarding Resident #1's fracture and the injury was discussed during the morning meeting on 06/19/17. The Administrator stated the facility felt the fracture was pathological and an investigation was not conducted. The Administrator further stated she was not aware of the requirements for reporting injuries of unknown origin.

Based on interview, record review, and facility policy review it was determined the facility failed to provide pharmaceutical services which included procedures to ensure the accurate acquiring, receiving, dispensing, and administration of all drugs and biologicals to meet the needs of each resident for eight (8) of nine (9) sampled residents. Review of Medication Administration Records (MARs) for Residents #1, #2, #3, #4, #6, #7, and #8 from March 2017 through 05/24/17 revealed that two hundred thirty-one (231) doses of medications were signed out on the medication's narcotic sheet (a record utilized to ensure medications classified as controlled could be accurately accounted for) but were not documented as being administered to the resident on the resident's MAR. Further review revealed nine (9) doses of medications that were documented as being administered on the resident's MAR, but were not signed out on the medication's corresponding narcotic control sheet. Review of Resident #5's narcotic control sheet for April 2017 revealed staff failed to ensure two (2) licensed nurses confirmed that narcotic medications were wasted properly as required by the facility's policy. Review of Resident #6's narcotic control sheet for April 2017 revealed staff had signed out and wasted three (3) controlled substances while Resident #6 was hospitalized . Review of a facility investigation dated 05/05/17 revealed Licensed Practical Nurse (LPN) #4 had signed out and wasted a controlled substance even though LPN #4 was not in the facility at that time. Additionally, review of Residents #3, #4, #5, #6, and #7's narcotic sheets from March 2017 through May 2017 revealed the facility failed to maintain the controlled medication narcotic sheets as required. Review of 902 KAR 55:035 revealed the medication Gabapentin will not be added to the controlled substance Schedule V formulary until 07/01/17. However, interview with the Director of Nursing on 05/27/17 at 3:27 PM, revealed that the facility had already been treating the medication Gabapentin as a controlled substance for some time, exact date unknown, and required that the same procedures be applied to Gabapentin as all other controlled medications. 1. Review of the facility's policy titled Policies for Medication Administration, dated October 2004, revealed staff would initial the Medication Administration Record (MAR) after administering medications to a resident, to indicate the resident had received the medication. Review of the facility's policy titled Controlled Drugs, not dated, revealed narcotic sheets would be maintained for each medication that was prescribed for residents and designated as a controlled medication. A) Review of Resident #1's medical record revealed the facility admitted the resident on 04/25/17 with [DIAGNOSES REDACTED]. Review of Resident #1's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of one (1) which indicated Resident #1 was severely cognitively impaired. Review of Resident #1's physician's orders [REDACTED]. Review of Resident #1's MAR for April and May 2017 revealed ten (10) doses of Oxycodone HCL IR 20 mg were signed out on the resident's narcotic sheet but were not documented as administered to Resident #1 on the resident's MAR. B) Review of Resident #2's medical record revealed the facility admitted the resident on 09/23/16 with [DIAGNOSES REDACTED]. Review of Resident #2's quarterly MDS assessment dated [DATE] revealed the facility assessed the resident to have a BIMS score of fifteen (15) which indicated Resident #2 was cognitively intact. Interview with Resident #2 on 05/24/17 at 1:25 PM revealed the resident expressed no concerns with receiving his/her medications as scheduled. Review of Resident #2's physician's orders [REDACTED]. Review of Resident #2's MAR for March 2017 and April 2017 revealed one (1) dose of Gabapentin 800 mg was signed out on the medication's corresponding narcotic control sheet, but was not documented as administered to the resident on Resident #2's MAR. Additionally, there were three (3) doses of Gabapentin 800 mg that were documented as administered on the resident's MAR but not signed out on the medication's corresponding narcotic sheet. C) Review of Resident #3's medical record revealed the facility admitted the resident on 04/10/17 with [DIAGNOSES REDACTED]. Review of Resident #3's admission MDS assessment dated [DATE] revealed the facility assessed the resident to have a BIMS score of fifteen (15) which indicated Resident #3 was cognitively intact. Interview with Resident #3 on 05/24/17 at 1:27 PM revealed the resident voiced no concerns related to receiving his/her medications. Review of Resident #3's physician's orders [REDACTED]. Review of Resident #3's MAR for April 2017 and May 2017 revealed thirty-six (36) doses of Norco 5 mg were signed out on the medication's corresponding narcotic control sheet but not documented as administered on Resident #3's MAR. D) Review of Resident #4's medical record revealed the facility admitted the resident on 08/10/16 with [DIAGNOSES REDACTED]. Review of Resident #4's quarterly MDS assessment dated [DATE] revealed the facility assessed the resident to have a BIMS score of three (3) which indicated Resident #3 was severely cognitively impaired. Review of Resident #4's physician's orders [REDACTED]. Review of Resident #4's MAR for March 2017 and April 2017 revealed seventeen (17) doses of Percocet 5-325 mg were signed out on the medication's corresponding narcotic control sheet but not documented as administered to the resident on Resident #4's MAR. E) Review of Resident #6's medical record revealed the facility admitted the resident on 01/14/16 with [DIAGNOSES REDACTED]. Review of Resident 6's quarterly MDS assessment dated [DATE] revealed the facility assessed the resident to have a BIMS score of fifteen (15) which indicated Resident #6 was cognitively intact. Resident #6 was hospitalized at the time of the investigation and was unable to be interviewed. Review of Resident #6's physician's orders [REDACTED]. Review of Resident #6's MAR for March 2017 and April 2017 revealed eighteen (18) doses of Percocet 7.5/325 mg were signed out on the medication's corresponding narcotic control sheet but not documented as administered to the resident on Resident #6's MAR. F) Review of Resident #7's medical record revealed the facility admitted the resident on 10/06/16 with [DIAGNOSES REDACTED]. Review of Resident 7's quarterly MDS assessment dated [DATE] revealed the facility assessed the resident to have a BIMS score of fifteen (15) which indicated Resident #7 was cognitively intact. Interview with Resident #7 on 05/24/17 at 2:55 PM revealed the resident had no concerns related to medication administration. Review of Resident #7's physician's orders [REDACTED]. Review of Resident #7's MAR for March 2017, April 2017, and May 2017 revealed nine (9) doses of Gabapentin 800 mg and one hundred twenty-four (124) doses of Norco 10/325 mg were signed out on the medication's corresponding narcotic control sheet but not documented as having been administered to Resident #7 on the resident's MAR. G) Review of Resident #8's medical record revealed the facility admitted the resident on 10/18/16 with [DIAGNOSES REDACTED]. Review of Resident 8's quarterly MDS assessment dated [DATE] revealed the facility assessed the resident to have a BIMS score of eight (8) which indicated Resident #8 was moderately cognitively impaired. Review of Resident #8's physician's orders [REDACTED]. Review of Resident #8's MAR for April 2017 and May 2017 revealed twenty-six (26) doses of Hydrocodone-Acetaminophen 5-325 mg were signed out on the medication's corresponding narcotic control sheet but not documented as being administered to Resident #8 on the resident's MAR. Interview with LPN #1 on 05/25/17 at 11:50 AM revealed she had been trained to sign out all controlled medications on the narcotic sheet, and then initial the resident's MAR when the medication had been administered to the resident. However, she stated that at times she had forgotten to complete the two-step process for each controlled medication. Interview with LPN #2 on 05/25/17 at 2:25 PM revealed she had been trained when giving a controlled medication to sign the narcotic sheet indicating the medication had been removed, and then initial the resident's MAR once the medication had been administered to the resident. However, LPN #2 stated, Sometimes it's easy to forget. Interview with LPN #3 on 05/26/17 at 12:59 PM revealed the nurses receive training every three (3) months on medication administration. LPN #3 stated she had been trained to sign the narcotic sheet indicating the medication had been removed, and then initial the resident's MAR once the medication had been administered to the resident. 2. Review of the facility's policy titled Controlled Drugs Policy and Procedure, not dated, revealed two (2) licensed nurses must witness and sign the destruction of any controlled substance. A) Review of Resident #5's medical record revealed the facility admitted the resident on 01/17/16 with [DIAGNOSES REDACTED]. Review of Resident 5's quarterly MDS assessment dated [DATE] revealed the facility assessed the resident to have a BIMS score of fifteen (15) which indicated Resident #5 was cognitively intact. Interview with Resident #5 on 05/24/17 at 1:40 PM revealed the resident had no complaints regarding medication administration. Review of Resident #5's physician's orders [REDACTED]. Review of Resident #5's MAR for 04/30/17 revealed one (1) dose of Klonopin 2 mg at bedtime was wasted without the required signatures of two (2) licensed nurses. Interview with LPN #1 on 05/25/17 at 11:50 AM revealed she had not received training that two licensed nurses were required to observe a controlled medication being wasted and that two nurses had to sign the narcotic sheet verifying that they each had witnessed the medication being disposed of. 3. Review of the facility's policy titled Policies for Medication Administration, dated October 2004, revealed when staff administered an as needed pain medication an entry was required to be made in the resident's record indicating why the medication was being administered. Review of the Lippincott Manual of Nursing Practice, Tenth Edition, revealed as needed medications were to be administered to a patient when the patient was experiencing symptoms and not to be administered routinely at specific times. Review of Resident #6's physician's orders [REDACTED]. Review of Resident #6's MAR for April 2017 revealed two (2) doses of Percocet 7.5/325 mg on 04/29/17 and one (1) dose of Percocet 7.5/325 mg on 04/30/17 as wasted on the narcotic sheet. However, Resident #6 was hosptalized on [DATE] and 04/30/17 and was not in the facility. Interview with LPN #1 on 05/25/17 at 11:50 AM revealed she had forgotten that Resident #6 was in the hospital after the controlled medication had been pulled from the narcotics package. LPN #1 was unable to state why she obtained the as needed medication to administer to Resident #6 without the resident having asked for the medication or displaying signs/symptoms that the medication was needed. 4. Review of the facility's policy titled Controlled Drugs, not dated, revealed narcotic sheets (a record utilized to ensure medications classified as controlled could be accurately accounted for) would be accurately maintained for each controlled medication that was prescribed for a resident. Review of Resident #8's physician's orders [REDACTED]. Review of Resident #8's MAR for 04/30/17 revealed LPN #4 had falsely documented that she removed and wasted Hydrocodone-Acetaminophen 5-325 mg on 4/30/17 at 6:00 AM for Resident #8. LPN #4 was not in the facility working on 4/30/17 at 6:00 AM because she had been unexpectedly suspended on 04/29/17 at 11:30 PM, related to an allegation of abuse. Interview with LPN #4 on 05/26/17 at 1:31 PM revealed she accidently signed out the medication on the wrong date and at the wrong time on 04/29/17. LPN #4 went on to state that Resident #8 had refused to take the medication when she attempted to administer it to the resident and therefore she wasted the medication. LPN #2 stated that she had been trained as a nurse that wasting narcotic medications required a second licensed professional to witness the destruction. However, LPN #2 stated she had failed to have another staff member witness her waste the Hydrocodone-Acetaminophen 5-325 mg on 04/29/17. 5. Review of the facility's policy titled Controlled Drugs Policy and Procedure, not dated, revealed that appropriate recording of all of controlled drugs would be maintained on all units. A) Review of Resident #3's physician's orders [REDACTED].#3 was ordered to receive the controlled medication Norco 5 mg every eight (8) hours as needed for pain. Review of Resident #3's narcotic sheets for March 2017 and April 2017 revealed from 03/01/17 to 04/11/17 the facility was unable to provide a narcotic sheet for the prescribed Norco medication. B) Review of Resident #4's physician's orders [REDACTED]. Review of Resident #4's narcotic sheets for March 2017, April 2017, and May 2017 revealed from 03/25/17 to 04/24/17, and from 05/01/17 to 05/05/17, the facility was unable to provide a narcotic sheet for the Percocet medication. C) Review of Resident #5's physician's orders [REDACTED]. Review of Resident #5's narcotic sheets for March 2017 and April 2017 revealed from 03/20/17 to 04/17/17 the facility was unable to provide a narcotic sheet for the Klonopin medication. D) Review of Resident #6's physician's orders [REDACTED]. Review of Resident #6's narcotic sheets for March 2017 and April 2017 revealed from 03/01/17 to 03/06/17, 03/29/17 to 03/31/17, and 04/01/17 to 04/11/17 the facility was unable to provide a narcotic sheet for the Percocet medication. E) Review of Resident #7's physician's orders [REDACTED]. Review of Resident #7's narcotic sheets for March 2017 revealed from 03/16/17 to 03/23/17 the facility was unable to provide a narcotic sheet for the Gabapentin medication. Interview with the Pharmacist Consultant on 05/26/17 at 5:41 PM revealed she monitored ten percent of the narcotics utilized in the facility monthly. She revealed she had not noticed a pattern of nurses wasting the medications and had no concerns with nurses not signing the MAR and narcotic sheets. Interview with the Director of Nursing (DON) on 05/27/17 at 3:27 PM revealed the nurses received quarterly trainings on medication administration. She further revealed two (2) nurses were required to sign when a controlled medication was wasted. She revealed when a narcotic was being administered, the MAR and the narcotic sheet was to be signed by the nurse administering the controlled substance. Further interview with the DON revealed the facility had no system in place to monitor narcotic sheets. She revealed she did not know what had happened to the residents' missing narcotic sheets. Interview with the Administrator on 05/26/17 at 4:08 PM revealed no procedure was in place to compare the MAR to the narcotic control sheets to ensure the medications were being signed out, accounted for, and administered appropriately. The Administrator stated she did not know what had happened to the missing narcotic sheets.

Based on observation, interview, record review, and review of the facility's policy it was determined the facility failed to ensure one (1) of nine (9) sampled residents (Resident #9) was treated with respect and dignity in a manner that promoted, maintained, or enhanced the resident's quality of life. Observation of incontinence care and hygiene on 05/25/17 for Resident #9 revealed staff was observed to provide care without closing the resident's privacy curtain. Resident #9's roommate could observe the incontinence care provided to Resident #9. The findings include: Review of the facility's policy, Confidentiality and Privacy, dated 05/01/11, revealed residents would be provided with privacy when receiving treatment and when personal care was being provided to the resident. Review of the facility's policy, Continence Care, not dated, revealed staff would screen and drape residents to ensure privacy. Review of the facility's policy, Personal Hygiene Care for the Female Resident, not dated, revealed staff would gather equipment and provide for resident privacy. An observation on 05/25/17 at 9:11 AM revealed Certified Nursing Assistant (CNA) #1 provided incontinence care and hygiene to Resident #9 without ensuring the resident's privacy curtain was closed. Further observation revealed Resident #9's roommate was in the room while the staff was providing care to Resident #9. Interview with Resident #9 on 05/25/17 at 10:24 AM revealed that the CNAs did not always pull the curtain during care. The resident stated that he/she would prefer that staff pulled the curtain when providing care to give him/her privacy. Interview with CNA #1 on 05/25/17 at 10:30 AM revealed she was trained to close the privacy curtain when providing care for residents. CNA #1 stated the curtain was difficult to open/close at times; however, she stated she should have ensured it was closed before she provided care to Resident #9. Interview with the Director of Nursing (DON) on 05/26/17 at 3:27 PM revealed direct care staff was expected to ensure the privacy curtain was pulled during resident care to promote dignity. She stated she conducted rounds daily to ensure privacy curtains were pulled during resident care. Further interview revealed she had not identified any concerns with staff not providing privacy during resident care.

