Every finding on record at Fountain Circle Care & Rehabilitation Center

Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure residents were permitted to share a room with their spouse when both residents resided in the facility and both consented, for 2 of 2 sampled residents reviewed for roommate change, Resident (R)2 and R77.Although R2 and R77 had been married for 66 years and expressed the desire to reside together, there was no documented evidence the facility made reasonable efforts to accommodate the married couple's request prior to the Surveyor's intervention. This failure resulted in prolonged separation and psychosocial distress for both residents. The findings include:Review of the facility's policy titled Resident Rights, last review dated 01/2026, revealed residents have the right to share a room with their spouse when both spouses reside in the facility and both consent.Review of the facility's policy titled Room/ Roommate Change Notification Policy, last review dated 01/31/2026, revealed intra-facility transfers may be initiated if requested by the resident, and the interdisciplinary team (IDT) will participate in making all resident room location decisions.1.During concurrent observation and interview, on 04/27/2026 at 10:08 AM, R2 was noted to reside in room [ROOM NUMBER]. R2 became tearful and with a shaky voice stated, My wife is here, and they are supposed to put us in a room together. We are supposed to spend the rest of our lives here, and we should be able to room together. R2 further stated, I worry about my wife and would be happier with her in my room. In continued interview, R2 stated the facility had previously offered him a room change; however, because the room was not with his wife, he declined the transfer. Review of R2's Face Sheet, located in the Electronic Medical Record (EMR), revealed the facility admitted the resident on 02/19/2026 with diagnoses including acute kidney failure, and major depressive disorder.Review of R2's Resident Progress Notes, dated 02/25/2026 at 9:36 AM, written by the Social Worker, revealed during a care conference, R2 stated his wife would be moving in soon and he would like to share a room with her.Review of R2's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/26/2026, revealed the facility assessed R2 as having a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating R2 was cognitively intact.Review of R2's Comprehensive Care Plan, dated 03/11/2026, revealed the resident exhibited depression, including sadness, tearfulness, and self-isolation, and was identified as at risk for decline in psychosocial well-being. Interventions included allowing the resident to express feelings, involving social services, and monitoring for psychosocial changes. However, there was no documented evidence the facility care planned the resident's preference to reside with his spouse.Review of R2's Resident Progress Notes, dated 03/29/2026 at 6:37 PM, written by the Nurse Practitioner (NP), revealed R2 and R 77 had been married for 66 years, and resided together at their home before entering long-term care. Further review of R2's EMR, revealed no documented evidence the facility addressed R2's request to room with his spouse (R77), or attempted to accommodate or offer a shared room after R2's spouse was admitted on [DATE]. Additionally, there was no documented evidence the Interdisciplinary Team (IDT) participated in decision-making regarding the request. Also, there was no documented evidence R2 declined to share a room with R77.2.During concurrent observation and interview, on 04/28/2026 at 9:20 AM, R77 was noted to reside in room [ROOM NUMBER]. She stated, I want to be with my husband. We have been married 66 years, and it is hard to be apart. R77 further stated she believed her husband would be emotionally better if they were able to share a room.Review of R77's Face Sheet, located in the EMR, revealed the facility admitted the resident on 03/05/2026 with diagnoses including generalized anxiety disorder, major depressive disorder, unspecified mood disorder, and paradoxical insomnia.Review of R77's admission MDS with an ARD of 03/12/2026, revealed the facility assessed the resident as having a BIMS score of 14 out of 15, indicating intact cognition.Review of R77's Comprehensive Care Plan, dated 03/25/2026, revealed the resident exhibited altered mood state, including sadness, anxiety, and decreased interest in activities. Further review revealed the resident was identified as at risk for decline in psychosocial well-being. Interventions included encouraging social engagement, contact with family, and providing emotional support. However, there was no documented evidence the facility care planned the resident's preference to reside with her spouse (R2).Review of R77's Resident Progress Notes, dated 04/22/2026 at 11:00 PM, written by the Licensed Clinical Social Worker (LCSW), revealed R77 came to the facility to be closer to her husband, who was also a resident at the facility. Per the Note, R77's plan was for them to move into a room together once one became available. Additional review revealed the resident was experiencing significant anxiety, distress, poor sleep, and poor appetite related to concerns involving her living situation and her husband being unhappy at the facility. R77 was concerned that R2 wanted to go home, and she felt compelled to leave with him, despite recognizing she would be unable to care for him.Further review of R77's EMR, revealed there was no documented evidence the Interdisciplinary Team (IDT) participated in decision-making regarding the request for R77 to share a room with her husband (R2). Continued review of R77's EMR, revealed there was no documented evidence R77 declined to share a room with R2.During an interview with the Social Worker, on 04/28/2026 at 9:30 AM, she stated R77 voiced she was fine waiting on an available room. However, R2 had made multiple requests to share a room with spouse (R77), and had become upset with the delay, including threatening to leave the facility. The Social worker was questioned about the lack of documentation related to the residents' request to share a room, in the Interdisciplinary Team (IDT) notes. She stated since the facility was actively working on the room change and R77 was fine waiting for a room change, the IDT did not feel the need to address the situation in the IDT notes. During continued interview with the Social Worker, on 04/28/2026 at 9:30 AM, she stated the facility had not been able to accommodate the request due to census and room configurations with shared restrooms, and it was difficult to ask other residents to move rooms if they did not want to relocate. During continued interview she stated it would likely be several more weeks before the married couple could reside together. However, observation on 04/28/2026 at 10:30 AM, revealed staff were preparing to move R2 and R77 into a shared room. This was approximately one hour after the Surveyor's inquiry regarding R2 and R77's request to reside in the same room.Review of R2's Resident Progress Note, dated 04/28/2026 at 10:36 AM, written by the Social Worker, revealed the son of R2 and R77 was notified of the planned room change so the married couple could reside together. The documentation did not indicate the family representative voiced concerns or objections about the couple sharing a room.Review of R77's Resident Progress Note, dated 04/28/2026 at 12:42 PM, written by Licensed Practical Nurse (LPN) 1, revealed R77 was in positive spirits regarding moving to reside with her husband.During observation on 04/28/2026 at 2:30 PM, R2 and R77 were noted to be residing together in the same room. Interview was conducted with both residents at the time of observation. R2 stated he was upset with the room size and further stated, I thought the semi-private rooms would be bigger. Additionally, R2 stated the facility asked him to remove his recliner because it was too large for the room and the situation made him want to return home and take his wife with him.R77 stated she got tore up easily and further stated her husband's frustration with the facility and desire to return home caused her chest pain. However, R77 stated she could not care for R2 at home and believed remaining at the facility was the best decision for both residents. The State Survey Agency (SSA) Representative immediately notified nursing staff regarding R77's complaints of chest pain.Review of R2's Resident Progress Note, dated 04/29/2026 at 1:28 PM, written by the Social Worker revealed R2 expressed dissatisfaction with the room setup following the room change; however, R2 stated he was staying where his wife was.An interview with the son of R2 and R77, was conducted on 04/29/2026 at 2:35 PM, while R2 and R77 were residing together in the same room. The son voiced concerns about the room layout and whether the arrangement would adequately meet R2's preferences. However, he did not state the married couple should remain separated.Review of R77's Resident Progress Note, dated 04/29/2026, at 6:30 PM, written by LPN 1, revealed the facility sent R77 to the local Emergency Department due to chest pain related to issues with her husband. It further revealed R77 was diagnosed with a urinary tract infection and returned to the facility.Review of R77's Resident Progress Note, dated 04/30/2026 at 9:14 AM, written by the Social Worker, revealed both R2 and R77 expressed a desire to continue residing together in the same room.Review of R77's Resident Progress Notes, dated 04/30/2026 at 7:37 PM, written by the Social Worker, revealed R77 stated she would like to give another try to stay in the room with her husband.During an interview with State Registered Nurse Aide (SRNA)8, on 04/29/2026 at 11:00 AM, she stated R2 had visited his wife daily while they were in separate rooms and had made multiple requests since R77's admission to the facility to share a room with his wife. During an interview with LPN8, on 04/29/2026 at 11:50 AM, she stated R2 and R77 visited each other daily while in separate rooms, and both had requested, since R77's admission to the facility, to share a room. Further, R2 had stated in the past that he would go home if the facility did not allow him and his spouse to live together.During an interview on 04/29/2026 at 3:00 PM, the Unit Manager stated R2 and R77 requested to share a room together and visited each other daily while waiting for a room. During an interview with the Administrator, on 04/29/2026 at 2:50 PM, he stated it was not right to ask another resident to move rooms to accommodate R2 and R77 sharing a room, even though they were married. The Administrator further stated R77 had made no request to share a room with R2 and he did not think R77 wanted to reside with her spouse.In an interview with the Administrator, on 04/30/2026 at 1:00 PM, he stated the Director of Nursing and Nurse Practitioner who cared for R2 and R77 were off on extended leave and unable to be interviewed at this time.During an interview with the Medical Director, on 04/30/2026 at 2:46 PM, he stated that, unless a married couple had a medical or safety contraindication, the facility should accommodate the residents' request to reside together.