Based on interview, record review, and review of a facility policy, it was determined the facility failed to protect one (1) of one (1) resident's rights to make choices regarding aspects of the resident's life at the facility (Resident #1). Review of Resident #1's record revealed the resident requested daily showers on 01/31/17; however, the facility failed to provide daily showers. The findings include: Review of the facility policy titled Bathing a Resident, date unknown, revealed staff was to schedule bath times based on resident preferences, tolerance, and ability. Further review of the policy revealed residents were to receive at least two (2) showers or tub baths per week and more frequently as needed. Review of the medical record for Resident #1 revealed the facility admitted the resident on 01/24/17 with [DIAGNOSES REDACTED]. Review of the Care Plan Conference Record, dated 01/31/17, revealed the resident requested to receive daily showers. Review of the resident's bathing record documentation revealed the resident received showers at least twice weekly as indicated by facility policy but did not receive daily showers as requested. Interview with the Director of Nursing (DON) and Administrator on 02/20/17 at 4:48 PM revealed residents had the right to choose frequency and timing of showers. Further interview revealed if Resident #1 had requested daily showers, they would expect staff to ensure the resident received daily showers. The DON and Administrator stated they were unaware of the request and were unsure how the request had been missed.

Based on observation, interview, and facility policy review it was determined the facility failed to provide housekeeping services to maintain a sanitary and comfortable environment. Observations of facility wheelchairs on 09/15/16 and 09/16/16 revealed four (4) of seventy (70) wheelchairs were dirty and in need of cleaning. The observations included food particles under the foam cushions, dust/debris on the seat rails, and hair tangled around the wheel axles. In addition to the wheelchairs being unsanitary, one (1) of the four (4) wheelchairs emitted an odor that smelled of urine and rotten food. The findings include: Review of the Night Shift Cleaning Schedule, undated, revealed wheelchairs were to be routinely cleaned on Wednesday, Thursday, Friday, and Saturday nights. Observation of Resident #8's wheelchair on 09/15/16 at 3:43 PM revealed what appeared to be multiple food particles mixed with urine under the foam cushion of the resident's wheelchair. The observation also revealed the wheelchair had dust and debris on the seat rails and hair tangled around the axles of the rear wheels. Observation of Resident #7's wheelchair on 09/15/16 at 3:45 PM revealed dust/debris on the seat rails, and hair tangled around the axles of the rear wheels. Observation of Resident C's wheelchair on 09/16/16 at 2:16 PM revealed what appeared to be food particles present under the foam cushion of the wheelchair and hair tangled around the axles of the rear wheels. Observation of Resident #15's wheelchair on 09/16/16 at 2:16 PM revealed what appeared to be food particles and debris present under the foam cushion of the wheelchair and hair tangled around the axles of the rear wheels. Interview with State Registered Nurse Aide (SRNA) #2 on 09/16/16 at 3:42 PM revealed night shift nurse aides were responsible for cleaning resident wheelchairs. Further interview with SRNA #2 revealed the nurse aides had a cleaning schedule that they were to follow. Interview with Licensed Practical Nurse (LPN) #2 on 09/16/16 at 3:43 PM revealed nurse aides who work night shift were responsible for cleaning resident wheelchairs and were to follow a cleaning schedule each night. Interview with the Director of Nursing (DON) on 09/16/16 at 3:51 PM revealed night shift nurse aides were responsible for cleaning resident wheelchairs. The DON also stated that she had conducted random audits of resident wheelchairs, but had not identified any of the wheelchairs observed by the surveyor to be in need of cleaning. Interview with the facility Administrator on 09/16/16 at 3:52 PM revealed she had noticed three wheelchairs in the facility previously within the last week (exact date unknown) that needed to be cleaned. However, she was not aware of the condition of Resident #8's wheelchair. The Administrator stated she had conducted wheelchair audits on resident wheelchairs and had not identified any resident wheelchairs in need of cleaning. Further interview with the facility Administrator revealed the night shift nurse who was responsible for making sure the nurse aides were cleaning the wheelchairs had been terminated.

Based on observation, interview, medical record review, hospital record review, and a review of the facility's policies, it was determined the facility failed to immediately consult with the resident's physician when the resident experienced a significant change in condition that required physician intervention for one of three sampled residents (Resident #1). Resident #1 returned from the hospital on [DATE] at 11:30 AM, and staff observed Resident #1 to yell out with repositioning and care; it was noted the resident had a bruise to the rib area. The nurse was notified but failed to notify the physician. On 10/08/13, at approximately 10:00 AM, and again at 3:00 PM, staff observed Resident #1 in bed with his/her right arm positioned under his/her back; the resident was not able to move his/her right arm and complained of pain when staff attempted to move his/her right arm. Staff informed Licensed Practical Nurse (LPN) #1 of the change in Resident #1's condition but the physician was not notified. On 10/09/13, at 7:15 AM staff observed bruising to Resident #1's right shoulder, scapula (shoulder blade), and the auxiliary (armpit) area, and the resident had facial grimacing and moaning with movement of the arm. The facility staff notified the physician at 8:30 AM on 10/09/13, approximately 22 hours after the first observation of a change in condition on 10/08/13 at 10:00 AM. Resident #1 was transported to the local hospital at 12:45 PM on 10/09/13, where the resident was diagnosed with [REDACTED]. The resident's humerus (shoulder) was also dislocated. The findings include: Review of the facility's policy entitled "Changes in Resident's Condition or Status," not dated, revealed Nursing Services was responsible to notify the resident's physician and responsible party when there was a significant change in the resident's physical, mental, or emotional status, a need to alter the resident's treatment, or when deemed necessary in the best interest of the resident. Review of the facility's policy entitled "Alert Charting," not dated, revealed a nurse had the responsibility to notify the resident's physician and responsible party of significant changes, including bruising or other unusual resident events, as part of the facility's "event follow-up" (incident/accident) protocol. Review of Resident #1's medical record revealed the facility admitted the resident on 10/11/06 with [DIAGNOSES REDACTED]. Further review of the clinical record revealed on 07/25/13, the facility assessed Resident #1 to have a Brief Interview for Mental Status (BIMS) score of 99 which indicated the resident was not interviewable. In addition, staff interviews also revealed the resident had moderately impaired cognitive skills. Review of nursing notes dated 10/07/13 at 5:54 AM, revealed Resident #1 had [MEDICAL CONDITION]-type activity at 5:30 AM. The physician was notified and the resident was transferred to the hospital. Interview with staff revealed Resident #1 returned from the hospital on [DATE] at 11:30 AM, following an evaluation of [MEDICAL CONDITION]-type activity. Upon the resident's return, staff observed Resident #1 to yell out when he/she was repositioned and care was provided. Staff observed the resident had a bruise to the rib area. Further interview revealed staff notified a nurse of the resident's condition; however, the nurse failed to document an assessment of the resident and failed to inform the resident's physician of the change in the resident's condition. Observations on 10/22/13 at 12:30 PM, 3:30 PM, 5:30 PM, and 7:00 PM, revealed Resident #1 lying in the bed with a sling and swath (used to prevent movement of an upper extremity) on his/her right arm. An attempt to interview Resident #1 was unsuccessful due to the resident's limited cognition. Interview on 10/22/13 at 4:50 PM with State Registered Nursing Assistant (SRNA) #2 revealed on 10/07/13 after Resident #1 returned from the hospital, she reported to Registered Nurse (RN) #1 that Resident #1 yelled out every time the SRNAs moved the resident; and the resident had a bruise to the rib area. According to SRNA #2, RN #1 assessed Resident #1; however, the SRNA was unaware of the actions of the RN after the assessment. Continued review of nursing notes dated 10/08/13 at 3:30 AM, revealed a new physician's orders [REDACTED].#1; however, there was no documented evidence the resident's physician had been informed of the resident's inability to move his/her right arm, or of the resident's facial expression of pain upon movement. Interview on 10/22/13 at 5:00 PM with SRNA #3 revealed after breakfast on 10/08/13, Resident #1 would "yell out" and resist when she tried to reposition him/her. SRNA #3 stated at approximately 10:00 AM on 10/08/13 she noticed Resident #1 lying on his/her right arm, the resident was unable to remove the arm from underneath him/her, and the resident's arm was "lifeless." The interview revealed at that time the SRNA reported the change in Resident #1's condition to Licensed Practical Nurse (LPN) #1. According to SRNA #3, Resident #1 also had a dark bruise to the collarbone. Interview with SRNA #3 revealed she informed LPN #1 again of the resident's condition on 10/08/13 at approximately 3:00 PM. However, the SRNA was not aware if LPN assessed the resident at that time. Interview on 10/22/13 at 5:45 PM, with SRNA #4 revealed on 10/08/13, during the 10:00 AM rounds, she observed Resident #1 lying with his/her right arm behind his/her back. SRNA #4 stated the resident grimaced every time his/her right arm was moved. The interview revealed the SRNA reported the change in the resident's condition to LPN #1 at that time. SRNA #4 stated she again reported the change in condition to LPN #1 at approximately 3:00 PM on 10/08/13. SRNA #4 stated she did not witness the LPN enter Resident #1's room to assess the resident's condition. SRNA #4 stated Resident #1 also had a black bruise to the right shoulder area, but she had not reported the bruise to the LPN. Interview on 10/23/13 at 10:05 AM with SRNA #6 revealed at the beginning of her shift on 10/08/13, at approximately 7:00 PM, SRNA #4 reported to her that Resident #1's right arm was "messed up" and that even though the SRNAs had reported the change in the resident's condition to LPN #1, nothing had been done for the resident. SRNA #6 stated Resident #1 had "screamed" when staff touched the resident's right arm while she had provided care that night. However, SRNA #6 did not report the resident's response to care to the evening shift nurse. According to SRNA #6, she had been told the day shift nurse was aware of the change in the resident's condition and assumed the nurse would have passed the information on to the evening nurse during shift report. Interview on 10/22/13 at 4:10 PM with LPN #1 revealed on 10/08/13, SRNAs #3 and #4 reported a change in Resident #1's condition to her. According to LPN #1, the SRNAs reported the resident would roll onto his/her right arm and was unable to move his/her arm. LPN #1 acknowledged she observed a dark purple bruise on Resident #1's clavicle on 10/08/13; however, the resident was able to move the right arm when she had asked him/her. The LPN stated she was unaware of any injuries sustained by Resident #1 that could have resulted in the bruise. Further interview revealed LPN #1 did not notify the resident's physician of the dark purple bruise, or of the information reported by the SRNAs related to a change in the resident's condition. LPN #1 acknowledged that according to the facility's policy it was the nurses' responsibility to contact the resident's physician with any change in the resident's condition and to document any changes or assessments in the nursing notes in the medical record. Review of the nursing note dated 10/09/13 at 2:08 AM, revealed the resident required the total assistance of two to four staff members for care because of the resident's resistant behaviors. Review of a late entry nursing note dated 10/09/13 at 3:14 PM, revealed at approximately 7:15 AM on 10/09/13, staff observed "dark bluish/purple/black" bruising to Resident #1's right shoulder, scapula (shoulder blade), and the auxiliary (armpit) area. The nursing note revealed Resident #1 had facial grimacing and moaning with movement of his/her right arm, and was "grabbing" with his/her left hand at his/her shoulder area. Further review of the nursing note revealed facility staff notified Resident #1's physician of the change in the resident's condition on 10/09/13 at 8:30 AM, and the resident was transported to the hospital on [DATE] at 12:45 PM for evaluation and treatment. Review of the hospital medical record revealed a Computed Tomography (CT) scan obtained of Resident #1's right shoulder on 10/09/13 revealed a "Comminuted fracture from the humeral head and neck with multiple fragments seen in the shoulder joint," and "Anterior cephalad dislocation of the humeral head." Interview on 10/23/13 at 11:00 AM with SRNA #5 revealed on the morning of 10/09/13 the SRNA noted something was wrong with Resident #1's arm; the SRNA stated the resident's arm was like a "dead arm." SRNA #5 stated he reported the resident's condition to LPN #2 and the LPN stated that nothing had been reported to her in shift report or throughout the night. The interview revealed LPN #2 assessed the resident, notified the resident's physician, and obtained physician's orders [REDACTED]. SRNA #5 stated Resident #1 had a T-shirt on and there was a visible dark bruise located on the right side of the resident's shirt collar. Review of LPN #2's written statement, obtained by the facility on 10/10/13, revealed on 10/09/13 at approximately 7:05 AM SRNA #5 asked the LPN about Resident #1's right arm. According to LPN #2's written statement, she assessed Resident #1, attempted to perform range of motion to the resident's arm, and the resident appeared to be in visible pain when moving his/her arm. The statement also revealed the resident had "deep purple bruising" to his/her armpit and shoulder. Attempts to interview LPN #2 on 10/22/13 at 6:15 PM, and on 10/23/13 at 8:00 AM, by telephone were unsuccessful; there was no answer and no voice mail to leave a message. Review of LPN #2's written statement confirmed that she had been informed of Resident #1's condition by SRNA #5, had contacted the resident's physician, and had transferred the resident to the hospital. Interview on 10/22/13 at 6:00 PM with RN #1 revealed Resident #1 had experienced a [MEDICAL CONDITION] on 10/07/13 at approximately 5:30 AM, and had been transported to the local hospital for evaluation and treatment prior to her scheduled shift on 10/07/13 that began at 7:00 AM. RN #1 stated she did not conduct a skin assessment upon Resident #1's return to the facility on [DATE] at approximately 11:30 AM and stated staff had not reported a change in Resident #1's condition at the time of his/her return to the facility or during the remainder of her shift on 10/07/13. Interview on 10/22/13 at 7:15 PM with the Assistant Director of Nursing (ADON) revealed on 10/09/13, at approximately 8:00 AM, SRNA #5 reported to her something was wrong with Resident #1's right arm and the ADON went to Resident #1's room. The ADON stated, "I could tell from the door" that the resident's right shoulder was higher than the left shoulder. The ADON stated the resident's right shoulder was swollen to the point that the resident's T-shirt sleeve was tight on the resident's arm. The interview revealed Resident #1 would not allow the staff to remove the shirt; however, there was visible [MEDICAL CONDITION] and bruising noted. The ADON stated that when she attempted to move Resident #1's right arm the resident "yelled out in pain." The ADON confirmed the resident's physician was immediately notified of the change in the resident's condition and the resident was transported to the hospital for further evaluation and treatment. Interview on 10/22/13 at 7:15 PM with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) revealed nurses were responsible to notify the resident's physician and responsible party if a resident experienced a change in condition. The interview confirmed LPN #1 had not conducted a thorough assessment of Resident #1 and had not notified Resident #1's physician of the change in the resident's condition on 10/08/13 at approximately 10:00 AM, or at 3:00 PM after staff reported the resident's change to the nurse. The DON stated LPN #1 was suspended during the investigation, received a written reprimand, and was allowed to return to work after she had been re-educated on the facility's policies. Interview with the Administrator on 10/22/13 at 8:20 PM revealed she had the responsibility to ensure Administrative staff implemented the facility's policies. In addition, the Administrator stated staff discussed areas of concern in the QA meetings, and she had been made aware of the incident and Resident #1's medical condition by the DON on 10/09/13. The Administrator stated the DON had conducted an investigation of Resident #1's injuries and had kept the Administrator updated on the progress of the investigation of how the injuries occurred.

Based on observation, interview, medical record review, hospital record review, facility policy review, and review of Nursing Practice Standards, it was determined the facility failed to ensure services provided met professional standards for one of three sampled residents (Resident #1). Interview with staff revealed Resident #1 returned from the hospital on [DATE] at 11:30 AM following an evaluation of [MEDICAL CONDITION]-type activity and upon the resident's return, staff observed Resident #1 to yell out with repositioning and care and noted the resident had a bruise to the rib area. Interview revealed staff notified a nurse of the resident's condition; however, the nurse failed to document an assessment of the resident and failed to inform the resident's physician of the change In addition, interview revealed on 10/08/2013, at approximately 10:00 AM and 3:00 PM staff informed LPN #1 that Resident #1 was lying on his/her right arm, was unable to move his/her right arm, and grimaced and yelled when staff attempted to move his/her arm or reposition the resident. However, LPN #1 failed to document an assessment of Resident #1's condition and failed to inform the physician of the resident's condition/complaints of pain. On 10/09/13 at 7:15 AM, the resident was noted to have "dark bluish/purple/black" bruising to the right shoulder, scapula (shoulder blade), and the auxiliary (armpit) area, and facial grimacing and moaning with movement of his/her right arm. On 10/09/13 at 8:30 AM facility staff notified Resident #1's physician of the change in the resident's condition and the resident was transported to the hospital on [DATE] at 12:45 PM for evaluation and treatment. Resident #1 was diagnosed with [REDACTED]. The resident's humerus (shoulder) was also dislocated. The findings include: Review of the National Federation of Licensed Practical Nurses publication dated October 2003, entitled "Nursing Practice Standards for the Licensed Practical/Vocational Nurse," section "Practice," revealed "The Licensed Practical/Vocational Nurse ...4. Shall know and utilize the nursing process in planning, implementing and evaluating health services and nursing care for the individual patient or group," and "Planning: The planning of nursing includes: 1) assessment/data collection of health status of the individual patient, the family and community groups. 2) reporting information gained from assessment/data collection." Review of the facility's policy entitled "Changes in Resident's Condition or Status," undated, revealed "All changes in the resident's medical condition must be properly recorded in the resident's medical record in accordance with the documentation policies and procedures." Review of the facility's policy entitled "Alert Charting," undated, revealed changes in physical, mental, behavioral, medical, and functional status "must be documented and monitored." The policy further stated an event follow-up which included bruises or other unusual resident event must be documented in the resident's medical record. Review of the clinical record revealed the facility admitted Resident #1 on 10/11/06 with [DIAGNOSES REDACTED]. On 07/25/13, the facility assessed Resident #1 to have a Brief Interview for Mental Status (BIMS) score of 99 which indicated the resident had limited cognition and was not interviewable. Review of nursing notes dated 10/07/13 at 5:54 AM, revealed Resident #1 had [MEDICAL CONDITION]-type activity at 5:30 AM, the resident was rigid for 10 minutes with no pupil reaction for 20 minutes, and staff administered oxygen to the resident. Facility staff contacted the resident's physician and transferred the resident to the hospital for further evaluation and treatment. Interview on 10/22/13 at 4:50 PM, with State Registered Nursing Assistant (SRNA) #2 revealed on 10/07/13, after the resident returned to the facility from the hospital on the day shift, she reported to Registered Nurse (RN) #1 that Resident #1 yelled out every time the SRNAs moved the resident and that the resident had a bruise to the rib area. According to SRNA #2, RN #1 assessed Resident #1; however, the SRNA was unaware of the actions of the RN after the assessment. RN #1 stated in interview conducted on 10/22/13 at 6:00 PM that she worked the day shift on 10/07/13 and provided care to Resident #1. RN #1 stated she worked the 7:00 AM to 7:00 PM shift, and prior to the start of her shift Resident #1 experienced a [MEDICAL CONDITION] and was transported to the local hospital. According to RN #1, she did not conduct a skin assessment of Resident #1 when he/she returned to the facility from the hospital at approximately 11:30 AM on 10/07/13. RN #1 stated no one had reported a change in Resident #1's condition during the remainder of her shift. Continued review of nursing notes dated 10/08/13 at 3:30 AM, revealed a physician's orders [REDACTED].#1. Interview on 10/22/13 at 5:00 PM with SRNA #3 revealed she worked the day shift on 10/08/13 and following breakfast, Resident #1 resisted care and yelled out when she attempted to reposition him/her, which was not reported. SRNA #3 stated at approximately 10:00 AM she noticed Resident #1 lying on his/her right arm. According to SRNA #3, Resident #1 was unable to move his/her right arm, the resident's right arm was "lifeless," and the resident had a dark bruise to the side of the neck. SRNA #3 stated she informed LPN #1 of the resident's condition; however, she did not see the LPN check the resident's status. In addition, SRNA #3 stated the resident's condition remained the same throughout her shift and at 3:00 PM she again informed LPN #1 of the resident's condition. The interview revealed nothing had been done for Resident #1 when the SRNA left work at 7:00 PM that evening. Interview on 10/22/13 at 5:45 PM with SRNA #4 revealed she had also worked the day shift on 10/08/13 and observed Resident #1 lying with his/her right arm behind the resident's back and stated the resident would grimace any time he/she, or staff, attempted to move the resident's right arm. The interview revealed the SRNA reported Resident #1's change in condition to LPN #1 twice during that shift. SRNA #4 stated Resident #1 also had a black bruise to the right shoulder area. Interview on 10/22/13 at 4:10 PM with LPN #1 revealed the LPN worked the day shift on 10/08/13 and had provided care to Resident #1. The LPN stated SRNAs #3 and #4 reported Resident #1 had rolled onto his/her right arm and was unable to move the arm. The interview revealed LPN #1 assessed Resident #1 and observed a dark purple bruise on the resident's clavicle; however, the LPN stated the resident was able to move his/her right arm. LPN #1 stated she was unaware of any injuries Resident #1 had sustained during her shift and had not documented the SRNAs' report that Resident #1 was unable to move his/her right arm and yelled when facility staff attempted to reposition him/her. In addition, LPN #1 stated she did not notify the resident's physician of the dark purple bruise or of the information reported by the SRNAs. LPN #1 acknowledged that in accordance with the facility's "Change in Condition" policy nurses were to notify the resident's physician and document any changes in a resident's condition. Interview on 10/23/13 at 10:05 AM with SRNA #6 revealed she worked the evening shift (7:00 PM to 7:00 AM) on 10/08/13 and provided care to Resident #1. SRNA #6 stated during shift report SRNA #4 reported Resident #1's right arm was "messed up" and that the day shift SRNAs had already reported the change in condition to LPN #1. However, SRNA #6 stated that according to SRNA 4, the LPN did not assess the resident. SRNA #6 stated Resident #1 "screamed" in pain anytime the staff touched the resident's right arm. According to SRNA #6, she did not report the resident's condition to the nurse on the second shift (LPN #2) because the SRNAs on the day shift had already informed the day shift nurse of the change in the resident's condition. Review of a nursing note dated 10/09/13 at 2:08 AM, revealed the resident required the total assistance of two to four staff members for care because of the resident's resistant behaviors. Interview on 10/23/13 at 11:00 AM with SRNA #5 revealed on the morning shift on 10/09/13, the SRNA noted something was wrong with Resident #1's arm; it was like a "dead arm." SRNA #5 stated he asked the night shift nurse (LPN #2) about the resident's condition. SRNA #5 stated LPN #2 informed him no one had reported any issues related to Resident #1's condition to her in the report she had received from the previous shift and no one had reported any concerns related to Resident #1 to her throughout the night. According to SRNA #5, Resident #1 had a T-shirt on and there was a visible dark bruise located on the right side of the resident's shirt collar. Review of documentation revealed the facility had obtained a written statement from LPN #2 on 10/10/13 related to an incident that involved Resident #1. Review of the statement revealed on 10/09/13 at approximately 7:05 AM, SRNA #5 asked LPN #2 about Resident #1's right arm. According to LPN #2's written statement, the LPN assessed Resident #1, attempted to perform range of motion on the resident's right arm, and the resident was in visible pain with movement of the arm. LPN #2 documented she immediately notified Resident #1's physician of the change in the resident's condition and received physician's orders [REDACTED]. Review of a late entry in the nursing notes by LPN #2, dated 10/09/13 at 3:14 PM, revealed at approximately 7:15 AM on 10/09/13 staff observed "dark bluish/purple/black" bruising to Resident #1's right shoulder, scapula (shoulder blade), and the auxiliary (armpit) area. The nursing note revealed Resident #1 had facial grimacing and moaning with movement of his/her right arm and was "grabbing with (his/her) left hand at (his/her) shoulder area." Further review of the nursing note revealed facility staff notified Resident #1's physician of the change in the resident's condition on 10/09/13 at 8:30 AM. The resident was transported to the hospital on [DATE] at 12:45 PM for evaluation and treatment. Review of a radiology report, dated 10/09/13, revealed Resident #1 sustained a "comminuted fracture from the humeral head and neck with multiple fragments seen in the shoulder joint. Anterior cephalad dislocation of the humeral head" (the long bone of the right arm and shoulder joint was splintered/fragmented and the shoulder was displaced from the normal position). Observations on 10/22/13 at 12:30 PM, 3:30 PM, 5:30 PM, and 7:00 PM revealed Resident #1 was in the bed, and a sling and swath was observed on the right arm. Attempts to interview Resident #1 were unsuccessful due to the resident's limited cognition. Interview on 10/22/13 at 7:15 PM with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed nurses were responsible to conduct an assessment of the resident and notify the resident's physician and responsible party if the resident experienced a change in condition. The DON and ADON confirmed LPN #1 did not document an assessment of Resident #1 or notify the resident's physician of a change in the resident's condition. According to the ADON, on 10/09/13 at approximately 8:00 AM SRNA #5 reported something was wrong with Resident #1's right arm and the ADON went to Resident #1's room to assess the resident. The ADON stated, "I could tell from the door" that the resident's right shoulder was higher than the left shoulder. The ADON stated the resident's right shoulder was swollen to the point that the resident's T-shirt sleeve was tight on the resident's arm. The interview revealed Resident #1 would not allow the staff to remove the shirt; however, there was visible [MEDICAL CONDITION] and bruising noted. The ADON stated she attempted to move Resident #1's right arm, the resident "yelled out in pain," and the resident's physician was immediately notified of the resident's change in condition. Interview revealed Resident #1 was transported to the hospital for further evaluation and treatment. Interview with the Administrator on 10/22/13 at 8:20 PM revealed she attended Quality Assurance (QA) meetings at the facility and staff concerns were discussed. According to the Administrator, the DON conducted the investigation of Resident #1's injury and updated the Administrator as the investigation progressed. The Administrator stated she was responsible to ensure the other Administrative staff implemented the facility's policies, and acknowledged the staff had failed to assess and notify Resident #1's physician of a change in the resident's condition in a timely manner.

Based on interview, record review, and review of facility quality management material it was determined the facility failed to identify issues which required quality assessment and assurance and to develop an appropriate plan of action. A review of facility incident reports/investigations revealed evidence of deficient practice related to the revision and updating of resident care plans. A review of two of six sampled residents (Residents #1 and #4) revealed the facility failed to identify the causative factors related to resident falls and to ensure plans of action to prevent resident falls had been implemented. Resident #1 and Resident #4 had sustained falls with injuries (Refer to F280 and F323). In addition, the facility failed to ensure a plan of correction for the deficiencies cited during the standard survey ending 05/17/12 had been implemented. The findings include: Review of the facility's written description of the Quality Management process (no date) revealed quality problems would be identified through the QA process and the committee would develop a plan, implement the plan, and monitor until determined the quality problem had been resolved. Review of the facility's plan of correction for deficiencies cited during the standard survey completed on 05/17/12 revealed the Nursing Management Team reviewed the 24-hour reports and care plans on a daily basis, Monday through Friday, to ensure proper documentation, notification of physician and responsible party, and care plan revisions had occurred. The plan also indicated the Director of Nursing (DON) and the Unit Supervisors would conduct audits of the 24-hour shift report to ensure care plans had been revised, as indicated, for changes in resident condition. According to the plan of correction, any issues identified in the audits would be reviewed monthly in the Performance Improvement Committee Meeting. In addition, the facility's plan of correction revealed a 100 percent audit of all care plans was completed on 06/08/12 to ensure care plans were followed as written. Review of the comprehensive care plan for Resident #1 dated 05/14/12 revealed the care plan failed to address the resident's use of a mechanical lift for transfers. On 07/23/12, Resident #1 sustained a fall from a mechanical lift. The resident was transported to an acute care hospital and diagnosed with [REDACTED]. Review of the facility's Incident Follow-up and Recommendation Form for Resident #1, dated 07/23/12, revealed a "QA Checklist" area with a section to document that the care plan had been updated and the date of the update; however, the section was blank. Review of the facility's Change of Condition Audit used to track care plan updates/revisions, dated 07/24/12, revealed the resident's medical record had been audited due to the patient's fall and the care plan had been updated. The audit form contained documentation of the resident's room number, date, name, any pertinent charting, and whether the physician and family were notified. Additionally, the form had an area for documentation of nursing note start date and nursing note stop date which was not dated for any of the audits conducted. Review of the facility's daily "stand up" meeting, dated 07/25/12, revealed the Director of Nursing was in attendance; however, there was no evidence the Executive Director (ED) was in attendance as required by the ED's signature on the attendance form. Review of the documentation of the meeting discussion revealed the committee discussed the fall sustained by Resident #1 on 07/23/12; however, there was no documentation the facility reviewed the resident's care plan or implemented any preventative measures to ensure the resident's safety. Interview with the Unit Supervisor for the Hope Hall on 08/01/12, at 10:20 PM, revealed she had been responsible for conducting the change of condition audit for Resident #1. The Unit Supervisor stated she checked the resident's care plan and thought it had been updated after the fall. The Unit Supervisor was unaware the care plan had no new interventions to prevent further falls related to the mechanical lift. Interview with the Director of Nursing (DON) on 07/31/12, at 4:35 PM, revealed the DON was responsible to ensure care plans were updated. According to the DON, the facility just "missed the ball" on Resident #1. 2. A review of the comprehensive care plan for Resident #4 revealed facility staff reviewed the plan on 06/02/12, and developed approaches to prevent falls. The plan included a chair alarm at all times, an anti-slip pad to the resident's wheelchair at all times, fall risk assessments to be conducted quarterly or with any significant change, a physical therapy or occupational therapy screen as needed, and to notify the physician of changes in the resident's condition. A review of the facility Incident Follow-up and Recommendation Form revealed Resident #4 had sustained falls on 02/19/12, 03/04/12, 03/22/12, and 05/26/12. A review of Resident # 4's Comprehensive Care Plan revealed staff had reviewed the plan on 06/02/12; however, the care plan had not been updated/revised after each fall. One intervention was added to the care plan on 05/26/12, following a fall, that required staff to conduct neurological checks, per facility protocol; however, there were no interventions developed to prevent further falls. Further review noted staff had indicated on the Incident Follow-up and Recommendation Form that the care plan had been updated. An interview conducted on 07/31/12, at 3:30 PM, with the Minimum Data Set (MDS) Coordinator revealed the MDS staff was responsible to ensure nursing staff on the units had updated the care plan to reflect the fall and had included any new interventions on the care plan. The MDS Coordinator stated every fall was discussed in the "morning meeting" with the Interdisciplinary Team (IDT) and the care plan was reviewed in the meeting to ensure the care plan had been updated. The MDS Coordinator stated a care plan conference had been held on 04/03/12 and 06/12/12, and at those times Resident #4's falls were discussed and care plans were reviewed. However, upon review of Resident #4's care plan, the MDS Coordinator confirmed the care plan had not been updated to reflect Resident #4's falls. The MDS Coordinator stated the failure of staff to update the care plan to reflect Resident #4's falls "must have been an oversight." During an interview with the ED on 07/31/12, at 5:15 PM, it was revealed the Interdisciplinary Team (IDT) was required to update the care plans at the morning meetings conducted by the supervisory staff. According to the ED, she does not verify staff has completed the required updates of the care plans. The ED stated the audit reports were taken to the facility's Quality Improvement meetings and discussed, but she did not personally review the audits.