Based on interview, record review, and review of facility's policy, the facility failed to ensure pain management was provided consistently with professional standards of practice for 1 of 4 sampled residents reviewed for pain management, Resident (R)152.The facility failed to assess, monitor, and timely intervene for uncontrolled post-surgical pain following R152's admission to the facility on [DATE] after surgical repair of a right distal femur fracture. These failures resulted in R152 experiencing uncontrolled pain requiring Emergency Medical Services (EMS) transfer to the hospital Emergency Department (ED) for further evaluation and treatment.Additionally, R152 sustained a fall on 02/16/2026 and the Nurse Practitioner (NP) ordered an MRI of the lumbar and thoracic area due to increased pain. However, after learning R152's insurance would not pay for the MRI, the NP discontinued the MRI order. R152 continued to experience increased back pain which was not tolerable with the ordered analgesics. However, the facility did not intervene timely and R152's family member had to request the resident be transferred to the hospital ED due to increased back pain on 02/17/2026.The MRI at the hospital revealed the resident had a new fracture that required her to be at the hospital from [DATE] until 03/04/2026 for therapy. The findings include:Review of the facility's policy titled, admission Criteria, revised 10/31/2025, revealed the facility will admit residents who can adequately and safely be cared for and whose medical and psychological needs can be met. The policy further revealed the facility will address concerns of residents and families during the admission process. Additionally, the policy stated the facility will address concerns of residents and families during the admission process and will receive appropriate medical and financial records before or upon the resident's admission.Review of the facility's policy titled, Pain Management, revised 02/03/2025, revealed the facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Further review of the policy, revealed upon admission and re-admission, a pain evaluation would be completed for each resident. The facility would provide pain management interventions to a resident experiencing pain, provide pain management that meets professional standards of practice, and provide pain management that follows the resident's comprehensive care plan.Review of the facility policy titled, Medication Administration - General Guidelines, dated 09/2018, revealed when PRN (as needed) medications are administered, staff would document the date and time of administration, complaints or symptoms for which the medication was given, results achieved from the medication, and the time results were noted. The policy further stated staff would observe residents for medication actions/reactions and record them in the nurse's notes as appropriate.In accordance with the Kentucky Revised Status (KRS) 314.021(2), nurses are responsible and accountable for making decisions that are based upon the individual's educational preparation and current clinical competence in nursing and require licensees to practice nursing with reasonable skill and safety. Nursing practice should be consistent with the Kentucky Nursing Laws, established standards of practice, and be evidence-based.Review of R152's Face Sheet, located in the Electronic Medical Record (EMR), revealed the facility admitted the resident on 02/13/2026 with diagnoses including periprosthetic fracture around the internal prosthetic right hip joint, other fracture of the lower end of the right femur with routine healing, encounter for orthopedic aftercare following surgical repair of the right femur fracture, chronic pain syndrome, and age-related osteoporosis.Review of R152's Care Plan, created on 02/13/2026, upon admit, identified the resident had complaints of right leg pain. Interventions included administering medications as ordered; encouraging the resident to request pain medication; observing for nonverbal signs and symptoms of pain; repositioning for comfort, and notifying the physician as needed when pain management was ineffective.Review of R152's Baseline 48-hour care plan, dated 02/14/2026, identified a pain goal for the resident: have pain at a tolerable level. The care plan identified that the resident verbalized or exhibited signs of pain related to a surgical wound to the right leg. Interventions included assessing and observing for signs and symptoms of pain; elevating the affected area; repositioning for comfort; administering analgesics per physician order; assessing and observing the effectiveness of pain approaches; and notifying the physician if pain approaches were ineffective in maintaining the resident's pain at a tolerable level.Review of R152's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/14/2026, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating intact cognition and ability to communicate needs and concerns.Review of R152's hospital Discharge summary, dated [DATE] at 1:25 PM, revealed the resident required intravenous (IV) Dilaudid (a potent opioid medication used to treat moderate to severe pain) during the hospitalization for management of acute post-surgical pain following surgical repair of a right periprosthetic distal femur fracture. The summary revealed IV Dilaudid was discontinued before discharge. Review of the discharge medications revealed ongoing pain management orders including Acetaminophen 1000 milligrams (fever reducer and pain reliever for mild/moderate pain) every 6 hours; Gabapentin 200 milligrams (used as anti-convulsant or to treat nerve pain) every 8 hours; Methocarbamol 1000 milligrams (skeletal muscle relaxer) every 6 hours, and Oxycodone 10 milligrams (powerful opioid medication used to treat severe pain) every 4 hours as needed for severe pain for up to 3 days.Review of R152's Hospital After Visit Summary, dated 02/13/2026 at 2:30 PM, revealed the resident received her last dose of Oxycodone 10 milligrams on 02/13/2026 at 11:31 AM.Review of R152's Admission/re-admission Report Sheet, dated 02/13/2026, at 2:30 PM, written by Licensed Practical Nurse (LPN)9, revealed R152 received Oxycodone 15 milligrams before transfer to the facility. The report further revealed the resident rated pain at a 10 out of 10 (meaning the highest level of pain) at the hospital.Review of R152's Resident Progress Note, dated 02/13/2026 at 6:55 PM, written by LPN9, revealed approximately 17 minutes after admission, the resident complained of pain rated at 9/10. The note revealed LPN9 contacted the after-hours physician and obtained a one-time dose of Oxycodone 5 milligrams from the emergency kit.Review of the [Facility Name] Narc Box updated 04/29/2024, revealed the facility had 6 Oxycodone/APAP 5/325mg Tablets in their emergency kit. Further, the document revealed that on 02/13/2026, a tablet was removed for R152. However, review of R152's Medication Administration History for 02/01/2026-02/28/2026, revealed the facility failed to document a follow-up pain assessment after administering the one-time order for Oxycodone 5mg on 02/13/2026 at 6:37 PM to indicate if the medication was effective for pain control.Review of R152's admission Pain Assessment, dated 02/13/2026 at 7:14 PM, revealed the resident reported pain frequently, rated pain 9/10, and reported pain interfered with therapy participation and day-to-day activities. This assessment occurred approximately 37 minutes after administration of PRN (as needed) Oxycodone 5 milligrams. Interview with LPN9, on 04/30/2026 at 3:54 PM, confirmed R152 was experiencing leg pain upon admission to the facility. LPN9 stated the pharmacy had not yet delivered R152's medication; therefore, she contacted the chronic pain management physician, who ordered Oxycodone 5 mg, which was one-half of the Oxycodone 10 mg dose ordered upon admission. LPN9 confirmed the only intervention implemented at that time was administering the reduced dose of pain medication.During an interview, on 04/29/2026 at 1:00 PM, LPN6 stated on 02/13/2026, the nurse from the previous shift reported administering PRN pain medication to R152 before shift change. LPN6 stated R152 continued to complain of pain; however, she did not complete a follow-up pain assessment and did not notify the physician the PRN pain medication was ineffective. LPN6 verified the resident's pain medications had not arrived during her busy shift, and she did not have the medications sent stat because the nurse on the previous shift had already sent the order in for the medications.During an interview, on 04/30/2026 at 5:44 PM, the Chronic Pain Physician stated R152 was admitted to the facility from the hospital and experienced pain upon admission. The Physician stated facility staff contacted him to request an emergency box (E-box) order for pain medication because the pharmacy had not yet delivered the resident's prescribed medications. He stated he understood R152 had received intravenous (IV) pain medication at the hospital before transfer; however, because he was unsure which pain medication the resident had previously received, he ordered Oxycodone 5 mg. When questioned what staff should do if a resident continued to experience pain after receiving pain medication, the physician stated staff should re-evaluate the resident and notify the physician if the medication was ineffective. An audio review of the 911 call placed on 02/13/2026 at 8:49 PM, revealed R152's family member called and reported the resident was in extreme pain, the facility did not have the resident's prescribed medications, and reported the medications would not be at the facility until after midnight. The family member stated, I can't leave her here in pain like this. Review of the hospital Emergency Department (ED) Discharge summary, dated [DATE] at 9:37 PM, revealed R152 presented via EMS with complaints of right leg pain following recent surgical repair of a femur fracture. Per the Summary, the resident stated she had not received pain medication from approximately noon until arrival at the facility and reported the facility was not managing her pain. Further, the resident reported her right leg was in tremendous pain from missing multiple doses of pain medication. Continued review of the hospital Summary, revealed nursing staff contacted the facility and confirmed R152's medications would not be available until approximately 2:00 AM. Review of the ED orders, revealed R152 received Fentanyl 50 micrograms intravenously (IV) at 9:42 PM (Fentanyl is a powerful synthetic opioid for use as an analgesic), Methocarbamol 500 milligrams by mouth at 10:19 PM, Gabapentin 300 milligrams by mouth at 10:19 PM, an additional dose of Fentanyl 50 micrograms IV at 10:42 PM, and Percocet 5/325 milligrams by mouth at 12:12 AM for pain management before return to the facility on [DATE] at 12:45 AM.In an interview with R152, on 04/29/2026 at 9:00 AM, she stated she was admitted to the facility following hospitalization for a femur fracture and experienced significant pain upon admission. R152 stated she requested pain medication shortly after arrival, and LPN 3 informed her the medication had not yet arrived from the pharmacy. R152 further stated nursing staff obtained one pain pill from the emergency kit; however, the medication did not adequately control her pain. In continued interview, R152 stated she was informed by nursing staff that additional medication would not arrive until later that night, and she could go home or take herself to the ED. R152 stated her family ultimately called 911 due to her uncontrolled pain.In an interview on 04/29/2026 at 8:45 AM, Family Member (FM)1 stated when R152 arrived at the facility on 02/13/2026, she was in extreme pain and had no pain medication available at the facility. FM1 stated nursing staff contacted the physician and administered Oxycodone 5 mg; however, it was not even close to the pain medication regimen the resident had previously received at the hospital. FM1 further stated R152 was crying in tears from pain, and the nursing staff informed the family the resident's medications would not arrive until 02/14/2026 at approximately 1:00 AM, and the medication carrier delivered medications to the facility every 12 hours. In continued interview, FM1 staff informed them that if they did not like the care provided, they could take the resident home or to the hospital ED. FM1 stated he, and FM2, decided to send the resident to the hospital ED due to uncontrolled pain. During an interview, on 04/28/2026 at 2:34 PM, the Unit Manager stated residents' medications called in as a STAT order had a four-hour turnaround time; however, the facility failed to order R152's medications as STAT on admission. The Unit Manager further stated staff should have completed a follow-up pain assessment one hour after R152 received pain medication to evaluate the effectiveness of the PRN Oxycodone 5 milligrams dose given on 02/13/2026 at 6:37 PM. Additionally, the Unit Manager stated staff should have notified the Nurse Practitioner (NP) or physician if R152 continued to experience pain or received no relief after pain medication administration.During an interview with the Pharmacist, on 04/30/2026 at approximately 4:00 PM, he stated R152's medications were not processed as stat orders on 02/13/2026. The Pharmacist stated STAT medication orders generally had an approximate four-hour turnaround time; however, R152's medications were not ordered STAT and were delivered sometime between approximately 2:00 AM and 5:00 AM on 02/14/2026. Further, the Pharmacist stated the exact delivery time could not be determined because the facility did not document the time medications were received. However, he believed delivery likely occurred closer to the later timeframe. The Pharmacist confirmed with this delivery R152 received Tylenol, Gabapentin, Robaxin, and Oxycodone 10 mg. The Pharmacist further confirmed Oxycodone 5 mg was removed from the emergency box on 02/13/2026, at approximately 6:37 PM.During an interview with the Administrator, on 04/28/2026 at 2:17 PM, he stated the facility attempted to ensure residents had the necessary medications and equipment before admission and relied on the hospital to administer the resident's last scheduled medication of the day before discharge. The Administrator stated nursing staff had administered pain medication to R152, and the resident continued to complain of pain. Further, the Administrator explained R152 could not receive additional medication at that time, and the resident or family subsequently called 911.During an interview, on 04/30/2026 at 2:50 PM, with the Medical Director, he stated transportation and transfer processes often increased a resident's pain level and residents were frequently in more pain after transfer than before discharge from the hospital. He stated he would have attempted to provide a pain medication dose equivalent to the resident's admitting ordered dose on 02/13/2026. The Medical Director further stated staff should have contacted the physician or Nurse Practitioner to discuss additional interventions when the resident continued to experience pain after medication administration. The Medical Director stated he would have sent the resident back to the hospital for further evaluation and treatment. Additionally, the Medical Director stated he would not want a situation like this for his patients or his own loved ones. 2. Review of R152's Resident Progress Notes, dated 02/16/2026 at 12:43 AM, written by LPN6, revealed scheduled Robaxin, Gabapentin, and Tylenol were effective for pain.Review of R152's Resident Progress Notes, dated 02/16/2026 at 8:00 AM, written by LPN8, revealed the resident was found on the floor after attempting to get up independently and complained of lower back pain. Per the note, the facility's Nurse Practitioner (NP) ordered lumbar and thoracic x-rays following the incident.Review of R152's Physical Medicine and Rehabilitation Initial Evaluation, dated 02/16/2026 at 11:54 AM, written by the Chronic Pain Management Physician, revealed R152 was experiencing pretty significant pain upon admission due to the pharmacy's failure to deliver medications. The physician further documented the resident was at high risk for functional impairment, contractures, pressure ulcers, poor healing, or additional falls without adequate therapy and pain control. The Physician documented the resident had a fall that morning and voiced a little bit of back pain. He further documented R152's pain appeared relatively well controlled at that time and recommended staff continue to monitor pain and adjust as necessary during the rehabilitation process.Review of R152's Resident Progress Note, dated 02/17/2026 at 10:57 AM, written by LPN 3, revealed the lumbar and thoracic spine x-ray results were received and identified as abnormal. The note revealed the NP received notification of R152's abnormal results and ordered an MRI (Magnetic Resonance Imaging-medical imaging technique using strong magnetic fields and radio waves to generate detailed 3D images of soft tissues, organs and bones) of the lumbar and thoracic area.Review of the Resident Progress Note, written by LPN3, on 02/17/2026 at 1:26 PM, revealed LPN3 contacted the NP regarding R152's insurance not covering the payment for MRI of the lumbar and thoracic area. The note further revealed the NP discontinued the MRI order and instructed staff to observe for worsening symptoms.During an interview on 04/29/2026 at 3:34 AM, the Unit Manager stated R152's insurance would not cover the cost of the MRI; therefore, the NP canceled the order and entered a new order to monitor the resident for worsening symptoms.Review of the Physical Therapy Treatment Encounter Note, dated 02/17/2026, at 5:34 PM, revealed R152's X-rays identified an L1 compression deformity following the resident's fall. The note revealed R152 appeared depressed, declined further participation in therapy, requested to remain in bed, and was tearful with increased lower back pain.During an interview on 04/29/2026 at 2:00 PM, the Physical Therapy Assistant (PTA) stated minimal therapy was completed with Resident 152 on 02/17/2026 due to back pain. The PTA further stated Resident 152 was having a lot of pain.R152's Controlled Medication Administration Record, reflected PRN (as needed) pain medication administration following the resident's fall on 02/16/2026. Oxycodone 10 milligrams was administered on 02/16/2026 at 8:45 AM; at 1:42 PM; and 8:25 PM; on 02/17/2026 at 4:00 AM; on 8:03 AM; and 1:13 PM (Resident transferred to the hospital ED on 02/17/2026; but received PRN pain medication three times prior to being transferred on that date)However, further review of the EMR, revealed additional intervention for pain management did not occur until FM2 requested the resident be transferred to the ER for further evaluation due to increased back pain.Review of R152's Resident Progress Note, written by the NP, on 02/17/2026 at 10:12 PM, revealed thoracic spine x-rays identified compression deformity, and lumbar spine x-rays identified significant compression deformity at the L1 vertebrae. Per the note, R152 continued to report increased low back pain. The NP explained the L1 compression deformity indicated loss of vertebral height due to compressive force, and imaging could not determine whether the injury was new or old. The note further revealed FM2 requested the resident be sent to the hospital ED for further imaging due to increased back pain.Review of the hospital Emergency Department Discharge records, dated 02/17/2026, revealed the patient (R152) continued to complain of persistent back pain following the fall at the facility. Additional imaging identified a T1 compression fracture and T5 superior endplate fracture, and trauma surgery admitted the resident for pain control and further evaluation.Review of R152's hospital Discharge Summary, revealed the hospital admitted the resident on 02/17/2026 and discharged her on 03/04/2026. Hospital documentation further revealed R152 expressed emotional distress related to her experience at the rehabilitation facility and the fall. Further review revealed R152 completed rehabilitation services in the hospital setting following hospitalization. R152 requested rehabilitation in the hospital setting due to concerns related to the resident's previous rehabilitation experience and the trauma reportedly experienced during the prior rehabilitation stay.During an interview on 04/29/2026 at 11:50 AM, LPN8 stated she cared for Resident 152 on 02/16/2026, the day the resident sustained the fall. LPN8 stated R152 attempted to ambulate alone in the room and fell. She stated after the fall, R152 experienced anxiety and verbalized increased lower back pain that required more frequent prn pain medication. LPN 8 further stated FM2 called and requested R152 be transferred to the hospital ED for further evaluation due to increased back pain.During an interview on 04/29/2026 at 8:45 AM, FM1 stated he contacted the local emergency department and provided details regarding R152's fall and new onset of back pain, at which time the emergency department staff suggested the resident come to the hospital for further evaluation. FM1 further stated FM2 contacted the NP regarding concerns with R152's increased back pain.During interview with R152, on 04/29/2026 at 9:00 AM, she stated following the fall on 02/16/2026, she developed worsening back pain, had increased difficulty getting out of bed, and she experienced increased pain with movement. She stated the medication regimen was no longer effective, and she required more frequent Oxycodone administration, which temporarily relieved the pain. However, she stated the pain returned quickly. In further interview, R152 stated she felt staff failed to acknowledge her complaints of pain, which made her feel unseen and unheard. R152 further stated she felt staff perceived her as only wanting pain pills.During an interview on 04/28/2026, the Administrator stated the facility was responsible for payment of medical services not covered by the resident's insurance, which would include an MRI. Further interview revealed the NP agreed to send R152 to the ER following the family's request for an additional evaluation, at which time the resident ultimately received the MRI.