Based on observation, interview, medical record review, and review of facility policy/procedure it was determined the facility failed to ensure the comprehensive care plan for two of six sampled residents (Residents #1 and #4) had been revised/updated to reflect the resident's needs. Resident #1 required the use of a mechanical lift for transfers; however, the resident's comprehensive care plan had not been revised/updated to reflect the resident's need for the mechanical lift or the number of staff required for transfers. Resident #1 fell from the mechanical lift on 07/23/12 and sustained a fractured clavicle (collarbone), fractured scapula (shoulder bone), and a strain to the back and neck. Resident #4 fell on [DATE] and sustained two lacerations to the right forehead that required sutures. The facility failed to revise/update the care plan to reflect interventions to prevent further falls and the resident sustained [REDACTED]. The findings include: Review of the facility policy titled "Falls Management" (not dated) revealed an interdisciplinary plan of care would be developed, implemented, reviewed, and updated as necessary to reflect each resident's current safety needs and fall reduction interventions. The policy revealed the care plan would be reviewed throughout the course of treatment by the interdisciplinary team to assure the most recent, updated, and resident-specific fall reduction interventions were incorporated, as necessary, into the plan of care. Review of facility policy titled "Falling Star/Falling Leaf Program" (not dated) revealed the care plan would be reviewed and updated as needed to reflect current fall risks and resident-specific interventions designed to reduce a recurrence of falls. 1. Review of the medical record of Resident #1 revealed the facility admitted the resident on 06/12/09 with [DIAGNOSES REDACTED]. A review of the most recent Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed Resident #1 to require extensive assistance of two persons for all transfers and activities of daily living. The facility had assessed Resident #1 to be nonambulatory. There was no assessment for the use of a mechanical lift. Review of the comprehensive care plan for Resident #1 dated 05/14/12 revealed approaches identified to prevent falls included assist with transfers/ambulation as needed, ensure the resident was wearing adequate footwear, and use a Broda chair with thigh straps when out of bed. The care plan did not include the use of a mechanical lift for transfers and/or obtaining weights of the resident. Documentation in the medical record revealed on 07/23/12 Resident #1 sustained a fall from a mechanical lift. Review of the facility's Incident Follow-up and Recommendation Form for Resident #1, dated 07/23/12, revealed the resident "tipped sideways out of the mechanical lift." Facility staff documented a recommendation on the incident form to send the resident to the hospital for evaluation and the follow-up on the form documented "no further incidents." The form contained a "QA Checklist" area with a section to document that the care plan had been updated and the date of the update; however, continued review of the incident report for Resident #1 revealed the section was left blank. Documentation in the medical record revealed the resident was transported to an acute care hospital and diagnosed with [REDACTED]. Interview with Licensed Practical Nurse (LPN) #2 on 07/31/12, at 9:05 AM, revealed she had developed the care plan dated 05/14/12 for Resident #1. LPN #2 stated if a resident required a mechanical lift for transfers, it should have been identified on the care plan. LPN #2 stated she was aware Resident #1 required a mechanical lift for transfers and/or weights but had failed to place it on the care plan or assess the resident for the use of the mechanical lift. Interview with Licensed Practical Nurse (LPN) #1 on 07/31/12, at 4:12 PM, revealed she was responsible for investigating falls. LPN #1 stated she was responsible for ensuring a follow-up that included interventions was implemented and that the care plan was updated. According to LPN #1, she should have made sure the care plan had been updated. Interview with the Director of Nursing (DON) on 07/31/12, at 4:02 PM, revealed the DON had reviewed LPN #1's fall investigation but failed to ensure the care plan had been updated. 2. A review of the medical record for Resident #4 revealed the facility admitted the resident on 02/10/09, with [DIAGNOSES REDACTED]. A review of the most recent quarterly Minimum Data Set ((MDS) dated [DATE], revealed the facility assessed Resident #4 as being alert and oriented with periods of confusion. Review of the Fall Risk Evaluation dated 06/02/12, revealed Resident #4 was assessed to be at high risk for falls. A review of the comprehensive care plan for Resident #4, reviewed by facility staff on 06/02/12, revealed the approaches developed by staff to prevent falls included: chair alarm at all times, Dycem (an anti-slip pad) to the resident's wheelchair at all times, fall risk assessments to be conducted quarterly or with any significant change, a physical therapy or occupational therapy screen to be requested as needed, and the physician would be notified as needed with changes in condition or for new orders. Further review of the medical record and review of the facility Incident Follow-up and Recommendation Form revealed Resident #4 sustained a fall on 02/19/12, 03/04/12, 03/22/12, and 05/26/12. Review of the Comprehensive Care Plan (reviewed 06/02/12) revealed the care plan had not been updated/revised after each fall. One intervention was added to the care plan on 05/26/12, following a fall, that directed staff to conduct neurological checks per facility protocol due to the fall. Continued review of the Incident Follow-up and Recommendation Form for each of the four falls revealed staff had indicated on the Incident Follow-up and Recommendation Form that the care plan had been updated. The review of the Incident Follow-up and Recommendation Form revealed the Interdisciplinary Team (IDT) had reviewed the falls that occurred on 02/19/12, 03/04/12, and 03/22/12, the day after the falls occurred and had indicated the Comprehensive Care Plan had been updated/revised. Documentation on the follow-up report revealed the fall that occurred on Friday, 05/26/12, was reviewed by the IDT on Tuesday, 05/29/12. Interview on 07/31/12, at 3:30 PM, with the MDS Coordinator revealed the MDS staff was responsible for initiating an investigation after any resident fall. The MDS Coordinator stated the MDS staff was to ensure the nurses had updated the care plan to reflect the fall and had included any new interventions on the care plan. The MDS Coordinator stated every fall was discussed in the "morning meeting" with the IDT and the care plan was reviewed in the meeting to ensure the care plan had been updated. The MDS Coordinator stated a care plan conference was also held on 04/03/12 and 06/12/12, and at those times Resident #4's falls were discussed and care plans were reviewed. However, upon review of Resident #4's care plan, the MDS Coordinator stated the care plan had not been updated to reflect Resident #4's falls. The MDS Coordinator stated she did not have an explanation of why the care plan had not been updated to reflect Resident #4's falls and concluded it "must have been an oversight."

Based on observation, interview, record review, facility policy/procedure review, and review of manufacturer's guidelines it was determined the facility failed to ensure two of six sampled residents (Residents #1 and #4) received adequate supervision and appropriate use of assistive devices to prevent accidents. The facility failed to ensure staff utilized safe technique while transferring residents with a mechanical lift. Resident #1 sustained a fractured clavicle (collarbone), a fractured scapula (shoulder bone), and a strain to the back and neck when the resident fell from the sling of a mechanical lift on 07/23/12. The resident had been placed in the mechanical lift to obtain a weight by a staff member. The facility's standard of practice was for two staff persons to assist with the mechanical lift; however, only one staff person was in attendance with Resident #1. The facility failed to identify the causative factors related to the fall and implement interventions to prevent further incidents. The facility also failed to follow manufacturer's guidelines related to care of the mechanical lift slings in the facility. Although the manufacturer's guidelines stated the slings were not to be bleached, the facility utilized a chlorine stain lifter when laundering the slings used in the facility. Additionally, the facility failed to have an effective system to thoroughly investigate falls to determine the possible cause/contributing factors of each fall and failed to implement interventions to prevent further falls for Resident #4. Resident #4 fell on [DATE] and sustained two lacerations to the right forehead that required emergency care with six sutures to the lacerated areas. The resident also sustained falls on 03/04/12, 03/22/12, and 05/26/12. However, the facility failed to thoroughly investigate each fall to determine causative factors, failed to assess the effectiveness of the interventions in place at the time of each fall, and failed to implement interventions to prevent further falls. The findings include: A review of the Falls Management Policy (not dated) revealed all falls would be reviewed by the Interdisciplinary Team (IDT) members following the daily "Stand Up" meeting. The IDT was also to review the incident report, fall history, the care plan, and other pertinent data to determine the need for further investigation. The policy revealed the need for further evaluation of the resident's health condition, the environment, equipment, medications, staff, resident practices, or other factors that may have contributed to the incident would be determined by the IDT in order to promote a comprehensive plan of care. According to the policy, the IDT would determine the need for development of any additional facility-wide or resident-specific interventions, staff, resident, and/or family education and training, or other follow-up measures that may be needed to reduce the risk of reoccurrence. Review of the facility's Mechanical Lift Guidelines dated 12/31/09, revealed all residents who required a mechanical lift would have the following in place: (1) Care Plan, (2) Updated Care Guide. Review of the manufacturer's guidelines for use of the mechanical lift revealed the lift could only be used with patients that had been assessed and approved for the procedure by the facility's professional staff. Further review of the guidelines revealed the facility was to make certain there was sufficient staff to accomplish the procedure. The number of staff requirement must be recorded during the patient's assessment and communicated to the lifting staff. 1. Based on a review of the medical record, the facility admitted Resident #1 on 06/12/09 with [DIAGNOSES REDACTED]. Documentation on the Quarterly Minimum Data Set (MDS) assessment, dated 05/14/12, revealed the facility assessed Resident #1 to be nonambulatory and to require the extensive assistance of two persons for all transfers and activities of daily living. Review of the comprehensive care plan for Resident #1 dated 05/14/12 revealed approaches identified to prevent falls included to assist the resident with transfers/ambulation as needed, to ensure the resident was wearing adequate footwear, and to use a Broda chair (a specialized high-back wheelchair) with thigh straps when the resident was out of bed. There was no documentation on Resident #1's plan of care that facility staff had identified that the resident required the use of a mechanical lift when staff assisted the resident to transfer and/or weigh the resident. Continued review of the medical record revealed Resident #1 sustained a fall on 07/23/12, when staff attempted to obtain the resident's weight with the use of a mechanical lift. Documentation on the facility incident report form revealed the resident slid from the sling of the lift onto the shower room floor and sustained a fracture to the clavicle and scapula in addition to a sprain to the resident's neck and back. Based on documentation on the facility's Incident Follow-Up and Recommendation Form, dated 07/23/12, CNA #7 attempted to weigh Resident #1 with the use of a mechanical lift, and the resident "tipped sideways out of the mechanical lift." Although the investigation contained two witness statements, there was no documented evidence the facility investigated the causative factors of the fall or that the mechanical lift had been utilized by one staff member. There was no documentation on the incident form that the facility had conducted a falls assessment or that the resident's care plan had been updated. Interview on 07/31/12, at 10:12 AM, with Certified Nursing Assistant (CNA) #7 revealed on 07/23/12 the CNA took the resident into the shower room in the Broda chair to provide privacy while the resident's weight was obtained. The CNA stated she used the mechanical lift to obtain the resident's weight. According to the CNA, a sling was already under the resident and the CNA attached the sling to the lift and raised the lift to obtain the weight. CNA #7 stated the resident's foot was touching the chair and, in order to obtain an accurate weight, the CNA pushed the chair away from the resident. At that time, CNA #7 stated she was standing to the left of the resident and the resident "slumped" over and slid out the right side of the sling onto the shower room floor. CNA #7 stated normally there would be two staff members to assist with the use of the mechanical lift for transfers and weights. According to CNA #7, she assumed she could obtain the weight without the assistance of another staff member. The CNA stated she "never imagined that would happen." CNA #7 confirmed it was facility standard of practice to have two staff members whenever a mechanical lift was used for transfers or weights. Interview with Registered Nurse (RN) #2 on 07/31/12, at 10:03 AM, revealed she had been on duty on 07/23/12 when Resident #1 sustained a fall. According to RN #2, she had responded to the CNA's call for help and found Resident #1 on the shower room floor. RN #2 confirmed CNA #7 had used the mechanical lift to obtain the resident's weight without a second staff member to assist. RN #2 stated use of the mechanical lift required two staff persons; however, CNA #7 had used the mechanical lift without assistance. Interview with CNA #6 on 07/31/12, at 9:10 AM, revealed she had been on duty on 07/23/12. CNA #6 stated she had been assigned to obtain resident weights. According to CNA #6 the facility utilized a mechanical lift to obtain resident weights. The CNA stated use of the mechanical lift required two staff members. Interview on 07/30/12, at 5:12 PM, with CNA #4 and CNA #5 revealed there were always two staff persons present when the mechanical lift was in use for patient care. CNA #4 stated she would not operate the mechanical lift without another staff member. Interview with the Director of Nursing (DON) on 07/31/12, at 4:02 PM, revealed the IDT had discussed the fall in the morning stand up meeting. According to the DON, she looked at the facility policy/procedure for use of mechanical lifts and the policy/procedure did not indicate two staff persons were required for use of the mechanical lift. The DON confirmed she did not review Resident #1's assessment nor did she review preventative measures after the incident. 2. Review of the manufacturer's washing instructions for the slings utilized with the mechanical lift revealed the maximum water temperature for washing the slings was 160 degrees, the slings were to be air dried, and bleach was not to be used to launder the slings (bleach could weaken the fibers and cause failure of the sling). Observations of the laundry area on 07/31/12, at 2:35 PM, revealed the facility utilized an ECOLAB three-part laundry system for washing. The system consisted of a detergent concentrate, a softener concentrate, and "Solid Stainaway" concentrate. Review of the Material Data Safety Sheet (MSDS) for the Solid Stainaway revealed the composition of the concentrate was troclosene sodium dihydrate. Troclosene sodium dihydrate can be used for bleaching textiles and, according to the encyclopedia Wikipedia.org, the mechanism action for the sodium dihydrate is noted to be the release of chlorine in low concentrations by a constant rate. Observations on 07/31/12, of the mechanical lift slings in use by the facility revealed there were nine white slings that were in use on 07/23/12. There were multiple blue plastic squares approximately one and one-half inches by one inch observed on each of the slings. Interview with the Director of Nursing on 07/31/12, at 2:10 PM, revealed the slings were in use at the time of Resident #1's fall on 07/23/12. The Laundry Supervisor confirmed in interview conducted on 07/31/12, at 2:30 PM, that the slings were washed using the Solid Stainaway concentrate. The Laundry Supervisor was unaware of any manufacturer's care instructions and confirmed no instructions were available for laundry staff. The Laundry Supervisor stated she was unaware the slings could not be bleached. The Laundry Supervisor also stated she was aware of the blue plastic squares on the slings. According to the Laundry Supervisor, staff did not always sort the slings properly and often left disposable incontinence briefs in the slings. The Laundry Supervisor stated the blue closures on the briefs adhered to the slings when they were washed together and could not be removed. 3. A review of the facility's policy entitled Fall Management (not dated) revealed the facility would promote programs geared to improving mobility and stamina, and reduce the risk of falls through a comprehensive, interdisciplinary process of assessment, care plan development, and implementation with ongoing monitoring and review. A review of the medical record for Resident #4 revealed the facility admitted the resident on 02/10/09, with [DIAGNOSES REDACTED]. Review of the Care Area Assessment (CAA) completed with the annual assessment dated [DATE], revealed the facility assessed Resident #4 as at risk for falls due to the need for staff assistance with transfers, ambulation, being impulsive, and the daily use of an antipsychotic medication, antidepressants, diuretics, and frequent urinary incontinence. A review of Resident #4's Annual Minimum Data Set (MDS) assessment signed as complete on 12/23/11, and the most recent quarterly MDS assessment signed as complete on 06/02/12, revealed the facility assessed the resident to require extensive assistance of one person for transfers to or from bed, chair, wheelchair, standing position, toilet use, and hygiene. A review of Resident #4's care plan dated 12/23/11, revised on 06/02/12, revealed the facility identified the resident as at risk for falls. The care plan revealed that approaches the staff could take to prevent resident falls included the use of a chair alarm at all times, an anti-slip pad to the wheelchair at all times, fall risk assessments to be conducted quarterly or with any significant change, a physical therapy or occupational therapy screen as needed, and for the physician to be notified for new orders when the resident experienced a change in condition. Continued review of the care plan revealed front anti-tip bars on the wheelchair implemented on 12/23/12 were discontinued on 06/14/12. Review of the monthly physician's orders [REDACTED].#4 had a chair alarm at all times and an anti-slip pad to the seat of the resident's wheelchair. A review of the Daily Care Directive dated 07/31/12, revealed safety devices in place for Resident #4 at that time included a lap tray, a chair pad alarm, and a brace to the resident's right lower leg and foot. The Care Guide further revealed Resident #9 required the assistance of one staff member for mobility/transfer, dressing, and toileting. An interview with Resident #4 on 08/01/12, at 9:35 AM, revealed the resident could reply to questions with one-word answers. When asked about falls Resident #4 stated "slip" and pointed to the wheelchair and then held up the call bell. Observation revealed Resident #4 was sitting in a recliner with an anti-slip pad on the seat of the recliner and a chair pad alarm was noted. Observation of the wheelchair revealed the wheelchair was equipped with a padded tray for only the right side of the wheelchair and had a footrest for the right leg. A chair pad alarm was noted on the wheelchair. A review of documentation in the medical record of Resident #4 and a review of nurse's notes and the facility "Incident Follow-up and Recommendation Forms" revealed Resident #4 had sustained falls on 02/19/12, 03/04/12, 03/22/12, and 05/26/12. According to the incident report dated 02/19/12, Resident #4 attempted to ambulate independently and lost his/her balance. However, the incident form contained one witness statement from a CNA that had answered Resident #4's call bell and, based on the CNA's witness statement, Resident #4 reported to the CNA that he/she had fallen out of the chair. It could not be determined by a review of the Incident Form what the resident's activity was at the time of the fall, or if facility staff had interviewed Resident #4 after the fall. Also, it could not be determined by a review of the investigation if the facility had considered causative/contributing factors to the fall. A review of the actions identified by the facility to prevent further falls revealed a therapy screen would be obtained, a "Falling Leaf" program would be implemented for thirty days, and the resident would be re-educated to not throw the chair alarm away. The recommendations/actions developed by the facility failed to document if staff had been educated/in-serviced to ensure the falls interventions were followed. The nurse's notes dated 02/19/12 (the day of the fall), revealed beads from a necklace "covered the floor," however, it could not be determined by a review of the nurse's notes if the resident's chair alarm was intact. As a result of the fall on 02/19/12, Resident #4 sustained two lacerations to the right forehead that required emergency care at the local hospital. According to the nurses' notes one laceration measured 1.2 centimeters by 1.5 centimeters and the second laceration measured 1.0 centimeters by 0.3 centimeters and depth was 0.3 centimeters. The nurse's notes revealed the resident returned to the facility on [DATE] with six sutures intact to the lacerated areas. Further review of the incident forms revealed on 03/04/12 and 03/22/12 Resident #4 fell asleep in the wheelchair and "flipped" out of the wheelchair and onto the floor and sustained bruising to the forehead. Review of the nurse's notes and the incident form failed to reveal if the chair alarm was in place and/or if the alarm sounded, if the front anti-tippers were present on the wheelchair or if a non-skid pad was in place on the seat of the resident's wheelchair. The facility failed to investigate causative factors of the falls and failed to evaluate the effectiveness of the interventions that were in place or document if other interventions had been considered. Also, it could not be determined based on a review of the report if Resident #4 remained on the Falling Leaf Program that was implemented after the fall on 02/19/12. Actions identified by the facility to be taken following the falls on 03/04/12 and 03/22/12 included to encourage the resident to take a rest period in the recliner. Review of the incident form and the nurse's notes revealed Resident #4 sustained a fall on 05/26/12 with no injury. Documentation on the incident form revealed the resident's chair alarm sounded and he/she was found sitting on the floor in front of the wheelchair. Further review of the incident form failed to indicate if the front anti-tippers were present on the wheelchair or if a non-skid pad was intact on the wheelchair seat. The incident form revealed Resident #4 was leaning forward in the wheelchair and slid onto the floor, but failed to indicate what activity the resident was involved in at the time of the fall. There was no documented evidence the facility conducted an interview with Resident #4 to determine his/her activity at the time of the fall or if the facility considered other causative factors. According to the incident form, the recommendations/actions to be taken by staff after the fall sustained on 05/26/12, included the same interventions identified as a result of the falls that occurred on 03/04/12, 03/22/12, and 05/26/12, with the addition of a recommendation to encourage the resident not to lean forward in the chair. An interview conducted with LPN #6 on 07/31/12, at 4:10 PM, revealed she was responsible for conducting fall investigations to ensure interventions were in place. LPN #6 stated every fall is discussed in the morning meeting to try to determine the cause of the fall and what actions to take to prevent additional falls. LPN #6 stated Resident #4 refused a bed, preferred to sleep in a recliner, and frequently fell asleep in the wheelchair. LPN #6 stated the intervention to encourage Resident #4 to sleep in the recliner had not been an effective intervention to prevent falls, and a new wheelchair had been purchased for Resident #4. An interview with the Director of Nursing (DON) on 07/31/12, at 4:40 PM, revealed when a resident sustained [REDACTED]. According to the DON, the Interdisciplinary Team (IDT) reviewed all incident reports the morning after a fall occurred, reviewed the resident's care plan, and reviewed and evaluated interventions for effectiveness. In addition, the DON stated a therapy screen would be requested if the resident did not receive therapy. Continued interview on 07/31/12, at 4:40 PM, with the DON revealed incident forms, the medical record, and interviews with staff were conducted as part of the investigation process. The DON stated all falls were discussed at the morning meeting to determine the effectiveness of the interventions. According to the DON, interventions used by the facility to prevent falls included the "Falling Leaf" program, to closely monitor the resident, to ensure personal items were in reach of the resident, encourage the use of the call bell, and to ensure the resident's pathways were clear. After review of the incident form for Resident #4's falls on 02/19/12, 03/04/12, 03/22/12, and 05/26/12, the DON confirmed the investigations were not thorough to determine causative factors, interventions were not evaluated to determine effectiveness, and different interventions had not been implemented.