Based on observation, interview, and review of the facility's policy, the facility failed to prepare and serve food in accordance with professional standards for food service safety. This had the potential to affect all residents who consume food from the kitchen. The findings include:Review of the facility's policy untitled and undated revealed all aprons were to be worn in kitchens while prepping food. Further review of the untitled and undated policy revealed aprons were not to be worn in halls, outside, and/or bathrooms at any time.Observation on 04/28/2026 at 3:40 PM, revealed [NAME] 1 was exiting the restroom wearing an apron. Observation of the same restroom in which Cook1 had exited, on 04/28/2026 to 3:42 PM, revealed there was no hanger on the back of the restroom door. During an interview, located in the facility's kitchen, with [NAME] 1, on 04/28/2026 at 3:44 PM and at 3:52 PM, he stated he took his apron off and hung it on the back of the door. In continued interview, he stated he should have taken the apron off prior to entering the restroom as there was the potential for cross contamination. During an interview with the Dietary Manager, on 04/28/2026 at 3:52 PM, he stated it was against policy to wear aprons into the restroom. He further stated there was the potential for cross contamination if a staff member failed to remove an apron prior to entering a restroom.During an interview with the Infection Preventionist (IP)/Staff Development Coordinator (IP/SDC), on 04/29/2026 at 1:47 PM, she stated it was an infection control issue and there was the potential for cross contamination if wearing an apron into the restroom.During an interview with the Director of Nursing (DON), on 04/30/2026 at 10:44 AM, she stated it was her expectation for staff to follow facility policies. During an interview with the Administrator, on 04/29/2026 at 3:55 PM, he stated due to the potential for cross contamination, aprons should not be worn into public rest rooms. He further stated this was an infection control issue.

Based on observation, interview, record review, review of the facility's policies, review of the Quality Assurance/Quality Assurance and Performance Improvement (QA/QAPI) Committee minutes, and review of the facility's Plan of Correction (PoC), the facility failed to maintain a QA/QAPI Program that developed and implemented appropriate plans of action to correct quality deficiencies. This was evidenced by repeat deficiencies related to the facility's failure to ensure there was an effective pain management program and infection control program. The facility failed to thoroughly perform an audit process, and the QAPI Committee failed to provide effective oversight and follow-up of identified concerns. This deficient practicelimited the facility's ability to ensure pain management was provided to residents who required such services and limited the ability to identify and correct problems related to infection control practices that had the potential to affect all residents. Therefore, the facility failed to have an effective functioning QAPI/QAA monitoring and governance system.The findings include:Review of the facility's policy titled Quality Assurance and Performance Improvement [QA/QAPI], undated, revealed the facility would develop, implement, and maintain an ongoing facility-wide QA/QAPI program designed to pursue quality of care actively.Review of the facility's PoC submitted for the 04/30/2026 Recertification Survey revealed the Facility Consultant re-educated the Administrator, Director of Nursing (DON), Unit Managers (UM), and the Infection Preventionist/Staff Development Coordinator (IP/SDC) on the Pain Management Policy and Medication Administration Policy.Review of the facility's PoC, dated 05/14/2026, indicated the DON or Unit Managers would assess five randomly selected residents to ensure pain was managed and all as-needed (PRN) pain medication administration was received, with follow-up to ensure effectiveness. The audits were weekly for four weeks, then every other week for four weeks, and then monthly for one month. Results of the audits were presented to the QA/QAPI Committee for review. Review of the facility's PoC, submitted for the 04/30/2026 Recertification Survey, revealed the Facility Consultant re-educated the Administrator, DON, Unit Managers (UMs), and IP/SDC on the Infection Control Policy and Enhanced Barrier Precautions Policy.Review of the facility's PoC, dated 05/14/2026, indicated the DON or IP/SDC would ensure ongoing monitoring of infection control practices once a week for four weeks, then once a month for two months. The audit results were referred to the QA/QAPI Committee to determine whether additional actions were needed. The QA/QAPI Committee included: the Administrator, Medical Director, DON, Assistant Director of Nursing (ADON), IP/SDC, Plant Operations Director (POD), Social Services Director (SSD), Activity Director (AD), Therapy Director (PT), Minimum Data Set Coordinator (MDS), and Business Office Manager (BOM). Further review of the facility's PoC, dated 05/14/2026, revealed starting on 05/15/2026, the Administrator would hold a weekly QA/QAPI meeting for four weeks, then monthly, to provide recommendations and further follow-up regarding the PoC. Initial audits would be reviewed during the QA/QAPI meeting on 05/22/2026 to ensure 100 percent compliance, and then at each QA/QAPI meeting for three months.Additional review of the PoC, dated 05/14/2026, revealed starting on 05/15/2026, the Administrator would hold a weekly QA/QAPI meeting for four weeks, then monthly, to provide recommendations and further follow-up regarding the PoC. Initial Infection Control and Pain audits would be reviewed during the QA/QAPI meeting on 05/22/2026 to ensure 100 percent compliance, and then at each QA/QAPI meeting for three months.Review of the QA/QAPI Committee meeting sign-in sheet and minutes, dated 05/15/2026, for an ad hoc QA/QAPI meeting, revealed the Medical Director, Interim Administrator, Interim DON, SCC, Director of Regulatory Compliance, UMs, and Advanced Practice Registered Nurse (APRN) were in attendance. The agenda included a discussion of the Infection Control and Pain Management PoCs.Review of the QA/QAPI Committee meeting sign-in sheet and minutes for a meeting held on 05/22/2026, revealed the Medical Director, Interim Administrator, Interim DON, SSD, BOM, and MDS Coordinator were in attendance. The agenda included a discussion on the PoC and related Infection Control and Pain Management audits.Review of the QA/QAPI Committee meeting sign-in sheet and minutes for a meeting held on 05/29/2026, revealed the Interim Administrator, SSD, Maintenance Director, and MDS Coordinator were in attendance. The agenda included a discussion on the PoC and related Infection Control and Pain Management audits.Review of the QA/QAPI Committee meeting sign-in sheet and minutes for a meeting held on 06/05/2026, revealed the Interim Administrator, Interim DON, SSD, and SCC were in attendance. The agenda included a discussion on the PoC and related Infection Control and Pain Management audits.During the On-site Revisit Survey concluded on 06/12/2026, the following deficient practice was identified:1a. The facility failed to assess, monitor, and timely intervene for uncontrolled post-surgical pain after R310's admission to the facility on [DATE], after a closed right fracture of the shaft of the fibula. Although pain medication was ordered, nursing staff failed to obtain the medication from the available emergency medication resources [Facility Name] Narc Box (E-box), to provide timely pain relief. Consequently, R310 did not receive prescribed pain medication until approximately 8 hours and 40 minutes after admission.1b. The facility failed to assess, monitor, and timely intervene for uncontrolled post-surgical pain after R301's admission to the facility on [DATE] after bilateral knee replacement with septic arthritis with bilateral wound vac placement, multiple lower extremity abscesses, and osteomyelitis. Although pain medication was ordered, the nursing staff failed to obtain the medication from the available E-box to provide timely pain relief. Consequently, R301 did not receive prescribed pain medication until approximately 9 hours after admission.1c. The facility failed to assess, monitor, and timely intervene for uncontrolled post-surgical pain after R302's admission to the facility on [DATE], after an open reduction internal fixation of the left ankle and tibia/fibula fracture of the left leg. Although pain medication was ordered, the nursing staff failed to obtain the medication from the available E-box to provide timely pain relief. Consequently, R302 did not receive prescribed pain medication until approximately 21 hours and 37 minutes after admission.2a. During an observation on 06/09/2026 at 9:10 AM, in the A-Wing, the Assistant Business Office Manager (ABOM) walked into Resident (R) 300's room to pass ice. The resident was on Contact Isolation precautions for Extended-Spectrum Beta-Lactamases (ESBL) in a wound. The ABOM failed to don (put on) the required personal protective equipment (PPE) prior to entering the room. The ABOM picked up R300's water pitcher, exited the room with R300's water pitcher in her hand, did not perform hand hygiene, and went directly to the shared ice bin, where she opened the lid and handled the ice scoop to obtain ice.2b. During an observation on 06/09/2026 at 9:19AM, LPN9 entered room [ROOM NUMBER] and obtained vital signs and then administered medications to R36. No hand hygiene was observed prior to resident contact. LPN9 then failed to perform hand hygiene prior to proceeding directly to R127, who was on EBP. She donned gloves but did not don a gown before she assessed vital signs, performed a blood glucose check, and administered medications to R127. Following completion of care, the LPN exited the room without sanitizing the vital sign equipment.2c. During an observation on 06/09/2026 at 10:10 AM, LPN9 was observed inside an EBP room providing direct care to R83, who was on EBP for a wound. The LPN donned gloves but was not wearing a gown. LPN9 obtained vital signs, performed a blood glucose check, and administered medications to R83.2d. During an observation on 06/09/2026 at 12:02 PM, LPN9 performed a fingerstick on R73, who was on EBP for a wound. LPN9 then failed to clean and disinfect R73's glucometer according to facility policy and the cleaning product's manufacturer's recommendations. LPN9 also failed to clean and disinfect a contaminated timer after use.2e. During an observation on 06/10/2026 at 9:10 AM, Physical Therapy Assistant (PTA)1 provided direct care in the Physical Therapy Department to R300, who was on contact isolation precautions for ESBL in a wound. PTA1 was not wearing any PPE. PTA1 was working with R300 using a resistance band, maintaining direct physical contact with the resident. At one point, the resistance band fell onto the floor. The PTA then picked it up and continued using it on the resident without first cleaning and disinfecting the band.During an interview on 06/10/2026 at 3:51 PM, Unit Manager (UM) 1 and UM2 each stated they provided nursing staff and State Tested Nursing Assistants (STNAs) infection control education, including EBPs, Transmission Based Precautions (TBPs), and hand hygiene. However, UM1 and UM2 both stated they did not complete formal infection control audits.During a telephone interview with the IP/SDC, on 06/11/2026 at 6:24 PM, she stated she participated in the development of the facility's PoC, including reviewing infection control deficiencies, developing corrective actions, and preparing staff education plans and post-tests. The IP/SDC stated the facility conducted weekly ad hoc meetings related to the PoC, which she attended.During continued telephone interview with the IP/SDC, on 06/11/2026 at 6:24 PM, she stated infection prevention and control education was provided to all staff, including licensed nurses, STNAs, physical therapy staff, housekeeping staff, the business office staff, and other ancillary departments. The IP/SDC stated education included hand hygiene, PPE use, TBP, EBP, and isolation signage. The IP/SDC stated staff completed post-tests and were re-educated if they did not demonstrate competency.The IP/SDC further stated she conducted direct observation audits of the facility's nursing staff, STNAs, and therapy staff to ensure compliance with PPE use, hand hygiene, and IPC practices. The IP/SDC stated she did not audit ancillary staff due to limited opportunities to enter resident rooms and was unable to observe business office personnel entering resident rooms during the audit periods. Furthermore, she stated no breaks in IPC practices were identified during the audits.During an interview, on 06/12/2026 at 1:00 PM, with the Interim DON, she stated she provided staff in-service training on EBP and isolation precautions. She stated staff was instructed to read and follow posted isolation signage, and she used examples of different isolation signs during the education to demonstrate the differences between them. She further stated she expected the staff to follow the instructions on the signs. Additionally, she stated she and the Unit Managers completed the nursing audits. She also stated the Staff Development Coordinator conducted audits but was primarily involved in staff training and education activities.During additional interview, on 06/12/2026 at 1:00 PM, with the Interim DON, she stated she attended QA/QAPI Committee meetings on 05/15/2026, 05/22/2026, and 06/05/2026. She stated discussions during those meetings included the facility's PoC and ongoing audits. The Interim DON stated no concerns regarding audit findings were identified or discussed during the meetings.During an interview, with the Medical Director, on 06/12/2026 at 1:20 PM, he stated he participated in discussions with facility leadership about the PoC following the previous Recertification Survey. He stated the deficiencies and concerns identified during the survey were reviewed in QA/QAPI meetings, where the team discussed strategies to achieve compliance. The Medical Director stated he attended all meetings either in person or by phone. The Medical Director further stated the QA/QAPI Committee's recent discussions focused on deficiencies in pain management and infection control. In addition, during the meetings they reviewed existing processes, identified opportunities for improvement, and developed interventions to address survey concerns.Further, the Medical Director stated the purpose of the QA/QAPI program was to identify areas needing improvement, review quality concerns, and implement corrective actions to enhance resident care. During additional interview with the Medical Director, on 06/12/2026 at 1:20 PM, he stated the QA/QAPI team members were responsible for communicating information from meetings to their respective departments and for monitoring compliance through observation and follow-up, including ensuring staff received appropriate education, understood expectations, and had the resources needed to comply with facility policies and procedures. He stated staff was expected to understand practices such as transmission-based precautions, proper donning and doffing of personal protective equipment, and the significance of isolation signage. He further stated staff should not only follow posted signs. but also understand the rationale behind them, noting additional education, demonstrations, and role-playing activities might be necessary to ensure competency.Furthermore, during continued interview with the Medical Director, on 06/12/2026 at 1:20 PM, he stated the QA/QAPI processes should ensure staff was educated and supported in making appropriate clinical decisions related to pain management. He stated he expected staff to promptly assess and treat pain using available resources to obtain medications when needed. The Medical Director further stated delays in pain management should be identified through the QA/QAPI process and addressed through corrective actions, staff education, and ongoing performance improvement efforts.During an interview with the Interim Administrator, on 06/12/2026 at 1:47 PM, he stated he attended all QA/QAPI Committee meetings and was involved in monitoring the PoC dated 05/14/2026. He stated he reviewed audits related to pain management and infection prevention and control. The Interim Administrator stated he had no concerns regarding the QA/QAPI process, education, or audits regarding the PoC. During further interview with the Interim Administrator, on 06/12/2026 at 1:47 PM, he acknowledged ongoing infection control concerns and stated QA/QAPI should evaluate whether audits, education, and interventions had been effective. Additionally, the Interim Administrator acknowledged concerns related to pain management and pharmacy delivery delays. He stated these concerns should have been evaluated through the QA/QAPI process by reviewing current practices, identifying process breakdowns, and implementing corrective actions when systems were ineffective. During additional interview with the Interim Administrator, on 06/12/2026 at 1:47 PM, the department leaders were expected to communicate QA/QAPI decisions to their staff and ensure corrective actions were implemented. When concerns were identified, leadership should determine the root cause to determine whether staff received adequate education, had the necessary resources, and understood expectations. He acknowledged drive-by training was ineffective and stated staff may require demonstrations, return demonstrations, and role-play to ensure competency.

Based on observation, interview, record review, and review of facility policy, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 8 sampled residents reviewed for infection control, Resident (R)71. The findings include:Review of the facility policy titled Enhanced Barrier Precautions, revised 03/25/2024, revealed This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The policy further revealed EBP are indicated for residents who have chronic wounds and or indwelling medical devices regardless of MDRO [multidrug-resistant organisms] statusReview of R71's Face sheet, located in the Electronic Medical Record (EMR), revealed the facility admitted the resident on 04/09/2026 with a diagnosis of end stage renal disease and dependence on renal dialysis.Observation on 04/27/2026 at 10:15 AM, revealed R71 had a dialysis catheter; however, there was no EBP signage posted on the door or the wall outside the resident's room to alert staff, visitors and other residents of the need for gown and glove use during high contact activities.During an interview on 04/27/2026 at 10:35 AM, with Licensed Practical Nurse (LPN) 4, she stated R71 should be in EBP. She stated all residents requiring hemodialysis who have external access should be in EBP to prevent the spread of germs.Review of R71's Care Plan, revealed the resident was care planned for requiring EBP related to dialysis catheter on 04/27/2026. Interventions, dated 04/27/2026, included: attempt to maintain environment cleanliness; disinfect high touch surfaces as able, PRN (as needed), PPE (personal protective equipment) as indicated; and report to physician signs and symptoms of infection as needed.However, R71 was not care planned for EBP until 04/27/2026, the date of State Survey Agency (SSA) entry.Review of R71's Orders, revealed an order for EBP was entered on 04/27/2026 at 3:36 PM. These orders were written the date of SSA entry.During an interview on 04/29/2026 at 2:27 PM, with LPN5, he stated he checked the resident's profile and signage and diagnosis to determine what PPE should be used when caring for a resident. He stated everyone should be checking for infection prevention and control to keep the residents and the staff free from infection. He further stated he thought R71 had EBP signage on the door all along.During an interview on 04/30/2026 at 9:25 AM, with the Infection Preventionist/Staff Development Coordinator (IP/SDC), she stated she was responsible for ensuring the resident had the correct precautions signs in place, and she followed an isolation grid and Centers for Disease Control and Prevention (CDC) guidelines. She stated anyone with a chronic wound, line or drain not natural to their body, or multidrug-resistant organism required EBP. She stated R71 should have been in EBP on admission as this was important to protect the residents and others.During an interview on 04/30/2026 at 10:35 AM, with the Interim Director of Nursing (DON), she stated it was her expectation for signage to be posted related to residents in EBP and for staff to wear the appropriate PPE when caring for residents with EBP. She stated this was important for infection control. Further, she stated to her knowledge, any resident with a foreign device should be in EBP.During an interview on 04/30/2026 at 10:45 AM, with the Administrator, he stated precaution signs should be hung when needed including appropriate signage for a resident with a dialysis catheter and signage should be followed to decrease the risk of infections.

Based on observation, interview, review of facility policy, and review of manufacturer's recommendations, the facility failed to ensure drugs and biologicals were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 3 medication refrigerators reviewed, Hall B refrigerator. The findings include:Review of the facility's policy titled Medication Storage, dated 01/2025, revealed Medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations, to keep their integrity and to support safe, effective Drug Administration.Observation on [DATE] at 10:23 AM, of the Hall B, medication refrigerator, revealed a vial of Tuberculin Purified Protein Derivative (Tubersol) was opened and undated.Review of the manufacturer's guidelines, revealed A vial of Tubersol which has been entered and in use for 30 days should be discarded.During an interview, on [DATE] at 2:15 PM, with Licensed Practical Nurse (LPN) 7, she stated multidose vials should be dated upon opening because they were time sensitive after opening. She stated this was important for infection control purposes.During an interview, on [DATE] at 2:27 PM, with LPN5/Unit Manager, he stated any multidose vial that had been opened should be dated at the time it was opened in order for staff to know when to discard the medication.During an interview, on [DATE] at 9:25 AM, with the Infection Preventionist (IP)/ Staff Development Coordinator (IP/SDC), she stated when a new medication was opened, it should be dated in order for staff to know it was still good, and to know when to discard it.During an interview, on [DATE] at 10:35 AM, with the Interim Director of Nursing (DON), she stated it was her expectation medications would be dated when they were opened to ensure residents were receiving medications that was not expired.During an interview, on [DATE] at 10:45 AM, with the Administrator, he stated it was his expectation medications were dated when opened to ensure residents were not administered expired doses.

Based on observation, interview, and review of the facility's policy, the facility failed to promote and facilitate resident self-determination through support of resident's choice related to getting out of bed for 1 of 3 sampled residents investigated for resident choices, Resident (R) 7.The findings include:Review of the facility's policy titled, Resident Rights, revised 01/31/2025, revealed All residents have the right to be treated with respect and dignity. These rights will be promoted and protected by the facility. All residents will be treated in a manner and in an environment that promotes maintenance or enhancement of quality of life. When providing care and services, the stakeholders will respect the resident's individuality and value their input by providing them a dignified existence, through self-determination and communication with and access to persons and services inside and outside the facility.Review of R7's Face Sheet, located in the Electronic Medical Record (EMR), revealed the facility admitted the resident on 10/25/2024 with diagnoses of muscle weakness, difficulty walking, lymphedema, need for assistance with personal care, depression, and anxiety.Observation of R7 on 04/27/2026 at 10:18 AM; 04/28/2026 at 12:40 PM; 04/29/2026 at 8:57 AM; and 04/30/2026 at 9:00 AM, revealed the resident was in bed. Interview with R7 during these observations, revealed he had not been offered assistance to get out of bed.During further interview with R7, on 04/29/2026 at 8:57 AM, he stated, it would be nice to get offered to get up, not that I would want to everyday, but I would like to have the option. R7 stated he was very seldom asked if he wanted to get out of bed. He further stated he was not offered Monday (04/27/2026), Tuesday (04/28/2026), or Wednesday (04/29/2026).Review of R7's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) 02/20/2026, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicting intact cognition.Review of R7's Comprehensive Care Plan, dated 11/14/2024, revealed the resident was at risk for social isolation. Interventions included invite or encourage to attend activity groups or choice as tolerated; provide activity opportunities that meet the resident's interests; and provide assistance to/from activities of choice as needed (all interventions dated 11/14/2024).Review of R7's Physical Therapy Treatment Encounter Note, dated 12/11/2025, revealed the mechanical lift continued to be used for out of bed transfers.During interview, on 04/29/2026 at 9:00 AM, with State Registered Nurse Aide (SRNA)7, she stated she was the aide assigned to R7 this shift, and she had not offered to assist the resident up during this shift. She stated the SRNAs were given a list of residents to assist up for the day and R7 was not on this list. When asked who provided the list, she stated it was passed on from the previous shift and she thought the Unit Manager was the one who made the list. She stated SRNAs should ask all residents if they would like to get up each day.During an interview, on 04/29/2026 at 10:25 AM, with SRNA1, he stated he was made aware of which residents to assist up out of bed by the nurses or the aides from the previous shift. He stated he also had a list of which residents to assist out of bed. SRNA1 further stated he assisted the residents who were on the list up out of bed, but did not offer to assist all the residents out of bed. Further, he stated he had not assisted R7 out of bed. During an interview, on 04/29/2026 at 10:41 AM, with SRNA10, she stated she was given a list of residents to get up and that was who she would assist out of bed. She stated LPN5 would make the list. Additionally, she stated if any other residents asked to get up, then she would get them up upon their requests. SRNA10 stated she did not ask R7 if he wanted to get up and did not know the reason.During an interview, on 04/29/2026 at 2:15 PM, with LPN7, she stated residents should be offered to be assisted up and out of bed every day because they should always be given an option, and if they refused then their refusal should be documented.During an interview, on 04/29/2026 at 9:10 AM, with Licensed Practical Nurse (LPN)5/Unit Manager, he stated R7 should be offered to be assisted up out of bed every day because all residents should have this choice. He stated it was his expectation that staff would document resident's refusals to get out of bed. He further stated he came in for his shifts in the mornings and rounded on all the residents to make a list of who wanted to get up out of bed. LPN5 stated R7 usually chose not to get out of bed, and this should be documented.However, review of R7's ADL (Activities of Daily Living): Transfers found under POC (Point of Care) RESPONSES in R7's EMR, revealed for the months of January, February, March, and April 2026, the majority of responses were documented as Activity did not occur, and only nine total refusals were documented (six in January, two in February, none in March, and one in April).During an interview, on 04/29/2026 at 12:05 PM, with the Rehab Manager, she stated physical therapy last saw R7 in December 2025 and would evaluate him again today or tomorrow, stating they completed the evaluations quarterly and as needed. She stated R7 could be transferred via mechanical lift.During an interview, on 04/30/2026 at 9:25 AM, with the Infection Preventionist/Staff Development Coordinator (IP/SDC), she stated all residents should be offered the chance to get up out of bed and if they refused then it should be documented that they refused. She stated residents should be given a choice and an opportunity to refuse.During an interview, on 04/30/2026 at 10:35 AM, with the Interim Director of Nursing (DON), she stated this was her first week in the facility as interim DON and she was learning the residents and the facility processes, but it was her expectation that all residents were offered assistance to get up and out of bed. She further stated they did have the right to refuse. She stated refusals should be documented and care planned appropriatelyDuring an interview, on 04/30/2026 at 10:45 AM, with the Administrator, he stated all residents should be offered to get out of bed for socialization and quality of life.

Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure that a resident who needed respiratory care was provided with such care, consistent with the physician's orders and professional standards of practice for 2 out of 4 sampled residents investigated for respiratory care, Resident (R) 6 and R48.The findings include:Review of the facility's policy titled, Oxygen Administration, dated 10/23/2020, revealed the purpose of the policy was for oxygen therapy to be administered as ordered by a physician. The policy stated the nurse should check the residents' medical record to confirm the presence of complete and appropriate physician's orders, determine the appropriate oxygen source and equipment needed for the physician's orders, gather appropriate supplies, and change the O2 (oxygen) tubing monthly and PRN (as needed). 1. Review of R48's admission Record, revealed the facility admitted the resident on 07/24/2025 with diagnoses to include acute kidney failure, unspecified-acute kidney injury, chronic obstructive pulmonary disease (COPD), emphysema, chronic respiratory failure, and acute respiratory disease.Review of R48's Physician's Orders, dated 07/24/2025, revealed orders for O2 tubing to be changed monthly.Review of R48's Physicians Orders, dated 07/24/2025, revealed orders for humidification to be checked every shift, and changed when empty.Review of R48's Comprehensive Care Plan (CCP), dated 08/12/2025, revealed the resident required the use of oxygen and a Continuous Positive Airway Pressure (CPAP) machine related to a diagnosis of COPD, emphysema, and chronic respiratory failure. Further review of the CCP revealed interventions included to change the resident's oxygen tubing monthly and as needed. Continued interventions revealed to check the oxygen's humidification bottle every shift and change when empty.Review of R48's Physician's Orders, dated 09/17/2025, revealed orders for O2 at 4 liters per minute (LPM) via nasal canula.Review of R48's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/30/2026, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition.Observation on 04/27/2026 at 11:55 AM; at 1:15 PM; and at 2:30 PM, revealed R48's O2 concentrator rate was set at 3 LPM and the oxygen tubing had no identification date of when it was last changed, and the empty humidification bottle was not dated.Observation on 04/28/2026 at 9:18 AM; at 11:04 AM, and at 2:46 PM, revealed R48's O2 concentrator rate was set at 3 LPM, the oxygen tubing had no identification date of when it was last changed, and the empty humidification bottle was not dated.Observation on 4/29/2026 at 9:00 AM, revealed R48's O2 concentrator rate was set at 3 LPM, the oxygen tubing had no identification date of when it was last changed, and the empty humidification bottle was not dated.During an interview with R48, on 04/27/2026 at 1:15 PM, she stated staff rarely changed her oxygen tubing and rarely changed her humidification bottles. During an additional interview with R48, on 04/28/2026 at 11:04 AM, and on 04/29/2026 at 9:00 AM, she stated staff had not changed her O2 tubing and had not replaced the humidification bottles since she last spoke with the State Survey Agency (SSA) Surveyor on 04/27/2026.2. Review of R6's admission Record revealed the facility admitted the resident on 04/24/2026 with diagnoses to include acute and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia, acute and chronic respiratory failure with hypoxia, acute respiratory disease, acute and chronic respiratory failure with hypercapnia, chronic obstructive pulmonary disease (COPD), unspecified, and dependence on supplemental oxygen.Review of R6's Physician's Orders, dated 09/18/2025, revealed orders for O2 at 3 LPM via nasal canula.Review of R6's Physician's Orders, dated 09/18/2025, revealed orders for O2 tubing to be changed monthly.Review of R6's Physician's Orders, dated 09/18/2025, revealed orders for humidification to be checked every shift, and changed when empty.Review of R6's CCP, dated 10/07/2025, revealed the resident required oxygen at 3 LPM via nasal canula and was at risk for active infection related to weakness, decreased mobility, COPD, episodes of hypoxia, and chronic respiratory failure with oxygen dependence. However, the resident's care plan did not include interventions related to the O2 tubing being changed monthly nor did it address the oxygen humidification to be checked every shift, as per the physician's orders.Review of R6's quarterly MDS, with an ARD of 03/20/2026, revealed the facility assessed the resident to have a BIMS score of 12 out of 15, indicating moderate cognitive impairment.Observation on 04/27/2026 at 10:22 AM; at 11:30 AM; and at 4:00 PM, revealed R6's O2 concentrator rate was set at 3 LPM, the oxygen tubing had no identification date of when it was last changed, and there was no humidification.Observation on 04/28/2026 at 9:14 AM, 11:06 AM, and 3:00 PM, revealed R6's O2 concentrator rate was set at 3 LPM, the oxygen tubing had no identification date of when it was last changed, and there was no humidification.Observation on 04/29/2026 at 9:05 AM, revealed R6's O2 concentrator rate was set at 3 LPM, the oxygen tubing had no identification date of when it was last changed, and there was no humidification.During interview with R6, on 04/27/2026 at 4:00 PM, she stated she could not recall the last time staff changed the oxygen tubing because it had been so long. Further, she stated they had never added humidification to the concentrator.During interview with R6, on 04/28/2025 at 3:00 PM, she stated staff had not changed her oxygen tubing since she spoke with the State Survey Agency (SSA) surveyor on 04/27/2026. She stated there was no humidification attached to the concentrator. During further interview with R6, on 04/29/2026 at 9:05AM, she stated staff had not changed her O2 tubing and there was no humidification attached to the concentrator since she last spoke with the SSA Surveyor (on 4/28/2026).During an interview, on 04/29/2026 at 2:15 PM, with Licensed Practical Nurse (LPN) 7, she stated nursing staff set up O2 for the residents and nursing staff should be assessing the tubing, humidification, and rate daily.During an interview, on 04/30/2026 at 9:25 AM, with the Infection Preventionist (IP)/ Staff Development Coordinator (IP/SDC), she stated O2 tubing was to be checked every day, and the Unit Managers were responsible for auditing the O2 to ensure residents were receiving the correct amount as well as ensuring the tubing was being changed.During an interview, on 04/29/2026 at 2:27 PM, with LPN5/Unit Manager, he stated oxygen tubing should be changed and dated every Sunday either by the nurse caring for the patient or the Unit Manager when performing the audits. He stated he completed weekly audits every Monday for proper O2 titration rate, change of tubing, and change of humidification. He further stated the facility did not have a respiratory therapist any longer and physicians wrote the orders for the O2 and monitoring.During an interview, on 04/30/2026 at 10:35AM, with the Interim Director of Nursing (DON), she stated it was her expectation for all staff to follow the policies on O2 use as well as the physician's orders. In interview with the Administrator, on 04/30/2026 at 10:45 AM, he stated O2 tubing and humidification should be labeled with date of change, and this should be checked every shift. He further stated this was important for staff to know when to change out the O2 tubing and humidification. The Administrator stated humidification should be changed when it was empty or low, as the resident's required moisture from oxygen use. He further stated the Unit Managers usually did weekly rounds/audits on Mondays to ensure all this was being completed.

Based on observation, interview, record review, and review of the facility's policy, the facility failed to provide services to dependent residents to maintain good personal hygiene for 1 of 25 sampled residents investigated for activities of daily living (ADL's) care, Resident (R) 6.The findings include:Review of the facility's policy titled, Activities of Daily Living [ADL's], dated 09/15/2023, revealed direct healthcare staff will support and encourage the resident to maintain adequate ADL's while attempting to allow the resident to be able to maintain as much independence as possible with their ADL's such as the following: bathing, grooming, eating, toileting, bed mobility, and transfers. Further review of the policy revealed, For residents unable to perform their own ADL's, the facility will provide the assistance needed for completion of care.Review of R6's admission Record, revealed the facility admitted the resident on 09/19/2025 with diagnoses including acute and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia, acute and chronic respiratory failure with hypoxia, muscle weakness (generalized), difficulty in walking, and need for assistance with personal care.Review of R6's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/20/2026, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating moderate cognitive impairment.Review of R6's Comprehensive Care Plan, dated 10/07/2025, revealed the resident had a self-care deficit related to impaired physical functioning and medical conditions as evidenced by the need for staff assistance for adequate completion of ADL care.Observation on 04/27/2026 at 10:22 AM; at 11:30 AM; at 2:35 PM; and at 4:00 PM, revealed R6's toenails extended well beyond the tip of the toe and multiple toenails appeared jagged and rough.In an interview, on 04/27/2026 at 11:30 AM, R6 stated on multiple occasions she had requested staff to please trim her toenails because they were snagging on the sheets. She stated, staff tell me they will be back to complete this, but they will never come back. She further stated she was very upset because she did not feel they would want their toenails that long and jagged. R6 proceeded to move her feet back and forth under the bed sheet to demonstrate how her toenails snagged on the sheet.Observation on 04/28/2026 at 9:14 AM; at 11:06 AM; and at 2:49 PM, revealed R6's toenails extended well beyond the tip of the toe and multiple toenails appeared jagged and rough.Observation on 04/29/2026 at 1:30 PM, revealed R6 had just returned to her room from receiving her shower and nail care had not been performed.In an interview, on 04/28/2026 at 2:05 PM, with State Registered Nurse Aide (SRNA) 11, she stated she assessed residents' toenails each shift and would perform nail care either based on her observation or on the patient's [resident's] request. She stated this was typically done during the residents' showers but could be performed at any time. In an interview, on 04/29/2026 at 9:03 AM, with SRNA5, she stated when bathing a resident, staff washed the resident's hair, body, and perineum area, and provided nail care to residents if it was needed or if the resident asked for it. When asked why SRNA staff may or may not perform nail care on a resident, she stated, if the resident is diabetic then podiatry will come to the facility to perform nail care, but a RN [Registered Nurse] is allowed to trim them too. If a resident is not a diabetic, anyone can do it. SRNA5 could not explain why nail care was not performed on R6 and stated, it should have been completed at her request or during her last shower. She further stated toenails should be assessed by all staff every shift. In an interview, on 04/29/2026 at 1:52 PM, SRNA7 stated shower schedules should always be followed and any SRNA could trim nails for all non-diabetic residents, and their nails were checked often. She stated nail care was usually performed when a resident was in the shower. When asked if she performed the shower for R6 today, she stated she did. She further stated she could not give any reason nail care was not performed during R6's shower. In an interview, on 04/29/2026 at 2:15 PM, with Licensed Practical Nurse (LPN) 7, she stated everyone caring for the residents was responsible for nailcare, and it was not just assigned to one person.In an interview, on 04/29/2026 at 2:27 PM, with LPN5/Unit Manager, he stated it was the responsibility of everyone providing care to the residents to assess and perform nail care. He stated nail assessments should be performed on each shift.In an interview, on 04/30/2026 at 9:25 AM, with the Infection Preventionist (IP)/ Staff Development Coordinator (IP/SDC), she stated resident nails should be checked daily and trimmed when needed or if the resident wanted them trimmed.In an interview, on 04/30/2026 at 10:35 AM, with the Interim Director of Nursing (DON), she stated it was her expectation for all staff to follow the policies on ADL's as well as patient care plans. In an interview, on 04/30/2026 at 10:45 AM, with the Administrator, he stated staff should always assess resident's nails during the shower schedule if not every shift.