Based on interview, record review, facility policy review, and hospital record review, it was determined the facility failed to implement policies/procedures that prohibit neglect of residents was implemented for one (1) resident (Resident #1) in the sample of thirteen (13) residents. The facility failed to ensure staff followed the Resident Abuse and Neglect policy/procedure to ensure residents received the necessary care and services to avoid physical harm. The facility had assessed Resident #1 as at risk for pressure sores, previously identified a wound to the left side of the resident's neck; however, the facility failed to identify the [MEDICAL CONDITION] collar strap as a causal factor for the development of a pressure sore on the neck, failed to implement interventions and failed to ensure staff provided care and services to protect the resident's skin from injury related to pressure from the [MEDICAL CONDITION] collar strap. On 11/04/11 at 9:00 AM, the facility transferred Resident #1 to the hospital for an elevated temperature. During the 35 minute ambulance transport, Paramedic interview revealed the resident had no covering/dressing applied to the left side of Resident #1's neck. Upon arrival to the hospital, hospital staff assessed Resident #1 as having a [MEDICAL CONDITION] collar strap (a strap used to hold the device that delivers oxygen to a resident with a [MEDICAL CONDITION] in place) which had incised into the neck with a flap of skin which lay over the strap. Hospital physicians revealed the "severity of the injury was avoidable"; the wound was "neglected", had to be "at least seven days" for the collar to have made the incision into the skin, which resulted in the resident's admission to the hospital with a [DIAGNOSES REDACTED]. The failure to ensure care and services were provided to protect residents from injury has caused, or is likely to cause, serious injury, harm, impairment, or death to Resident #1 and other residents in the facility. Immediate Jeopardy was determined to exist on 11/04/11 and is ongoing. (Refer to F314) The findings include: A review of the facility's policy/procedure for Resident Abuse and Neglect (no date provided) revealed neglect must be identified and corrected quickly. The facility policy/procedure defined neglect as the failure to provide the necessary care to meet each resident's needs. Further review revealed, "Associates want to take good care of our resident's needs. Regardless of the cause, neglect must be identified and corrected quickly." Interview, on 12/09/11 at 12:50 PM, with the paramedic who transported Resident #1 to the hospital on [DATE] revealed he was notified of a resident at the facility that needed transportation to the hospital due to a fever. The paramedic stated the trip from the facility to the hospital took approximately thirty five (35) minutes. The paramedic also stated he had suctioned the resident during the trip but had not removed the [MEDICAL CONDITION] collar and did not remember a covering/dressing applied to the left side of Resident #1's neck. Interview with the Emergency Department (ED) Registered Nurse (RN) on 12/09/11, at 10:04 AM, revealed she had provided care for Resident #1 upon the resident's arrival to the ED on 11/04/11. According to the RN, the ambulance personnel assisted the resident onto a stretcher. She turned the resident to the side to obtain a rectal temperature, and observed the wound to the resident's neck. The RN stated a section of the strap that secured the resident's [MEDICAL CONDITION] collar could not be observed, was covered with skin, and had yellow drainage. According to the RN, the strap appeared to have grown into the resident's skin. The RN obtained pictures and notified the ED physician and the Charge Nurse of the assessment. The RN was instructed by the physician and the Charge Nurse to notify Social Services because the wound did not appear to have received care. A review of the emergency department physician's notes revealed the [MEDICAL CONDITION] strap that was applied to Resident #1's neck had incised into the resident's neck with a flap of skin which had grown over the [MEDICAL CONDITION] strap. Social Services was contacted due to the appearance of the resident's neck, and a photograph was obtained. Review of the Hospital photograph of Resident #1's neck wound, dated 11/04/11 at 12:07, revealed Resident #1'[MEDICAL CONDITION] had incised into the resident's neck and a flap of skin lay over a portion of the neck strap. A review of the hospital admission physician notes, dated 11/04/11 at 4:45 PM, revealed the resident was assessed, upon admission to the hospital, with a wound on the left side of the neck from the [MEDICAL CONDITION] collar. A review of the surgical consultation dated 11/04/11 revealed the [MEDICAL CONDITION] collar had "eroded through the resident's neck." Interview with the Emergency Department physician, on 12/09/11 at 10:35 AM, confirmed Resident #1 was received in the Emergency Department (ED) on 11/04/11 and, according to the ED physician, there had not been a dressing on the resident's [MEDICAL CONDITION] wound and the [MEDICAL CONDITIONS] collar strap appeared to have grown into the skin. The ED physician stated he informed the ED nurse that he felt the resident had suffered "abuse" and a report should be made to Social Services. The ED physician stated a [MEDICAL CONDITION] collar would occasionally cause a little redness or a small ulcer and, according to the ED physician, the "severity of the injury could have been avoided." Interview, on 12/06/11 at 11:40 AM, with the physician that admitted Resident #1 to the hospital revealed the physician consulted a surgeon when he saw the condition of the resident's neck. The physician stated the [MEDICAL CONDITION] collar was too tight and the strap had gone into the skin on the resident's neck. The physician stated the injury did not happen quickly, in his opinion it was neglected for "a couple of weeks." The physician stated the resident was "admitted to the hospital with [REDACTED]." Review of the hospital record for Resident #1 revealed the resident's wound on the neck had been cultured and the results revealed a heavy growth of [MEDICAL CONDITION] (MRSA), a heavy growth of Providencia Stuartii (an organism found in complicated urinary tract infections), and a heavy growth of MDR (multi-drug resistant) Acinetobacter Baumannii (an organism that cna cause skin and wound infections). The resident was treated at the hospital with [MEDICATION NAME] 1300 milligrams (mg), intravenously every 12 hours. Interview with the surgeon, on 12/07/11 at 9:25 AM and again on 12/09/11 at 10:58 AM, revealed he had been consulted to evaluate Resident #1 related to the [MEDICAL CONDITION] collar. The surgeon stated he removed the [MEDICAL CONDITION] collar at the resident's bedside and that the [MEDICAL CONDITION] collar was "upside down" and was "too tight." The surgeon stated the [MEDICAL CONDITION] collar strap had made an incision into the resident's skin from the pressure of the strap. According to the surgeon, the injury "could not have happened overnight" and would have taken "at least seven days" to make an incision into the skin. The surgeon stated the [MEDICAL CONDITION] collar could not have been checked in "any normal period of time." According to the surgeon, the standard of care for a [MEDICAL CONDITION] would include suctioning along with cleaning and removal of the [MEDICAL CONDITION] collar. The surgeon also stated it was "unlikely routine [MEDICAL CONDITION] care had been conducted." Additionally, interview with Resident #1's primary physician, on 12/09/11 at 3:15 PM, revealed the physician had been informed by nursing facility staff (he did not remember the date) that the resident had returned from the hospital and the [MEDICAL CONDITION] strap had become embedded into the skin of the resident's neck. The physician confirmed he did not visualize the resident's pressure sore at that time. After a review of the photograph of Resident #1's neck that had been taken by hospital staff on 11/04/11, the physician stated he was unaware the resident's neck was in that condition. According to the physician, it would have taken "a while" for the pressure sore to develop in to that condition, probably longer than seven days. Medical record review revealed the nursing facility admitted Resident #1 on 09/10/10 with [DIAGNOSES REDACTED]. Review of the Comprehensive Admission assessment with an assessment reference date of 01/12/11 (no signed completion date) revealed the facility assessed Resident #1 as at risk for pressure ulcers, having a [MEDICAL CONDITION] and requiring oxygen via a [MEDICAL CONDITION] collar. On 05/15/11, the facility documented the resident returned to the facility after a hospitalization with a Stage II pressure ulcer to the left side of the neck. Review of the plan of care for Resident #1 dated 06/29/11, revealed the resident was to receive [MEDICAL CONDITION] care every shift and as needed and staff was to change the oxygen tubing every week on Wednesday. The resident's care plan also revealed staff was to turn and reposition the resident every two hours and to assess the decubitus (pressure sore) size, stage, depth, and the absence or presence of infection. On 10/21/11 an intervention was added for staff to apply [MEDICATION NAME] to the Stage II pressure ulcer on the left neck and change every three days. Interview with Licensed Practical Nurse (LPN) #2, on 12/07/11, at 4:25 PM, revealed the LPN provided care for Resident #1 on her scheduled work days. LPN #2 stated she had provided care for Resident #1 on Monday, 10/31/11, at which time she stated the pressure sore on the resident's neck was not open and was "just scabbed over"; however, during an interview on 12/09/11, at 4:15 PM, LPN #2 stated she could not remember what the wound looked like. According to LPN #2, facility policy/procedure stated staff was to document the wound's appearance but she did not document the appearance of the wound. LPN #2 stated she performed [MEDICAL CONDITION] care for Resident #1 several times a shift. The LPN stated she removed the [MEDICAL CONDITION] collar during [MEDICAL CONDITION] care and when the straps were secured back she would pad the straps to keep them away from the resident's skin. Interview with Registered Nurse (RN) #1, on 12/07/11 at 1:15 PM and on 12/12/11 at 3:20 PM, revealed she provided care for Resident #1 on her scheduled work days and had last provided cared for the resident on 10/31/11. RN #1 stated the resident had a pressure sore on the left side of the neck that had been present for several months and had received treatments at the facility. RN #1 stated she assumed the pressure sore was due to the [MEDICAL CONDITION] collar straps. According to RN #1, the resident's [MEDICAL CONDITION] collar straps were usually padded to keep them away from the resident's skin. RN #1 was unsure if all staff kept the straps padded. Care plan and record review revealed no evidence the facility had developed and implemented an intervention to include padding the [MEDICAL CONDITION] strap for Resident #1 to prevent the occurrence of or to prevent worsening of the neck wound. Interview, on 12/08/11 at 10:05 AM, with the Speech Therapist (ST) revealed the ST had worked with Resident #1 on 10/31/11, 11/02/11 and 11/04/11. According to the ST, she would unbuckle the [MEDICAL CONDITION] collar by unsnapping the green straps and letting them fall to the sides. The ST was unaware of a wound on the left side of the resident's neck. The ST stated she had not routinely observed a dressing on the resident's neck or under the [MEDICAL CONDITION] collar. Interview with LPN #1, on 12/07/11 at 4:08 PM and on 12/09/11 at 2:40 PM, revealed LPN #1 had been the nurse responsible for the care of Resident #1 on 11/04/11 at which time she had performed [MEDICAL CONDITION] care for Resident #1. Interview with the Director of Nursing (DON), on 12/07/11 at 2:10 PM and on 12/09/11 at 4:50 PM, revealed she had observed the pressure sore on Resident #1's neck on 11/04/11 and described the pressure sore as "beefy red" and having a skin flap prior to the facility transferring Resident #1 to the hospital on [DATE] due to an elevated temperature. While continued interviews with the nursing facility staff (LPN #1, LPN #2, RN #1, and the DON) revealed the facility denied having observed Resident #1 with the [MEDICAL CONDITION] strap incised into the resident's neck, review of the hospital photograph of Resident #1 taken on 11/04/11 revealed the [MEDICAL CONDITION] strap had incised into the resident's neck and a flap of skin laid over a portion of the neck strap. Continued interview with the emergency room Physician, on 12/09/11, revealed that the neck looked like the hospital picture. It was "one of the worst things I've seen come from a nursing home," as the resident "arrived in the (hospital) in that condition." Interview with the Unit Supervisor, on 12/07/11 at 2:00 PM, revealed she did not know if staff had delivered the care and services for Resident #1 because she had asked staff if they had performed [MEDICAL CONDITION]/wound care to the resident's neck; however, had not actually observed staff provide the care. Interview with the Director of Nursing (DON) on 12/07/11, at 2:10 PM and on 12/09/11, at 4:50 PM, revealed the DON stated staff performed [MEDICAL CONDITION] care every shift and removed the [MEDICAL CONDITION] collar every day. The DON also stated staff kept the [MEDICAL CONDITION] straps padded with gauze. The DON could not confirm the [MEDICAL CONDITION] straps were padded with gauze prior to the resident's transfer to the hospital on [DATE]. Interview with the facility Administrator, on 12/12/11, at 3:11 PM, revealed the Administrator relied on the DON and the unit managers to ensure care was delivered to residents. The Administrator stated the DON had the responsibility to ensure pressure ulcers were monitored/tracked, and to verify staff competency. According to the Administrator, the unit managers were responsible for monitoring staff practice. The Administrator stated she became aware of the physician's report from the 11/04/11 hospital admission for Resident #1 which indicated the strap of the [MEDICAL CONDITION] collar had become embedded in the resident's skin and that Adult Protective Services had initiated and investigation related to Resident #1 on 11/07/11. The Administrator stated she questioned staff about the resident's condition and had determined the resident returned from the hospital "in that condition." The Administrator stated the [MEDICAL CONDITION] collar strap had become embedded in the resident's skin at the hospital. While the Administrator detailed she had questioned staff regarding the resident's pressure ulcer to the neck, there was no documented evidence that the facility had identified suspected neglect, conducted an investigation or followed the facility policy and procedure related to abuse and neglect.