Based on interview and review of the facility's policy, the facility failed to ensure residents had the right to receive mail delivered to the facility on Saturdays. This affected all 125 current residents in the facility. During a group interview on 03/05/2025 the Resident Council members stated they did not receive mail on Saturdays. In an interview with the Assistant Business Office Manager (ABOM) and the Administrator on 03/06/2025, it was confirmed that mail delivered from the Post Office to the facility on Saturday after 5:00 PM was not sorted or delivered by staff until the following Monday. The findings include: Review of the facility's policy titled, Resident Rights, revised 01/31/2025, revealed the facility was responsible to ensure residents were treated with respect and dignity. Furthermore, the policy stated the facility ensured the residents' right to privacy in sending and receiving mail. During an interview with Resident (R) 3, R28, R43, R61, R64, R75, R82, and R107 on 03/05/2025 at 11:00 AM, at the Resident Council meeting, the State Survey Agency (SSA) Surveyor interviewed residents as to whether they received mail at the facility, including on Saturdays. All eight residents present stated they did not receive mail on Saturdays, except for special package deliveries from delivery services. R61 stated mail was delivered from the Post Office on Saturdays. However, R61 stated if mail was delivered to the facility after 4:30 PM, it would not be sorted and delivered to the residents. R61 further stated during the week, the Social Services Director (SSD) sorted the mail, and he (R61) then distributed it to the residents. However, R61 stated the SSD and other front office staff were unavailable to sort mail on weekends, which prevented him from delivering it. During an interview with the ABOM on 03/06/2025 on 5:13 PM, she stated mail was delivered from the Post Office on Saturdays. She stated there had been times when the mail had not been delivered to the facility on a Saturday. The ABOM stated she had contacted the Post Office and discussed the issue with the local Postmaster. She further stated if mail was delivered after 5:00 PM, there was no one in the Business Office who was able to sort resident mail from facility mail. She stated the facility should possibly consider ensuring mail delivery on Saturday because it was the residents' right to receive communication from outside the facility. During an interview with the Administrator on 03/06/2025 at 5:13 PM, she stated mail was delivered from the Post Office most Saturdays. However, she stated there had been instances where no mail delivery occurred. She stated the facility was one of the last stops on the postal carrier's route, resulting in mail arriving after 5:00 PM on Saturdays. She stated she did not have front office staff available after 5:00 PM on Saturdays. The Administrator stated she would contact the local Postmaster to discuss their concerns. The Administrator stated it was the residents' right to receive mail on Saturdays. She stated it was essential for their well-being and quality of life.

Based on observation, interview, review of the Centers for Disease Control and Prevention's (CDC) document, review of the website www.drugs.com, review of medication package inserts, and review of the facility's policy, the facility failed to ensure drugs, biologicals, and vaccines were stored per currently accepted professional principles and failed to ensure appropriate environmental controls were used to preserve their integrity. This deficient practice was found in 3 out of 3 medication refrigerators, and 2 out of 5 medications carts, affecting 25 residents, Resident (R) 17, R11, R17, R19, R21, R23, R25, R36, R37, R38, R45, R46, R47, R52, R58, R61, R62, R68, R79, R92, R98, R117, R229, R230, and R231. Observation of the A, B, and D Hall Units' medication refrigerators revealed multiple vials of Flucelvax and Fluzone (influenza vaccines) and Spikevax (COVID-19 vaccine), multiple multidose vials of Tubersol purified protein derivative (PPD) (diagnostic tuberculin skin test), and resident medications were stored in the medication refrigerators, outside of the recommended temperature parameters. Additionally, all three of the units' medication refrigerators were overcrowded, limiting proper airflow. Observation of D Hall Unit's Medication Cart revealed staff failed to discard expired medication. Observation of the B Hall Unit's Medication Cart revealed staff failed to date opened medications, failed to properly store insulin, failed to discard items with compromised packaging, and failed to dispose of expired medications or medications with specific expired dates after opening. The findings include: Review of the CDC's document, Vaccine Storage and Handling, updated 03/29/2024, revealed proper vaccine storage and handling played critical roles in efforts to prevent vaccine-preventable diseases. Per the document, vaccines exposed to storage temperatures outside the recommended ranges could have decreased efficacy, creating limited protection; and exposure to temperatures 32 degrees Fahrenheit (F) or colder could destroy its potency. Review of the facility's policy titled, Medication Storage, dated January 2025, revealed medications and biologicals must be stored according to the manufacturers' guidelines or pharmacy recommendations to ensure their integrity and to facilitate safe and effective administration. Per the policy, those medications that required refrigeration or must be kept at temperatures between 36 to 46 degrees F should be placed in a refrigerator equipped with a thermometer for monitoring purposes. The policy state the temperatures of any refrigerator storing vaccines should be checked and recorded twice daily. Per the policy, outdated, contaminated, or deteriorated (cracked, soiled, or without closers) medications were removed from stock. Review of the A, B, and D Hall Unit's Medication Temperature Logs, for March 2025, revealed all documented temperatures were between 36 to 46 degrees F. Review of PPD's package insert/product label revealed it was used as an aid in the detection of infection with mycobacterium. Further review revealed a multi-dose vial of PPD, which had been opened and used, should be discarded after 30 days. Review of Fluzone's package insert/product label revealed Fluzone was a vaccine indicated for active immunization for the prevention of influenza. Further review revealed Fluzone should be stored between use at temperatures between 35 to 46 degrees F, and it should be discarded if the vaccine was frozen. Additionally, product labeling indicated not to use after the expiration date. Review of the website www.drugs.com revealed Flucelvax was a vaccine indicated for active immunization for the prevention of influenza. Further review revealed Flucelvax should be stored between use at temperatures between 35 to 46 degrees F, and it should be discarded if the vaccine was frozen. Additionally, product labeling indicated not to use after the expiration date. Review of the website www.drugs.com revealed Spikevax was a vaccine indicated for active immunization to prevent COVID-19. Further review revealed Spikevax should be stored frozen between minus 58 to 5 degrees F. Continued review revealed after thawing, Spikevax could be stored refrigerated between 36 to 46 degrees F for up to 60 days or up to the expiration date printed on the carton, whichever came first. According to the manufacturer's instructions, Spikevax should not refreeze once thawed. Review of the website www.drugs.com for insulins revealed opened (in-use) vials and injection pens, stored at room temperature, should be discarded after 28 days. Further review revealed unopened insulin lispro injections should be stored in the refrigerator at 36 to 46 degrees F until the first use. The unopened multidose vials and prefilled pen would be good until the expiration date on the package if they remained refrigerated until use. 1. Observation of the D Hall Unit's Medication Storage Room on 03/05/2025 at 8:45 AM, revealed a small medication storage refrigerator was on the floor between the shelving system. The temperature reading of the thermometer inside of the refrigerator was at 32 degrees F. Additionally, the refrigerator was over-packed with very little room for proper airflow. Medications and biologicals found in the refrigerator at below acceptable levels included: seven intravenous (IV) bags of R38's daptomycin (antibiotic) 500 milligram (mg)/50 milliliter (mL); five IV bags of R38's cefepime (antibiotic) 2 gm (grams)/50 mL, one IV bag of R23's cefepime 1 gm/50 mL, seven IV bags of R21's cefazolin (antibiotic) 2 gm/50 mL; R98's Ozempic pen (semaglutide); one vial of Risperdal (anti-psychotic) 12 mg; one house stock multidose vial of Fluzone 0.5 mL with an expiration date of 06/2025; two vials of insulin glargine 100 units (u) for R21 and R25; one house stock multidose vial of PPD; three of R52's Trulicity 0.75 mg/0.5 mL pens (dulaglutide); R23's Wegovy 0.5 mg/0.5 mL pen (semaglutide); R17's Wegovy 0.25mg/0.5mL pen; 12 IV bags of R92's daptomycin 300 mg/100 mL; and 13 IV bags of R23's cefepime 1 g/50 mL. 2. Observation of D Hall Unit's Medication (Cart 1) on 03/05/2025 at 9:00 AM, revealed 24 famotidine (stomach acid reducer) 20 mg tablets and 18 pravastatin (statin) 40 mg tablets for R37 with an expiration date 03/01/2025. Additionally, R58's fluoxetine (anti-depressant) 20 mg tablets had expired on 03/01/2025. During interview with the D Hall Unit Manager (DHUM) on 03/05/2025 at 9:10 AM, she stated the refrigerator was checked at least daily, and temperatures were recorded on the Medication Refrigerator Temperature Log by Central Supply during the week and by nursing staff on weekends. The DHUM further stated the nursing staff was responsible for ensuring medications were labeled according to the facility process, which was to record the date opened on the medication package when the medication had been opened. Furthermore, she stated if an item was found to be expired, not labeled, or stored improperly, the nursing staff was responsible to discard the medication according to policy. The DHUM further stated the importance of that was to ensure the safety of all residents. During interview with the Administrative/Corporate Consultant (CC) on 03/05/2025 at 9:23 AM, she stated the Medication Storage Room for D Hall shared space in a small room with the facility's computer server and wiring equipment. The CC further stated expired medications should not be kept in the medication cart. She stated nursing staff should adhere to facility policy regarding the removal of expired medications, as this was important for resident safety. Additionally, the CC stated medications past their expiration date lost their effectiveness. 3. Observation of B Hall Unit's Medication Cart 1 on 03/05/2025 at 9:25 AM revealed one packaged Zofran (for nausea) tablet without a resident label in the top drawer of the cart. Additionally, the following medications or items were found to be without an opened date, improperly stored, or expired: one open bottle of Sprite cola, half full, in the bottom of the medication cart; one bottle of ProHeal concentrated liquid protein was found with an uncovered drilled hole in the protective cap, causing the product to spill out onto the sides of the bottle; three opened packages of albuterol nebulizer solution 2.5 mg/0.5 mL (bronchodilator) not in the original pharmacy packaging and not protected from light; R46's iprat/albuterol 0.5 3(2.5) mg/3 mL (bronchodilator) inside a foil package that was not dated, opened, and exposed to light; R36's bottle of generic mouthwash was opened with the date of 8/12/2022; and R68's Bion Tears (ocular lubricant) with an opened date of 01/21/2025. During interview with the B Hall Unit Manager (BHUM) on 03/05/2025 at 9:25 AM, he stated the nursing staff was responsible for ensuring medication were dated when opened. The BHUM stated that expired, incorrectly labeled, or improperly stored items should be discarded. He stated the medication storage refrigerator was checked daily, with temperatures recorded on the Medication Refrigerator Temperature Log by Central Supply during the week and by nursing staff on weekends. He stated those measures were vital for ensuring medication potency and resident safety. 4. Observation of B Hall Unit's Medication Storage Refrigerator on 03/06/2025 at 9:15 AM revealed a small refrigerator that had very little room for proper airflow. The temperature reading of the thermometer inside of the refrigerator was 50 degrees F. Further observation revealed medications and biologicals inside the refrigerator included: one house stock multidose vial of PPD stored in the door of the refrigerator; R79's Ozempic 4 mg/3 mL, Ozempic 2 mg/3 mL, and Ozempic 8 mg/3 mL pens; one vial of R36's Semglee (insulin glargine) 100 units/mL; R11's Trulicity 0.75/0.5 mL pen, Lantus 1.5/0.5 pen, and a vial of insulin lispro 100 units/mL; two of R7's Trulicity 0.75/0.5 mL pens, and one vial of R19's Lantus 100 units/mL. 5. Observation of A Hall Unit's medication storage room on 03/06/2025 at 9:15 AM revealed two milk crates full of expired or discontinued residents' medications. These crates were unlabeled and available for use. During interview with the CC on 03/06/2025 at 9:15 AM, she stated during an audit of the A Hall Unit's Medication Cart on 03/05/2025, she pulled the medications from the cart. She stated according to facility policy, medication carts and storage areas were monitored on a regular basis. She further stated the pharmacy picked up expired and discontinued medications regularly. 6. Observation of A Hall Unit's Medication Storage Refrigerator, revealed it was a small refrigerator located on the floor that had very little room for proper airflow. The temperature reading of the thermometer inside of the refrigerator was 28 degrees F. Medications and biologicals inside the refrigerator included: one vial of R47's insulin glargine 100 units/mL; one vial of R61's insulin lispro 100 units/mL; three bags of R229's IV daptomycin 700 mg/100 mL; six bags of R92's daptomycin 300 mg/114 mL; R230's acidophilus (probiotic); one vial of R21's insulin glargine 100 units/mL; one vial of R62's Novolog (insulin aspart) 100 units/mL; R98's Ozempic 0.25/0.5 pen; two vials of R117's Risperdal 12 mg; R45's hydrocortisone 25 mg suppository (for hemorrhoids); one tube of lidocaine for R231; R17's Wegovy 0.5 mg/0.5 mL pen; one multidose vial Fluzone (house stock); three multidose vials of PPD (house stock); 16 vials of Flucelvax with an expiration date of 06/02/2025 (house stock); eight vials of Flucelvax with an expiration date of 06/13/2025; and 30 vials of Spikevax 2024-2025 (house stock). During interview with Licensed Practical Nurse (LPN) 2 on 03/06/2025 at 9:59 AM, she stated medication storage refrigerators should be kept between 36 to 46 degrees F. LPN2 stated she did not know why the refrigerator was at 28 degrees F. She stated nursing staff only checked the medication refrigerator temperatures on weekends. During interview with the Infection Preventionist/Staff Development Coordinator (IP/SDC) on 03/06/2025 at 3:32 PM, she stated it was the responsibility of the nurse to monitor the medication storage refrigerators like any other medication. She stated the facility should follow manufacturer's guidelines for proper temperature storage. She stated it was important because prolonged exposure outside of the correct medication temperature range could affect efficacy. She further stated medications and vaccines could not be stored in the refrigerator door as temperatures could fluctuate from the inside of the refrigerator. Additionally, the IP/SDC stated medications should be stored in such a way as to ensure proper airflow to ensure consistent temperatures. She stated all medications should be dated when opened. According to the IP/SDC, she stated each medication cart had a cheat sheet that listed frequently used medications and insulins, along with their storage requirements. The IP/SDC she expected that the nursing staff be familiar with the cheat sheet. During continued interview with the IP/SDC on 03/06/2025 at 3:32 PM, she stated that Central Supply monitored the refrigerators throughout the week, while nurses were responsible for conducting checks on weekends. She stated staff members were expected to verify that temperatures remained within the acceptable range. When the State Survey Agency (SSA) Surveyor inquired about the frequency of nursing leadership audits for the medication carts and refrigerators, the IP/SDC stated, I have taken medications out of the cart. I have not found anything in the refrigerators, but I have only checked twice. The IP/SDC stated all medications should be dated when opened, and staff must adhere to the facility's policies concerning medication storage. She stated expired medications could pose a risk if administered, raising safety concerns. She further stated it was important to follow physician's orders and monitor medication storage to maintain the health and well-being of the residents. During interview with the acting Director of Nursing (DON) on 03/06/2025 at 3:57 PM, she stated she expected the nurses to discard expired medications. She stated nursing staff was educated on medication administration and storage during their orientation upon hire. The DON stated it was her expectation that medications and vaccines were stored according to currently accepted professional standards and under the appropriate environmental controls to protect the efficacy of the medication and vaccines for the safety of the residents. During interview with the Administrator on 03/06/2025 at 5:06 PM, she stated it was her expectation that medications and vaccines were stored according to the facility's policy to protect the efficacy of medications and vaccines for the safety of the residents.