Based on interview, record review, review of the Allegation of Compliance and the facility's file it was determined the Immediate Jeopardy identified during the abbreviated survey (12/12/11) had been removed on 12/14/11 related to the failure to provide resident care in accordance with the individualized care plan. However, noncompliance continued to exist at a S/S of "D" as the facility had not completed the Quality Assessment and Assurance (QAA) initiative related to staff monitoring, analysis of monitoring audit results, and development and implementation of the Plan of Correction (POC) to ensure care was provided in accordance with each resident's individualized care plan. The findings include: Review of the acceptable Allegation of Compliance (AOC) received on 12/22/11, revealed on 12/12/11, the facility conducted assessments on all current residents and reviewed all current residents' medical records to identify any issues related to the provision of care. Record review revealed the facility provided education for all staff on 12/13/11, 12/14/11, 12/22/11, and 12/23/11, which included the requirement to provide care based on the resident's individual care plan. Emphasis was placed on the need to provide care and services to prevent pressure ulcers and promote healing of current pressure ulcers. Interviews were conducted on 12/27/11, with the Executive Director (ED), Director of Nursing (DON), Regional Director of Clinical Services (RDCS), the Minimum Data Set (MDS) Coordinator, four State Registered Nursing Assistants (SRNAs), three Licensed Practical Nurses (LPNs), and two Registered Nurses (RNs). All interviews revealed staff had received re-education related to providing care in accordance with the individualized care plan and each staff member demonstrated a working knowledge of their responsibilities for residents at risk for the development of pressure ulcers. Review of the facility's file revealed the facility had not submitted their plan of correction for the identified deficiencies from the abbreviated survey of 12/12/11. Interviews conducted with the ED, DON, and RDCS on 12/27/11, from 4:10 PM to 4:50 PM, revealed quality assurance activities had been initiated; however, the facility needed to continue quality assurance activities to ensure compliance with established policies and procedures related to the provision of care after staff re-education was provided.

Based on staff interview, review of the clinical record, review of hospital records and the facility Wound Care/Treatment Guidelines policy, it was determined the facility failed to ensure one (1) of thirteen (13) residents received necessary treatment and services to promote healing and prevent infection of pressure sores. Upon admission, the facility assessed Resident #1 to be at risk for pressure sore development; however, the facility failed to implement interventions to prevent infection and/or promote healing after the development of a pressure ulcer to the resident's neck. In addition, the facility failed to perform weekly wound assessments according to their policy, failed to follow the care plan, and supervisory staff failed to ensure the necessary care was provided to the resident. The facility transferred the resident to the hospital on [DATE] due to an elevated temperature. Interview with the Paramedic who transported Resident #1 on 11/04/11 revealed no dressing to the wound on the resident's neck. Upon admission to the hospital, hospital staff found the resident's [MEDICAL CONDITION] collar strap had embedded into the skin on the left side of the neck with no dressing in place when the resident arrived in the hospital Emergency Department. The hospital admitted Resident #1 with a [DIAGNOSES REDACTED]. The laboratory results identified the neck wound had three microorganisms which included, [MEDICAL CONDITION], Providencia stuartii, and MDR (multi-drug resistant) Acinetobacter Baumannii. Interviews with the hospital physicians revealed the resident's wound had been "neglected" for at least seven days and the severity of the injury could have been avoided. Due to the facility's failure to provide the necessary care and services the resident required hospitalization to treat [MEDICAL CONDITION] due to the neck wound resulting in wound treatment and antibiotic therapy. The facility's failure to provide treatment to the resident's pressure ulcer has caused, or is likely to cause, serious injury, harm, impairment, or death to Resident #1 and other residents in the facility. Immediate Jeopardy was determined to exist on 11/04/11 and is ongoing due to the facility's failure to identify the incident as neglect and failure to identify that facility staff were not assessing or providing treatment to Resident #1 in accordance with facility policy/procedure. The findings include: Interview on 12/09/11, at 12:50 PM, with the Paramedic who transported Resident #1 to the hospital on [DATE] revealed the only care the paramedic rendered en route to the hospital was monitoring the resident's vital signs and suctioning the resident as needed. The paramedic did not remember seeing a dressing on the resident's neck. The paramedic stated he did not observe any padding to the [MEDICAL CONDITION] collar straps. Interview on 12/09/11, at 10:04 AM, with the Emergency Department (ED) RN who initially assessed Resident #1 revealed the RN had started an assessment of the resident; she observed the straps from the [MEDICAL CONDITION] collar and noted the strap on the left side appeared to be embedded into the resident's skin. The RN stated there was no protective dressing on the wound when the resident arrived in the ED. The RN photographed the resident's wound in accordance with hospital policy. A review of the photograph taken in the hospital Emergency Department of Resident #1's neck wound on 11/04/11, at 12:07 PM, revealed the wound was on the left side of the resident's neck. A green strap was observed attached to a [MEDICAL CONDITION] collar (a device for oxygen delivery placed over a [MEDICAL CONDITION]) and proceeded around the resident's neck. A measurement device present in the photograph revealed an approximate 4.5 centimeter (cm) area of the green strap obscured by a yellow substance in the middle of the area, strings of a yellow/pink substance was on the left of the area and a flesh colored substance was on the right of the wound. Review of the physician's hospital admission documentation dated 11/04/11, revealed the resident had an area on the left side of the neck "what appears that her [MEDICAL CONDITION] collar has been eroding into the left side of the neck." Interview on 12/09/11, at 10:35 AM, with the ED physician who treated Resident #1 on 11/04/11 revealed upon assessment of the resident in the ED the [MEDICAL CONDITION] collar straps "appeared to have grown into the resident's skin." The ED physician stated he spoke with the nurse and informed the nurse to notify social services. According to the ED physician, he felt the resident had suffered "abuse." The ED physician stated [MEDICAL CONDITION] collar straps "could cause some redness to the neck with wear." The ED physician stated he not see a dressing on the resident's neck upon admission to the ED. According to the ED physician, "the severity of the pressure ulcer could have been avoided." Interview on 12/06/11, at 11:40 AM, with the Hospitalist (a physician employed by the hospital who admits and treats patients in the hospital who do not have a primary physician with admitting privileges at the hospital) revealed he admitted the resident to the hospital and consulted a surgeon immediately when he observed the condition of the resident's pressure ulcer on the neck. The Hospitalist stated in his opinion the injury was the result of the tight [MEDICAL CONDITION] collar and that it had taken more than a couple of days for the pressure ulcer to get in "that condition." The Hospitalist stated he admitted the resident to the hospital with a [DIAGNOSES REDACTED]." Interview with the surgeon on 12/07/11, at 9:25 AM and on 12/09/11, at 10:58 AM, revealed the pressure ulcer to the left side of Resident #1's neck was more of a laceration due to pressure from the [MEDICAL CONDITION] collar strap. According to the surgeon, the pressure from the strap had lacerated (cut) the skin of the resident's neck and the wound contained yellow drainage and a "flap" of skin over the strap. According to the surgeon, the [MEDICAL CONDITION] collar was on too tight and upside down. The surgeon stated it would have taken "at least seven days" for the strap to have made an incision into the skin. The surgeon stated it was unlikely routine [MEDICAL CONDITION] care was done for the resident and that the [MEDICAL CONDITION] collar had not been checked in any normal period of time. According to the surgeon, he "unsnapped and pulled out" the [MEDICAL CONDITION] collar strap. Review of the laboratory results for Resident #1 obtained at the hospital revealed a culture of the wound on the left side of the resident's neck, collected on 11/04/11, contained a heavy growth of three organisms; [MEDICAL CONDITION] (MRSA), Providencia Stuartii (most often found in complicated urinary tract infections), and MDR (Multi-Drug Resistant) Acinetobacter Baumannii (can cause various infections including skin and wound infections). The resident was treated with [MEDICATION NAME] 1300 milligrams (mg) intravenously every 12 hours for the organisms. Review of the nursing facility policy/procedure Wound Care/Treatment Guidelines (revised 05/21/04), revealed a licensed professional was to conduct a weekly skin assessment and the skin was to be observed for pressure damage caused by medical devices. The assessments were to include measurement and a description of the wound. The policy stated the results of the skin assessment were required to be documented on the Weekly Skin Integrity Data Collection Form and the Weekly Pressure Ulcer Record was required to be used for weekly assessment of existing wounds. In addition, the policy revealed the care plan should reflect the current status of the wound and appropriate goals. Review of the medical record of Resident #1 revealed the facility admitted the resident on 09/10/10 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) Assessment with a completion date of 04/16/11 revealed the resident had been readmitted to the facility after a hospital stay for an elevated temperature. The resident was assessed as at risk for pressure sores and had two Stage II pressure ulcers (one on the sacrum and one on the left heel) with the most severe type of tissue in the ulcer bed to be [MEDICATION NAME] tissue (new skin growing in a superficial ulcer). Review of the Nursing Service Data Collection Tool (completed upon a resident's return from the hospital), completed by facility staff, dated 05/15/11, after return from another hospital admission (05/02/11 to 05/15/11), revealed the resident returned to the facility with a Stage III pressure ulcer to the back of the neck. However, according to the Pressure Ulcer Status Record, completed by facility staff, dated 05/15/11, the pressure ulcer was a Stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough) and measured 3 cm long by 0.4 cm wide by 0.1 cm deep. Review of the interim care plan for Resident #1 dated 05/31/11, revealed the Stage II pressure ulcer on the back of the neck was to be cleaned with normal saline and triple antibiotic ointment was to be applied twice daily for 14 days. A review of the Quarterly MDS Assessment with an assessment reference date of 07/11/11, revealed Resident #1 had one Stage II pressure ulcer (unidentified location) and one Stage III pressure ulcers (unidentified location). The assessment revealed the Stage III pressure ulcer was present upon admission/reentry to the facility after a hospital stay from 06/19/11 to 06/29/11. The assessment further revealed the Stage III pressure ulcer was 3 cm long by 1 cm wide and slough (yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous) was the most severe type of tissue present in the pressure ulcer bed. A review of the Weekly Skin Integrity Data Collection forms for resident #1 dated 05/20/11, 06/05/11, 07/10/11, 08/12/11, and 08/19/11) revealed resident #1 had an area to the left side of the neck. The Weekly Skin Integrity Data Collection form stated "If Open Area, proceed to appropriate skin condition record". Review of the facility's Pressure Ulcer Status Record revealed staff were to document the stage of the pressure ulcer, measurements, drainage, odor, color, tunneling if present, appearance of the wound, response to treatment and the date the physician and/or dietary were notified. However, a review of the Pressure Ulcer Status Records revealed no evidence the facility had completed the form for 05/20/11 or 06/05/11. Review of the care plan for Resident #1 dated 06/29/11 revealed the resident had a Stage III pressure ulcer (no site documented) and was at risk for complications such as poor/delayed wound healing, infection or further deterioration. The goal was for the pressure ulcer to demonstrate progression towards healing as evidenced by reduction in size and to remain free from signs and symptoms of infection with the following interventions: (1) assess decubitus size, stage, depth, absence or presence of infection and location and report to physician (2) turn and reposition every 2 hours and as needed (3) keep clean and dry (4) assess progress towards healing and need to alter treatment regimen (5) notify physician as needed for new orders or changes in skin condition. Further review of the Weekly Skin Integrity Data Collection form dated 07/10/11, revealed the resident had an open area to the left side of the neck. A review of the Pressure Ulcer Status Record revealed no evidence staff had completed the form for 07/10/11. On 08/05/11 an intervention was added to the care plan to apply wound gel to the left side of the neck and under the [MEDICAL CONDITION] collar each shift, apply a dry protective dressing for 10 days and re-evaluate. Review of the Weekly Skin Integrity Data Collection form dated 08/12/11 and 08/19/11 revealed the resident had an open area to the left side of the neck. Review of the Pressure Ulcer Status Record revealed no wound assessment for 08/12/11 or 08/19/11. On 08/18/11 an intervention was added to apply triple antibiotic ointment and a dry protective dressing to the left side of the neck for ten days and then re-evaluate the wound. Further review of the Pressure Ulcer Status Records revealed there was no documentation of an assessment/status of the pressure sore to the resident's neck until 08/24/11. Skin assessments were not completed on 06/12/11, 06/19/11, 06/26/11, 07/17/11, 07/24/11, or 07/31/11, due to the resident being out of the facility. According to the 08/24/11 Pressure Ulcer Status Record, the pressure ulcer to the left side of the "neck at [MEDICAL CONDITION] collar" was a Stage II and measured 1 cm by 1.5 cm. There was no documentation of the wounds depth, drainage, odor, color, appearance, or response to treatment. There was no further documentation the facility assessed the pressure ulcer utilizing the Pressure Ulcer Status Record until 09/12/11 when the pressure ulcer was documented as a Stage II pressure ulcer that measured 3 cm by one 1 cm, indicating the wound had become larger since 08/24/11. Further review of the Pressure Ulcer Status Record for Resident #1 dated 09/22/11 revealed the pressure ulcer was a Stage II that measured 3.5 cm long by 1 cm wide, but no documentation of the appearance of the wound or response to treatment was documented and the wound measurement was 0.5 cm larger. Further review of the Pressure Ulcer Status Record dated 09/26/11 revealed the Stage II pressure ulcer had increased in size and measured 6.5 cm long by 1.5 cm wide. A review of the physician orders, dated 09/26/11, revealed the treatment was changed and staff was to apply Santyl ointment with a dry protective dressing, then re-evaluate in 14 days. Further review of the Pressure Ulcer Status Record revealed on 10/3/11, Resident #1's Stage II pressure ulcer to the neck had decreased in size and measured 3.5 cm by 1 cm. According to the documentation, there was a scant amount of drainage, no odor or tunneling and the wound was pink. On 10/10/11, staff documented on the Pressure Ulcer Status Record that the pressure ulcer was a Stage III (a full thickness of skin is lost, exposing the subcutaneous tissues-presents as a deep crater with or without undermining adjacent tissue). According to the documentation, the pressure ulcer measured 4 cm by 1 cm. There was no documentation of the wound depth, drainage, odor, color, appearance, or response to treatment, and no documentation the physician was notified of the increase in the size of the wound, even though the order dated 09/26/11, stated to reevaluate the treatment in 14 days. According to the 10/17/11 Pressure Ulcer Status Record, resident #1's pressure ulcer to the neck continued to be a Stage III and had increased in size and measured 4 cm by 2 cm, with no depth. There was no documentation of the wound's appearance, drainage, color, odor, or response to treatment. However, the record revealed the pressure ulcer had improved, and the physician was not notified. A review of the physician orders [REDACTED].#1 revealed the treatment was changed to apply a DuoDerm dressing to the Stage II pressure sore every three days for fourteen days, and then reassess. However, the treatment to the neck was changed three days later on 10/24/11 to a dry protective dressing every shift and as needed. Review of the physician's progress notes in the medical record of Resident #1 from 05/17/11 through 11/12/11 revealed no documentation of a pressure ulcer to the resident's neck until 11/12/11. Further review of the Pressure Ulcer Status Records for 10/25/11 and 10/31/11, revealed resident #1's pressure ulcer was assessed as a Stage III, but decreased in size to 2.5 cm by 1 cm on 10/31/11. There was no documentation of pressure ulcers odor, color, or appearance. Staff had documented a Stage III to the left side of the resident's neck on 10/10/11, 10/17/11, 10/25/11, and 10/31/11. Facility staff had documented stage and measurements of the pressure sore, but did not document appearance of the wound, odor, color, or response to treatment as required by the facility policy. In addition, a review of the Initial Data Collection Tool/Nursing Service forms completed when the resident returned from a hospital stay on 05/31/11, 06/15/11, 06/29/11, 08/06/11, 09/08/11, 09/22/11, 10/03/11 revealed staff was to indicate size, and depth of all pressure sores and vascular ulcers. Staff had not documented size and/or depth of the documented pressure sores on the form. Review of the treatment record for Resident #1 dated October 2011, revealed staff documentation from 10/24/11 to 10/31/11 that a dry protective dressing was applied to the resident's pressure ulcer on the left side of the neck. The November 2011 treatment record documented that staff had applied a dry protective dressing to the pressure ulcer on the resident's neck from 11/01/11 to 11/04/11. Interview on 12/07/11, at 4:08 PM and 12/09/11, at 2:40 PM, with Licensed Practical Nurse (LPN) #1 revealed she had been responsible for the care of Resident #1 on 11/04/11. According to LPN #1, she had provided wound care the morning of 11/04/11 prior to the resident's transfer to the hospital. LPN #1 stated she placed a dry protective dressing onto the pressure ulcer on the resident's neck and put padding under the [MEDICAL CONDITION] collar straps. Interview with Registered Nurse (RN) #1 on 12/07/11, at 1:15 PM and on 12/12/11, at 3:20 PM revealed the RN had provided care for Resident #1 on 10/31/11. According to RN #1, she had provided wound care to the pressure ulcer on the resident's neck on 10/31/11, and stated the wound was a "cut" and had a "flap" of skin in the cut. RN #1 stated she assumed the pressure ulcer came from the straps on the [MEDICAL CONDITION] collar. The RN stated she kept the straps padded with gauze to keep the straps from direct contact with the resident's skin. RN #1 stated she was unaware if all staff kept the straps padded. Interview with LPN #2 on 12/07/11, at 4:25 PM, and 12/09/11, at 4:15 PM, revealed the LPN had assessed and measured the wound on 09/26/11, 10/10/11, 10/17/11, 10/25/11, and 10/31/11. The LPN could not recall the wound's appearance on 10/31/11, but stated the wound did not appear the same as in the photograph taken at the hospital on [DATE]. The LPN stated she was aware of the facility policy/procedure to document the wound's appearance but she had failed to document the appearance. The LPN stated she kept the [MEDICAL CONDITION] collar straps padded to keep them off the resident's skin. According to LPN #2, the resident's pressure ulcer was probably caused by the [MEDICAL CONDITION] collar straps. Interview with the facility's Speech/Language Therapist (SLP) on 12/08/11, at 10:05 AM, revealed the SLP had conducted speech therapy with Resident #1 on 10/31/11, 11/02/11, and 11/03/11. The SLP stated she did not notice a wound on the resident's neck. According to the SLP, she would unbuckle the [MEDICAL CONDITION] collar to access the [MEDICAL CONDITION] but did not remove the [MEDICAL CONDITION] collar straps. The SLP stated on some occasions there would be a lot of dressings but not routinely. The SLP stated she did not remember seeing anything around the [MEDICAL CONDITION] collar straps. Interview with the Unit Supervisor on 12/07/11, at 2:00 PM, revealed she monitored staff performance by asking staff if they had completed wound care and/or [MEDICAL CONDITION] care. The Unit Supervisor stated she did not visually monitor staff and did not know if the treatments had actually been completed but relied on staff documentation and did not monitor to ensure staff completed skin/wound assessments per the facility policy. According to the Unit Supervisor, the resident had been treated for [REDACTED]. The Unit Supervisor stated the resident's pressure ulcer "had never been completely healed since August 2011." Interview with the Director of Nursing (DON) on 12/07/11, at 2:10 PM, revealed the DON had visualized Resident #1's pressure ulcer to the neck on 11/04/11 prior to the resident's transfer to the hospital. According to the DON, the pressure ulcer was a "beefy" color with a skin flap. The DON stated staff kept the [MEDICAL CONDITION] straps padded to keep them off the resident's skin. According to the DON, staff was required to assess and document resident wounds each week. The DON stated she "flipped" through the documentation of the wounds every three to four weeks but did not check to ensure the assessments had been completed in accordance with facility policy. Interview on 12/09/11, at 3:15 PM, with the primary physician for Resident #1 at the facility revealed he was unaware of the condition of the resident's pressure ulcer to the neck until he saw the photographs taken at the hospital. The physician stated he had been informed several months ago (could not remember the exact date) by facility staff that the resident had returned from the hospital with the pressure ulcer; however, the physician stated he had not visualized the pressure ulcer at that time. The physician stated he did not recall if staff "told me what it looked like" when he ordered a dressing change but staff would inform him of the need to change treatment due to not healing well. The physician stated he normally would document in the physician's progress notes if he had visualized the wound. According to the physician, the condition of the pressure ulcer at the time of admission to the hospital on [DATE] "had taken a while to develop, probably longer than seven days."