2. Review of R90's Resident Face Sheet revealed the facility admitted the resident on 08/02/2021 with diagnoses including colitis (inflammation of the large intestine), unspecified dementia, and hemiplegia (paralysis of one side) following a cerebral vascular accident (stroke). Review of R90's quarterly MDS, with an ARD of 01/24/2025, revealed the facility assessed the resident to have a BIMS score of 15 out of 15, indicating the resident was cognitively intact. Review of R90's Progress Note, dated 02/20/2025, revealed the facility transferred R90 to the hospital on that date due to continued complaint of pain of the left hip following a fall reported on 06/22/2024. Further review revealed the facility documented they sent all appropriate paperwork to the resident and her representative. Review of R90's medical record revealed no evidence R90 received a completed Notice of Transfer or Discharge form, with notification of appeal rights or that the appeal rights were discussed with the resident. During interview with R90 on 03/06/2025 at 11:45 AM, she stated she did not recognize the blank Notice of Transfer or Discharge form the SSA Surveyor showed her. 3. Review of R110's Resident Face Sheet revealed the facility admitted the resident on 10/31/2024 with diagnoses including cerebral infarction (stroke), aphasia (difficulty speaking, writing, or understanding written words), and congestive heart failure. Review of R110's quarterly MDS, with an ARD of 02/28/2025, revealed the facility assessed the resident to have a BIMS score of 5 out of 15, indicating the resident had severe cognitive impairment. Review of R110's Progress Note, dated 03/03/2025, revealed the facility transferred R110 to the hospital on that date due to a critically low potassium level. Further review revealed the facility documented they sent all appropriate paperwork to the resident and her representative. Review of R110's medical record revealed no evidence R110, or his Resident Representative (RR) received a completed Notice of Transfer or Discharge form or that the transfer or discharge notice, with notification of appeal rights, was discussed with the resident or RR. R110 was not interviewable due to mental cognition. Interview by telephone was attempted with R110's wife on 03/06/2025 at 3:28 PM. However, she did not answer the call, and no voicemail was available. R110's wife did not return the SSA Surveyor's call. 4. Review of R25's Resident Face Sheet revealed the facility admitted the resident on 07/05/2023 with diagnoses of depression, anxiety disorder, and dementia. Review of the facility's document Census, revealed R25 was sent to the hospital on [DATE]. However, there was no documentation by the facility stating a completed Notice of Transfer or Discharge form was sent to R25's responsible party. During interview with R25's RR on 03/04/2025 at 4:23 PM, she stated the facility did not mail or provide her with a Notification of Transfer or Discharge form when R25 was sent to the hospital on [DATE]. During interview with Licensed Practical Nurse (LPN) 1 on 03/06/2025 at 1:30 PM, he stated he had never seen a Notice of Transfer or Discharge form nor provided it to any resident transferred to the hospital. During interview on 03/06/2025 at 11:52 AM, Registered Nurse (RN) 3 stated she had never seen the form, Notice of Transfer or Discharge, and had not provided that form to any resident she transferred to the hospital. She further stated the only paperwork she completed when she sent a resident to the hospital was a transfer form of clinical information for the receiving facility and a bed hold policy form for the resident. During interview with RN6 on 03/06/2025 at 1:30 PM, she stated she had never seen a Notice of Transfer or Discharge form nor provided it to any resident transferred to the hospital. She stated the only paperwork she completed was the inter-hospital transfer form with relevant clinical information and a bed hold policy form. During interview on 03/06/2025 at 2:30 PM, the A Hall Unit Manager (AHUM) stated her expectations for nurses sending residents to the hospital was that they would complete a bed hold policy form to give to the resident and a transfer communication form to provide to Emergency Medical Services (EMS) and the receiving facility. During interview with the Business Office Manager (BOM) on 03/06/2025 at 10:46 AM, she stated she was responsible for sending residents and their representatives the bed hold agreement but did not send the Notice of Transfer or Discharge form outlining the resident's appeal rights. During interview with the Administrative/Corporate Consultant on 03/06/2025 at 10:51 AM, she stated that the facility was required to send a Notice of Transfer or Discharge form with residents transferred or discharged to the hospital. Per interview, this form included the resident's rights and the contact information for state agencies in case the facility did not readmit them. Additionally, the Administrative Consultant stated she could not provide evidence that the facility had given the correct form to residents who were transferred or discharged to the hospital. During interview with the acting Director of Nursing (DON) on 03/06/2025 at 3:57 PM, she stated she initially believed the facility needed to provide the bed hold form to the resident and the inter-hospital transfer form to the receiving facility. However, she stated after speaking with the Administrative/Corporate Consultant, she was made aware of the Notice of Transfer or Discharge form, which informed residents of their appeal rights, which was also required. She stated staff education on utilizing the Notice of Transfer or Discharge form for all transfers had begun and would continue. During interview with the Administrator on 03/06/2025 at 5:06 PM, she stated the facility's practice regarding resident transfer notices prior to today were the resident was provided with a bed hold agreement, and the receiving facility was sent pertinent clinical information on an inter-hospital transfer form. She stated she had been advised by the Administrative/Corporate Consultant earlier that staff was required to discuss and complete the Notice of Transfer or Discharge form with the resident or resident's representative. She further stated she would implement the correct procedure moving forward. Based on interview, record review, and facility document and policy review, the facility failed to notify the resident and/or the resident's representative of the transfer or discharge and the reasons for the move in writing and in a language and manner they understood as soon as practicable. The facility further failed to ensure the notice included the reason, date, and location for the transfer, as well as a statement of the resident's appeal rights, and the contact information for the state Long-Term Care Ombudsman. The deficient practice was identified for 4 of 5 residents investigated for hospitalizations, Resident (R) 25, R47, R90, and R110. The findings include: Review of the facility's policy titled, Transfer/Discharge Notice, dated 02/03/2025, revealed the facility was to ensure appropriate notices and documentation were provided for all transfers. Further review revealed the facility was to respect residents' rights while complying with federal and state regulations related to transfers. Review of the facility's blank document Notice of Transfer or Discharge, not dated, revealed the form contained spaces for staff to fill in relevant resident information, as well as the reasons for transfer/discharge, contact information for the state agency responsible for appeals, and contact information for the state ombudsman. 1. Review of R47's Resident Face Sheet revealed the facility admitted the resident on 12/18/2024 with diagnoses including acute and chronic respiratory failure, dependence on renal dialysis, and type 2 diabetes. Review of R47's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/31/2025, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the resident was cognitively intact. Review of R47's Progress Note, dated 02/20/2025, revealed the facility transferred R47 to the hospital on that date due to a critically elevated potassium level. Further review revealed the facility documented they sent all appropriate paperwork to the resident and her representative. Review of R47's medical record revealed no evidence she received the Notice of Transfer or Discharge form. During interview on 03/06/2025 at 1:37 PM, R47 stated she did not recognize the blank transfer form the State Survey Agency (SSA) Surveyor showed her. She further stated her husband handled all her paperwork. Interview was attempted with R47's husband via telephone on 03/06/2025 at 1:44 PM. However, he did not answer either of the two numbers listed, no voicemail was available, and he did not return the SSA Surveyor's call.