Based on interview, record review, review of the facility's Allegation of Compliance and the facility's file it was determined the Immediate Jeopardy identified during the abbreviated survey (12/12/11) had been removed on 12/14/11 related to the failure to provide necessary care and services for a resident with a pressure ulcer. However, noncompliance continued to exist at a S/S of "D" as the facility had not completed the Quality Assessment and Assurance (QAA) initiative related to staff monitoring, analysis of audit results, and the development and implementation of the Plan of Correction (POC) related to the provision of care for pressure ulcer management. The findings include: Review of the acceptable Allegation of Compliance (AOC) received on 12/22/11, revealed the facility conducted assessments on all current residents on 12/12/11. On 12/13/11, nursing administration (Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, Minimum Data Set Coordinator, and Unit Managers) observed all licensed nurses perform wound treatments to ensure the documentation and assessment of wounds was accurate in regards to wound status, staging, treatment, and measurements. All residents were reassessed on 12/13/11, by the nurse management team (Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, Minimum Data Set Coordinator, and Unit Managers) utilizing the Braden scale for risk factors related to the development of pressure ulcers. Record review revealed the facility provided in-service education for all staff on 12/12/11, 12/13/11, 12/22/11, and 12/23/11, with an emphasis on pressure ulcers, wound care policy, guidelines, correct staging of wounds, and assistive devices that could cause pressure wounds. Interviews were conducted on 12/27/11, with the Executive Director (ED), Director of Nursing (DON), Regional Director of Clinical Services (RDCS), the Minimum Data Set (MDS) Coordinator, four State Registered Nursing Assistants (SRNAs), three Licensed Practical Nurses (LPNs), and two Registered Nurses (RNs). All interviews revealed staff had received re-education related to providing care in accordance with the individualized care plan and each staff member demonstrated a working knowledge of their responsibilities for residents at risk for the development of pressure ulcers. Additionally, licensed staff received education related to accurate wound documentation, wound care policy, correct staging of wounds, and assistive devices that may cause pressure wounds. Review of the facility's file revealed the facility had not submitted their plan of correction for the identified deficiencies from the abbreviated survey of 12/12/11. Interviews conducted with the Administrator, the DON, and the RDCS on 12/27/11, from 4:10 PM to 4:50 PM, revealed quality assurance activities had been initiated; however, the facility needed to continue quality assurance activities to ensure compliance with established policies and procedures related to pressure ulcer management after the provision of staff re-education.

Based on staff interview, physician interviews, record review, and a review of facility policies, it was determined the facility failed to be administered in an effective and efficient manner to ensure that one (1) of thirteen (13) residents received care and services to attain or maintain their highest practicable physical well-being. The facility failed to ensure one (1) of thirteen (13) sampled residents (Resident #1) received care and services for the treatment of [REDACTED]. On 11/04/11 the facility transferred Resident #1 to the hospital due to an elevated temperature. Interview on 12/09/11, at 12:50 PM, with the Paramedic who transported Resident #1 to the Emergency Department of the hospital on [DATE], revealed the Paramedic could not recall a dressing to the left side of the resident's neck on 11/04/11. Upon arrival to the hospital, hospital staff assessed the resident and determined the strap to the resident's [MEDICAL CONDITION] collar had become embedded into the skin on the left side of the resident's neck. The resident's attending physician at the facility had prescribed a wound treatment that included a dry protective dressing to the left side of the resident's neck on a daily basis; however, upon the resident's arrival to the hospital, there was not a protective dressing covering the wound. Interview with Resident #1's physician revealed, based on observation of the photograph taken at the hospital, facility staff could not have provided care to the resident's neck wound for "more than seven days." The facility's failure to ensure Resident #1 received care and services to promote healing and worsening for a pressure ulcer placed residents in the facility at risk for serious injury, harm, impairment, or death. Immediate Jeopardy was identified on 12/12/11 and determined to exist on 11/04/11 and is ongoing due to the facility's failure to identify neglect and that staff did not implement the facility policy/procedure related to wound surveillance and wound treatment. Deficiencies were cited at 42 CFR 483.13 Resident Behavior and Facility Practices (F224), 42 CFR 483.20 Resident Assessment (F282), 483.25 Quality of Care (F314), and 42 CFR 483.75 Administration (F490 and F520) at a scope and severity of "J." Substandard Quality of Care was identified at 42 CFR 483.13 Resident Behavior and Facility Practices and 42 CFR 483.25 Quality of Care. (Refer to F314 and F224.) The findings include: A review of the photograph obtained by hospital staff in the hospital Emergency Department on 11/04/11 revealed Resident #1 had a wound on the left side of the resident's neck. A green strap was observed attached to a [MEDICAL CONDITION] collar (a device for oxygen delivery placed over a [MEDICAL CONDITION]) and continued around the resident's neck. A measurement device present in the photograph revealed an approximate 4.5 centimeter (cm) area of the green strap obscured by a yellow substance in the middle of the area, strings of a yellow/pink substance was on the left of the area and a flesh colored substance was on the right of the wound. Review of the physician's hospital admission documentation dated 11/04/11, revealed the resident had an area on the left side of the neck "what appears that her [MEDICAL CONDITION] collar has been eroding into the left side of the neck." According to interviews on 12/07/11 and 12/09/11 with the Emergency Department (ED) staff, ambulance paramedic, consulting surgeon and review of a photograph of Resident #1 obtained in the ED, the resident did not have a dressing intact to the left side of the neck and the [MEDICAL CONDITION] strap was embedded into the residents skin upon arrival to the hospital. Interviews with the consultant surgeon on 12/07/11 and again on 12/09/11 revealed, in his opinion, the resident could not have received care to the wound area on the neck for at least seven days. Interview on 12/09/11 with the resident's attending physician at the facility revealed the wound area identified in a photograph taken by hospital staff on 11/04/11 would have taken more than seven days to get into a condition with the strap of the [MEDICAL CONDITION] embedded into the resident's skin. A review of the facility policy/procedure Wound Care/Treatment (undated) revealed staff was to complete a weekly assessment on all wounds. The assessment was to include measurement and a description of the wound. Review of the facility policy/procedure [MEDICAL CONDITION] Care (undated) revealed the area around a [MEDICAL CONDITION] stoma required cleansing/treatment, the inner cannula of the [MEDICAL CONDITION] required cleaning and/or changed to meet hygiene protocol, and drain sponges and [MEDICAL CONDITION] "ties" required changing secondary to soiling. Review of the facility policy/procedure Resident Abuse and Neglect revealed neglect was usually not intentional and that, although Associates wanted to take good care of residents, but for a number of reasons, the necessary care was not always provided to meet the resident's needs. According to the policy, neglect must be identified and corrected quickly. Review of the Pressure Ulcer Status Record for Resident #1 from 05/15/11 through 10/31/11 revealed staff had conducted weekly wound documentation. Review of the documentation revealed staff had documented the stage of the wound and measurement but did not provide a description of the wound. Review of the Pressure Ulcer Status Record for Resident #1 dated 10/03/11 revealed the resident had a Stage II pressure ulcer to the neck that measured 3.5 centimeters (cm) by 1.0 centimeters. On 10/10/11 staff documented the wound was a Stage III pressure ulcer that measured 4.0 cm by 1.0 cm (larger and a worsening stage than the previous week) and documented "no change." Review of the medical record of Resident #1 revealed the resident had been transferred to the hospital on [DATE] for an elevated temperature. Based on documentation by hospital staff, Resident #1 was found to have a strap that secured the [MEDICAL CONDITION] collar embedded into the skin on the left side of the resident's neck. Interviews with Licensed Practical Nurse (LPN) #2 on 12/07/11 at 4:25 PM and 12/09/11 at 4:15 PM; with Registered Nurse (RN) #1 on 12/07/11 at 1:15 PM and 12/12/11 at 3:20 PM; and with LPN #1 on 12/07/11 at 4:08 PM and 12/09/11 at 2:40 PM, revealed they had provided care to Resident #1 from 10/31/11 to 11/04/11 and had applied a dry protective dressing to the wound on the left side of the resident's neck and had also padded the straps to the [MEDICAL CONDITION] collar. Interview with the Unit Supervisor on 12/07/11, at 2:00 PM, confirmed Resident #1 had a pressure sore the left side of the neck that had been assessed on the resident's return from a hospitalization in May 2011 (exact date unknown). The Unit Supervisor stated she could not confirm that staff had delivered the care and services for resident #1 because she had only "asked" staff if they had performed [MEDICAL CONDITION]/wound care to the resident's neck, and had not actually observed the provision of the care. Interview with the Director of Nursing (DON) on 12/07/11, at 2:10 PM, 12/09/11, at 4:50 PM and on 12/12/11, at 5:00 PM, revealed the Unit Supervisor had the responsibility to ensure staff provided wound treatments. The DON stated a weekly pressure ulcer tracking report had been developed for documentation of the status of pressure ulcers and that she relied on accurate documentation of the pressure ulcers by staff for the report. The DON stated that she reviewed the information on a weekly basis then forwarded her report to the corporate Regional Director of Clinical Services. According to the DON, she did not review the Pressure Ulcer Status Reports on a regular basis. The DON stated she "flipped" through the reports every three to four weeks and was not aware that staff had not completed the reports in accordance with facility policy. Interview on 12/12/11, at 3:40 PM, with the Corporate Regional Director of Clinical Services revealed the DON had the responsibility to ensure care was delivered to residents in accordance with the resident's care plan. Interview with the facility Administrator on 12/12/11, at 3:11 PM, revealed the Administrator relied on the DON and the unit managers to ensure care was delivered to residents. The Administrator stated the DON had the responsibility to ensure pressure ulcers were monitored/tracked, and to verify staff competency. According to the Administrator, the unit managers had the responsibility to monitor staff practice. In addition, the Administrator acknowledged she was aware of the physician's report of Resident #1's hospitalization which indicated the strap of the [MEDICAL CONDITION] collar had become embedded in the resident's skin. The Administrator stated she questioned staff about the resident's condition and had determined, based on the interviews, the resident had returned from the hospital "in that condition." The Administrator stated the [MEDICAL CONDITION] collar strap had become embedded in the resident's skin during the resident's hospitalization . The Administrator could provide no documented evidence of a formal investigation of neglect conducted by the facility or action taken to ensure neglect would not recur despite being notified by Adult Protective Services of their investigation into the allegation of neglect.

Based on interviews, record reviews and review of facility policy/procedure for wound and [MEDICAL CONDITION] care, it was determined the facility failed to ensure services were provided by staff in accordance with the written the plan of care for one (1) of thirteen (13) sampled residents (Resident #1). The facility failed to ensure the resident's pressure ulcer had been assessed and treatment provided in accordance with the care plan and facility policy. The facility assessed Resident #1 as having a pressure sore to the left side of the neck and the plan of treatment was to apply a dry, protective dressing to the site. On 11/04/11, the facility transferred Resident #1 to the hospital due to an elevated temperature. Interview with the Paramedic who transported Resident #1 to the Emergency Department of the hospital on [DATE], revealed the Paramedic could not recall a dressing to the left side of the resident's neck. Upon admission to the hospital it was discovered the strap for the resident's [MEDICAL CONDITION] collar was embedded into the resident's neck. The resident had no dressing to the wound upon arrival to the hospital and interviews with the ED physician, Hospitalist, and surgeon confirmed the [MEDICAL CONDITION] collar strap was embedded in the resident's skin due to staff failure to provide routine care. This failure placed Resident #1 and other residents at risk for serious injury harm impairment or death. Immediate Jeopardy was identified on 12/12/11, was determined to exist on 11/04/11, and is ongoing due to the facility's failure to identify that staff did not implement facility policy/procedure related to surveillance of wounds and the provision of wound care. The findings include: Interview on 12/09/11, at 12:50 PM, with the Paramedic who transported Resident #1 to the Emergency Department of the hospital on [DATE], revealed the Paramedic could not recall a dressing to the left side of the resident's neck on 11/04/11. Resident # 1's hospital record was reviewed and revealed the resident had been transported from the facility to the hospital due to an elevated temperature on 11/04/11 at 9:58 PM. A review of the photograph taken in the hospital Emergency Department of Resident #1's neck wound on 11/04/11 revealed the wound was on the left side of the resident's neck. A green strap was observed attached to a [MEDICAL CONDITION] collar (a device for oxygen delivery placed over a [MEDICAL CONDITION]) and proceeded around the resident's neck. A measurement device present in the photograph revealed an approximate four and one-half (4.5) centimeter (cm) area of the green strap obscured by a yellow substance in the middle of the area, strings of a yellow/pink substance was on the left of the area and a flesh colored substance was on the right of the wound. Review of the physician's hospital admission documentation, dated 11/04/11, revealed the resident had an area on the left side of the neck "what appears that his/her [MEDICAL CONDITION] collar has been eroding into the left side of the neck." Interviews on 12/07/11 and 12/09/11 with the hospital Emergency Department (ED) physician, ED Registered Nurse, Resident #1's admitting physician, and the consultant surgeon revealed the wound to the left side of the Resident's neck was not covered with a dressing when the resident arrived to the hospital. Interview with the consultant surgeon on 12/07/11, at 9:25 AM, revealed it would have taken at least seven days for the [MEDICAL CONDITION] collar strap to incise the resident's skin. According to the consultant surgeon, it was unlikely routine [MEDICAL CONDITION] care had been provided and it did not appear that the area had been checked in any normal period of time. A review of the facility policy/procedure Wound Care/Treatment Guidelines (no date provided) revealed licensed staff was to complete a weekly assessment of all wounds. The assessment was to include measurements and a description of the wound. Review of the medical record of Resident #1 revealed the facility admitted the resident on 09/10/10 with [DIAGNOSES REDACTED]. Documentation on a Comprehensive Assessment (01/21/11) revealed Resident #1 was dependent upon staff for all activities of daily living and was at risk for the development of pressure sores. The assessment revealed Resident #1 had a Stage I pressure sore to the left heel. Review of the comprehensive care plan for Resident #1 dated 06/29/11, revealed interventions developed for the resident's [MEDICAL CONDITION] included the provision of oxygen at 40% via [MEDICAL CONDITION] mask, [MEDICAL CONDITION] care every shift, and as needed, and to change the resident's oxygen tubing every week (on Wednesday). Further review of the comprehensive care plan revealed interventions related to the resident's pressure sores and included an assessment of the decubitus (pressure sore) size, stage, depth, absence or presence of infection and location. Staff was to turn and reposition the resident every two hours, and as needed, and to assess progress toward wound healing and the need to alter the treatment regimen. Based on documentation, the facility readmitted Resident #1 on 05/14/11 after a hospitalization for an elevated temperature. Upon readmission to the facility, facility staff assessed Resident #1 and noted the resident had a pressure sore to the left side of the neck. Review of the facility's Pressure Ulcer Status Record revealed staff were to document the stage of the pressure ulcer, measurements, drainage, odor, color, tunneling if present, appearance of the wound, response to treatment and the date the physician and/or dietary were notified. However, a review of the Pressure Ulcer Status Records revealed no evidence the facility had completed the form for 05/20/11 or 06/05/11. Review of the interim care plan for Resident #1, dated 05/31/11, revealed the Stage II pressure ulcer on the back of the neck was to be cleaned with normal saline and triple antibiotic ointment was to be applied twice daily for 14 days. Review of the Quarterly Assessment reference date 07/11/11 revealed Resident #1 had one Stage II pressure ulcer (unidentified location) and one Stage III pressure ulcer (unidentified location). Review of the Weekly Skin Integrity Data Collection form dated 07/10/11, revealed the resident had an open area to the left side of the neck. A review of the Pressure Ulcer Status Record revealed no evidence staff had completed the form for 07/10/11. On 08/05/11 an intervention was added to the care plan to apply wound gel to the left side of the neck and under the [MEDICAL CONDITION] collar each shift, apply a dry protective dressing for 10 days and re-evaluate. Review of the Weekly Skin Integrity Data Collection form dated 08/12/11 and 08/19/11 revealed the resident had an open area to the left side of the neck. Review of the Pressure Ulcer Status Record revealed no wound assessment for 08/12/11 or 08/19/11. On 08/18/11 an intervention was added to apply triple antibiotic ointment and a dry protective dressing to the left side of the neck for ten days and then re-evaluate the wound. Further review of the Pressure Ulcer Status Records revealed there was no documentation of an assessment/status of the pressure sore to the resident's neck until 08/24/11. Skin assessments were not completed on 06/12/11, 06/19/11, 06/26/11, 07/17/11, 07/24/11, or 07/31/11, due to the resident being out of the facility. On 09/09/11, an intervention was added to the care plan and included the application of a triple antibiotic ointment and a dry protective dressing to the left side of the resident's neck for ten days and then to re-evaluate the wound. An intervention was added on 10/21/11 to apply DuoDerm to the Stage II ulcer on the left side of the resident's neck and to change the dressing every three days for fourteen days. On 10/24/11, documentation revealed the treatment to the left side of the resident's neck had been changed to application of a dry protective dressing each day. Documentation on the treatment record revealed staff provided wound care as ordered. Interview with Licensed Practical Nurse (LPN) #1 on 12/07/11, at 4:08 PM, and again on 12/09/11, at 2:40 PM, revealed the LPN had provided wound care to Resident #1 on the day the resident was transferred to the Emergency Department (ED) of an acute care facility on 11/04/11. According to LPN #1, she had placed a gauze pad to the pressure ulcer on the left side of the resident's neck, had changed the [MEDICAL CONDITION] collar, and had put padding under the [MEDICAL CONDITION] collar straps. Interview with Registered Nurse (RN) #1 on 12/07/11, at 1:15 PM and again on 12/12/11, at 3:20 PM, revealed RN #1 provided wound care to Resident #1 on 10/31/11. According to RN #1, she changed the dressing to the wound on the left side of Resident #1's neck on 10/31/11 and had used gauze and pads to pad the [MEDICAL CONDITION] collar strap. Interview with LPN #2 on 12/07/11, at 4:25 PM and again on 12/09/11, at 4:15 PM, revealed LPN #1 had measured the pressure ulcer of Resident #1 on 10/31/11 (four days prior to the resident's hospitalization ). The LPN stated on 12/07/11, that the wound was "scabbed over" on 10/31/11, but on 12/09/11 the LPN stated she could not remember the appearance of the pressure ulcer on the day of the assessment, 10/31/11. According to LPN #2, staff kept the resident's [MEDICAL CONDITION] collar padded and changed the dressing to the wound each day. Interview with the facility's Speech/Language Therapist (SLP) on 12/08/11, at 10:05 AM, revealed the SLP had conducted speech therapy with Resident #1 on 10/31/11, 11/02/11, and 11/03/11, and had not noticed a wound on the resident's neck. According to the SLP, she would "unbuckle" the [MEDICAL CONDITION] collar to access the [MEDICAL CONDITION] but did not remove the [MEDICAL CONDITION] collar straps. The SLP stated on some occasions there were dressings in place to the resident's neck, but not on a routine basis. The SLP also stated she did not remember seeing anything (padding) around the straps of the [MEDICAL CONDITION] collar. Interview with the Unit Supervisor on 12/07/11, at 2:00 PM, confirmed Resident #1 had a pressure sore the left side of the neck for approximately three to four months. According to the Unit Supervisor, the resident had been assessed to have the pressure area on the resident's return from a hospitalization but could not recall the date. The Unit Supervisor stated she did not know if staff had delivered the care and services for resident #1 because she had asked staff if they had performed [MEDICAL CONDITION]/wound care to the resident's neck and had not actually observed staff provide the care in accordance with the resident's care plan. Interview with the Director of Nursing (DON) on 12/07/11, at 2:10 PM, and again on 12/09/11, at 4:50 PM, revealed, to her knowledge, staff provided wound care each day to the left side of Resident #1's neck and kept the area padded with gauze. The DON stated she monitored the hallways "all" day to verify resident's received care and services as planned and observed wound care on a "random" basis. The DON stated she had observed Resident #1 on 11/04/11, the day the resident was hospitalized due to an elevated temperature, and the wound to the resident's neck was "beefy" red in color and she also observed a "skin flap" over the wound. Interview conducted on 12/09/11 at 3:15 PM with Resident #1's attending physician at the facility revealed the physician was unaware of the condition of the resident's pressure ulcer until he had viewed the photograph obtained by the hospital. According to the physician, it would have taken more than seven days for the condition of the wound at that time to occur. While the facility staff interviews and record reviews revealed staff conducted assessments and provided treatment to Resident #1's neck wound, Paramedic and hospital staff interviews revealed the resident arrived at the hospital without a dressing to the wound. Additionally, interviews with physicians revealed that appropriate [MEDICAL CONDITION] care required removal and cleaning daily; however, the appearance of the resident's wound would have taken at least seven days without care to have occurred.

Based on interview, record review, review of the Allegation of Compliance and the facility's file it was determined that Immediate Jeopardy identified during the abbreviated survey (12/12/11) had been removed on 12/14/11 related to neglect. However, noncompliance continued to exist at a S/S of "D" as the facility had not completed the Quality Assessment and Assurance (QAA) initiative related to staff monitoring, analysis of monitoring, results of audits, and the development and implementation of the Plan of Correction (POC) as related to neglect. The findings include: Review of the acceptable Allegation of Compliance (AOC) received on 12/22/11, revealed the facility conducted assessments on all current residents on 12/12/11. On 12/13/11, the nursing management team (Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, Minimum Data Set Coordinator, and Unit Manager) reassessed all current residents for risk factors related to pressure ulcer development. Review of facility in-services revealed staff was re-educated on 12/13/11. Staff not available on 12/13/11, would not be allowed to work until they had completed the in-service offering. The in-service placed an emphasis on pressure ulcer education, Neglect and Abuse education, and the Elder Justice Act. Interviews were conducted on 12/27/11, with the Executive Director, the Director of Nursing (DON), the Regional Director of Clinical Services (RDCS), the Minimum Data Set (MDS) Coordinator, four State Registered Nursing Assistants (SRNAs), three Licensed Practical Nurses (LPNs), and two Registered Nurses (RNs). All interviews revealed staff had received re-education related to facility policies and procedures and demonstrated a working knowledge of their responsibilities. Review of the facility's file revealed the facility had not submitted their plan of correction for the identified deficiencies from the abbreviated survey of 12/12/11. Additionally, interviews conducted with the RDCS on 12/27/11, at 4:50 PM, with the Executive Director on 12/27/11, at 4:45 PM, and with the DON on 12/27/11, at 4:10 PM, revealed performance improvement activities had been initiated; however, the facility needed to continue quality assurance activities to ensure compliance with established policies and procedures related to abuse/neglect, after the provision of staff re-education.

Based on interview, record review, review of the Allegation of Compliance, and the facility's file it was determined that Immediate Jeopardy identified during the abbreviated survey (12/12/11) had been removed on 12/14/11 related to neglect, care plan implementation, and pressure ulcer management. However, noncompliance continued to exist at S/S of "D" as the facility had not completed the Quality Assessment and Assurance (QAA) initiative related to staff monitoring, analysis of monitoring, results of audits, and the development and implementation of the Plan of Correction (POC) to prevent recurrence of noncompliance. The findings include: Review of the acceptable Allegation of Compliance (AOC) received on 12/22/11, revealed the facility conducted assessments on all current residents on 12/12/11. On 12/13/11, the nursing management team (Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, RAI Coordinator, and Unit Manager) reassessed all current residents for risk factors related to pressure ulcer development. The Executive Director received education from the Regional Director of Clinical Services related to QAA activities. Review of facility provided in-services revealed staff was re-educated on 12/13/11, and any staff not available on 12/13/11, would not be allowed to work until they had completed the in-service offering. The in-services placed an emphasis on pressure ulcer education, Neglect and Abuse education, and the Elder Justice Act. Additionally, licensed staff received education related to accurate wound documentation, wound care policy, correct staging of wounds, and assistive devices that may cause pressure wounds. Interviews were conducted on 12/27/11, with the Executive Director, the Director of Nursing (DON), the Regional Director of Clinical Services (RDCS), the Minimum Data Set (MDS) Coordinator, four State Registered Nursing Assistants (SRNAs), three Licensed Practical Nurses (LPNs), and two Registered Nurses (RNs). All interviews revealed staff had received re-education related to facility policies and procedures for wound care, assistive devices, oxygen administration, skin assessments, and Abuse/Neglect and demonstrated a working knowledge of their responsibilities. Review of the facility's file revealed the facility had not submitted their plan of correction for the identified deficiencies from the abbreviated survey of 12/12/11. Additionally, interviews conducted with the RDCS on 12/27/11, at 4:50 PM, with the Executive Director on 12/27/11, at 4:45 PM, and the DON on 12/27/11, at 4:10 PM, revealed performance improvement activities had been initiated; however, the facility needed to continue quality assurance activities to ensure compliance with established policies and procedures related to abuse/neglect, provision of care through care plan implementation, and pressure ulcer management after further re-education of staff.