Based on observation, interview, review of a Centers for Medicare and Medicaid Services (CMS) memorandum, review of a Centers for Disease Control and Prevention (CDC) document, and review of the facility's policies, the facility failed to establish and maintain an infection prevention and control program (IPCP) designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 40 residents reviewed for infection control, Resident (R) 68 and R45. The facility also failed to conduct an annual review of their IPCP. Observation of R68's wound care revealed Registered Nurse (RN) 1 failed to wear a gown while performing it, and the resident's door did not have an Enhanced Barrier Sign (EBP) sign posted. Observation of R45's room revealed it had a Contact Precautions sign posted, but State Registered Nurse Aide (SRNA) 3 pushed a mechanical lift out of the room and entered another resident's room without performing hand hygiene prior to exiting R45's room and before entering the other resident's room. The findings include: Review of the facility's policy titled, Infection Control, effective date 01/23/2024, revealed the facility's policies and practices were intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. However, there was no documentation the policy was reviewed or updated annually. Review of the facility's policy titled, Enhanced Barrier Precautions Policy, last revised 03/25/2024, revealed if a resident was placed on Enhanced Barrier Precautions (EBP), appropriate signage was placed at the room entrance so that personnel and visitors were aware of the need for and the type of precautions. Review of the Centers for Medicare and Medicaid Services (CMS) memorandum from its Center for Clinical Standards and Quality/Quality, Safety & Oversight Group, QSO-24-08-NH, dated 03/20/2024, revealed EBP were used in conjunction with standard precautions and expanded the use of personal protective equipment (PPE) to donning (putting on) of gown and gloves during high-contact resident care activities such as wound care. Review of the Centers for Disease Control and Prevention (CDC) document C. diff: Facts for Clinicians | C. diff | CDC, dated 03/05/2024, revealed clostridium difficile (C. diff, a bacteria that caused severe diarrhea) spores could transfer to residents from the hands of healthcare personnel who had touched a contaminated surface or item; an alcohol based hand sanitizer was not effective against C. diff; and washing hands with soap and water was required for hand hygiene. 1. Observation of R68's door on 03/03/2025 at 4:48 PM revealed there was no EBP sign on the door. Observation on 03/03/2025 at 4:50 PM revealed RN1 performed wound care to R68's left hip. RN1 was not wearing a gown. While cleaning the wound, RN1 laid her arm on the bed. During interview with RN1 right after the wound care, she stated she forgot all about the gown. She further stated it was important to wear a gown during wound care to prevent the spread of germs. During interview with the Assistant Director of Nursing (ADON) on 03/05/2025 at 3:33 PM, she stated when a resident had a wound, the staff was to wear a gown and gloves. She stated nurses put precaution signs on the residents' doors. She stated she performed rounds to assure staff was wearing the appropriate PPE. When questioned what could occur if a staff member did not wear a gown and performed wound care, she stated she could not answer to that. During interview with the Director of Nursing (DON) on 03/05/2025 at 3:24 PM, she stated she was the interim DON. She further stated she had been at the facility for about two months. She stated she had a meeting with the staff at different times, educating staff on infection control. She stated at those meetings she educated on EBP, what it was needed for and what the precaution signs stated. When questioned about the incident, she stated RN1 might have been nervous because a State Survey Agency (SSA) Surveyor was observing. She further stated because there was not an EBP sign on the door, that could have contributed to the problem. She stated, after the incident, a sign was placed on the door, and RN1 was reeducated on EBP. She further stated if a staff member was not wearing a gown while providing wound care, it could have caused a spread of infection. During interview with the Administrator on 03/06/2025 at 10:44 AM, she stated, I guess the infection control policies should be updated yearly. She further stated corporate updated the policies and sent them to her by e-mail. She stated she then educated the staff on the policy updates. She stated she was on the floor often, monitoring staff to assure they were following the IPCP. She stated if she saw a staff member not following the policy, she educated immediately and might send the staff for training. She also stated if staff did not follow the IPCP, that could contribute to the spread of an infection. During interview with the corporate [NAME] President of Clinical Operations on 03/06/2025 at 3:14 PM, she stated the clinical department was responsible to assure the policies were up-to-date and accurate. She stated the [NAME] Presidents of each department and the Chief Nursing Officer met as a team and reviewed the policies. She stated the compliance department put policies in a Web based program, and the old policies were archived. 46710 2. Review of R47's Resident Face Sheet revealed the facility admitted the resident on 02/03/2025 with diagnoses including clostridium difficile (C. diff). Review of R47's Comprehensive Care Plan (CCP) revealed the facility identified the resident required contact precautions for C. diff; however, the care plan did not specify interventions related to hand hygiene. Observation on 03/05/2025 at 8:51 AM revealed R45's room had a Contact Precautions with Special Enteric Guidance sign posted on the door. The sign instructed staff to wash hands with soap and water before leaving the room. Continued observation on 03/05/2025 at 8:51 AM revealed SRNA3 pushed a mechanical lift out of R45's room but failed to perform hand hygiene prior to exiting. Further observation revealed SRNA3 exited R45's room and entered R130's room without performing hand hygiene. During interview on 03/05/2025 at 8:59 AM, SRNA3 stated she failed to wash her hands with soap and water after removing the mechanical lift from R45's room. During interview on 03/06/2025 at 3:57 PM, the interim DON stated she expected staff to wash their hands with soap and water prior to exiting a room in contact precautions with enteric instructions due to clostridium difficile. She further stated she had reeducated SRNA3 that she needed to perform hand hygiene with soap and water, even if she had not performed incontinence care for R47 because clostridium difficile spores live on surfaces in the resident's room. In an interview on 03/06/2025 at 5:06 PM, the Administrator stated she expected staff to wash their hands with soap and water prior to exiting a room when the resident had clostridium difficile. She further stated proper hand hygiene was important to prevent the spread of the bacteria.

Based on interview, record review, review of the facility's policies, and review of the Center's for Disease Control and Prevention (CDC) guidelines, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent and control the development and transmission of communicable diseases, including COVID-19. The facility failed to implement interventions per the Centers for Medicare and Medicaid Services (CMS), the Center's for Disease Control and Prevention and the Kentucky Department for Public Health (Health Department) State guidelines for COVID-19. Observations, on 08/31/2021 and 09/01/2021, revealed improper hand hygiene and improper use of Personal Protective Equipment (PPE) on the COVID Unit and on the A Wing (gloves, eye protection, and proper mask) for three (3) of six (6) sampled residents, Residents #2, #3, and #4. Additional observation, on 08/31/2021, revealed no posted signage on the COVID Unit or on isolation room doors on the A Wing. Staff interviews on the COVID Unit and in the Dietary Department revealed improper sanitization of the meal tray cart for the COVID Unit. The findings include: Review of the facility's policy titled, Infection Control, dated October 2018, revealed infection control policies and practices were intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. Additionally, infection control policies and practices applied equally to all personnel, consultants, contractors, residents, visitors, volunteers, workers, and the general public. Per the policy, infection control policies and practices were to prevent, detect, investigate and control infection; maintain a safe, sanitary environment; establish guidelines for implementing Isolation Precautions; establish guidelines for availability and access of supplies and equipment; maintain records of incidents and corrective actions; and provide guidelines for safe cleaning and reprocessing of reusable resident-care equipment. Further, the Quality Assurance Performance Improvement (QAPI) Committee, established, reviewed, and revised Infection Control policies and practices and helped department heads and managers ensure that they were implemented and followed. Continued review revealed all personnel would be trained on Infection Control policies and practices upon hire and periodically thereafter. Review of the facility's policy titled, Categories of Transmission-Based Precautions, dated October 2018, revealed Transmission Based Precautions (TBP) were initiated when a resident developed signs and symptoms of a transmissible infection; arrived for admission with symptoms of infection; or had a laboratory confirmed infection; and, was at risk of transmitting the infection to other residents. Additionally, standard precautions were used when residents were cared for at all times regardless of their suspected or confirmed infection status. Per the policy, TBP's were additional measures to protect staff, visitors, and other residents from becoming infected. These measures were determined by the specific pathogen and how it was spread from person to person. There were three (3) types of TBP: Contact, Droplet, and Airborne. TBP's were used only when the spread of infection could not be reasonably prevented by less restrictive measures. Further, when a resident was placed on TBP, appropriate notification should be placed on the room entrance door and on the front of the chart so that personnel and visitors were aware. The signage informed the staff of the type of CDC precaution(s), instructions for the use of PPE, and/or instruction to see a nurse before entering the room. Per the policy, when TBP's were in effect, if re-use of items was necessary, the item would be cleaned and disinfected according to current guidelines. Continued review of the facility's policy titled, Categories of Transmission-Based Precautions, dated October 2018, revealed Droplet Precautions might be implemented for an individual documented or suspected to be infected with microorganisms transmitted by droplets that could be generated by the individual coughing, sneezing, talking, or by the performance of procedures such as suctioning. Additionally, residents in Droplet Precautions could be cohorted with residents infected with the same microorganism or with limited risk factors. Per the policy, masks would be worn when entering the room. Further, gloves, gowns, and eye goggles should be worn if there was risk for spraying respiratory secretions. Review of the facility's policy titled, Novel Coronavirus (COVID-19), last revised on 06/28/2021, revealed CMS defined Core Principles and best practices that reduced the risk of COVID-19 transmission. Facilities, residents, and visitors were expected to adhere. Core Principles included but were not limited to: hand hygiene; face mask covering nose and mouth; instructional signage on infection control precautions; appropriate use of PPE; and cleaning and disinfecting high frequency touched surfaces. Additionally, in the case of suspected COVID-19 or residents unvaccinated, the facility should place the resident in Droplet Precautions for fourteen (14) days, and require any person entering the resident's room to wear a gown, gloves, a mask (respirator), and eye protection. Further, a respirator mask would be used in accordance with CDC recommendations in appropriate TBP settings. Eye protection would be worn by staff during an outbreak, until the facility went fourteen (14) days without a new positive case. Review of Resident #2's medical record revealed the facility readmitted the resident, on 08/25/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's August 2021 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's Comprehensive Care Plan (CCP), dated 08/25/2021, revealed the resident was at risk for active infection related to potential exposure to COVID-19. The goal was the resident would not demonstrate signs or symptoms of an active COVID-19 infectious process. The interventions included isolation as warranted per the resident's conditions and to maintain appropriate PPE according to state requirements and availability. Review of Resident #2's Electronic Medical Record, Preventative Health, revealed the resident refused his/her first COVID-19 vaccine on 08/25/2021. Review of Resident #3's medical record revealed the facility readmitted the resident, on 08/04/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #3's August 2021 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observations revealed the resident was in droplet precaution isolation, cohorted with Resident #4. Review of Resident #3's CCP, dated 08/24/2021, revealed the resident was at risk for active infection related to potential exposure to COVID-19. The goal was the resident would not demonstrate signs or symptoms of an active COVID-19 infectious process. The interventions included isolation as warranted per the resident's conditions and to maintain appropriate PPE according to state requirements and availability. Review of Resident #3's Electronic Medical Record, Preventative Health, revealed the resident refused his/her first COVID-19 vaccine on 06/23/2021. Review of Resident #4's medical record revealed the facility readmitted the resident, on 08/14/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #4's August 2021 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #4's CCP, dated 08/16/2021, revealed the resident was at risk for active infection related to potential exposure to COVID-19. The goal was the resident would not demonstrate signs or symptoms of an active COVID-19 infectious process. The interventions included isolation as warranted per the resident's conditions and to maintain appropriate PPE according to state requirements and availability. Review of Resident #4's Electronic Medical Record, Preventative Health, revealed the resident received his/her first COVID-19 vaccine on 08/20/2021. Further, there was no documented evidence the resident had received his/her second COVID-19 vaccine. Observations, on 08/31/2021 at 9:08 AM, of the A Wing, revealed three (3) residents with over the door PPE supplies hanging on their doors; Resident #2, Resident #3 and Resident #4. PPE available on each door included respirator mask, gloves, and gowns. There were no disinfecting wipes, eye protection, or surgical masks. Additionally, there was no signage on Resident #2 or Resident #3's doors indicating the type of CDC precaution(s), instructions for the use of PPE, and/or instruction to see a nurse before entering the room. Resident #4's door had a sign stating See Nurse before entering. Interview with Licensed Practical Nurse (LPN) #1 at this time revealed A Wing isolation rooms were for newly admitted residents who had respiratory concerns or had a laboratory confirmed illness that required TBP. Continued observation, on 08/31/2021 at 9:12 AM, of the COVID Unit, revealed no signage indicating the type of CDC precaution(s), instructions for the use of PPE, and/or instruction to see a nurse before entering the Unit. Observations, on 08/31/2021 at 11:43 AM, A Wing, Resident #4, revealed the resident's call light was on above the door. Certified Nursing Assistant (CNA) #4 came from the nursing station to the doorway wearing dedicated PPE: a surgical mask and face shield. CNA #4 did not perform hand hygiene, donned a gown, and grabbed two (2) gloves in her hand. She did not don the gloves and did not don a respirator mask before she entered the room and closed the door. Additional observations revealed at 11:44 AM, CNA #4 exited Resident #4's room wearing a surgical mask and face shield. Further, there was no surgical mask or disinfectant wipes on the over door PPE container, and CNA #4 went down the hallway to the nurse's station. On 08/31/2021 and 09/01/2021 CNA #4 was not available for interview. Observations, on 08/31/2021 at 11:45 AM, A Wing, Resident #4, revealed Therapist #1 exited the resident's room wearing a surgical mask and eye protection. He did not change his surgical mask or clean his eye protection. Further, there was no surgical mask or disinfectant wipes on the over door PPE container The State Survey Agency (SSA) Surveyor attempted to interview Therapist #1, on 08/31/2021 at 4:30 PM; however he was not available for interview. Additional observations, on 08/31/2021 at 12:00 PM, of the COVID Unit revealed CNA #2 in the Dining Room interacting with residents with no gloves on her hands. The Administrator directed the CNA to don gloves, and CNA #2 donned gloves without performing hand hygiene. Additional observations on 08/31/2021 at 12:00 PM, of the COVID Unit, revealed CNA #3 with no eye protection and no gloves on. Further, at 12:10 PM, observation revealed CNA #3, without gloves and eye protection, assisted a resident with hand hygiene using a moistened wipe. Then, she used hand sanitizer on her hands and then assisted another resident with hand hygiene without donning gloves or eye protection. From 12:00 PM until 12:15 PM, CNA #3 was in the Dining Room, assisting residents without gloves or eye protection. CNA #2 directed CNA #3 to don gloves and eye protection; however, CNA #3 did not perform hand hygiene before donning gloves or eye protection. Interview with the Administrator and Registered Nurse (RN) #1/Unit Manager D Wing and COVID Unit, on 08/31/2021 at 12:15 PM, revealed all staff on the COVID Unit should always be in PPE to include a KN95 mask, eye protection, gown, and gloves. Per the interview, gloves should be changed between residents with hand washing. Additionally, the double door between the COVID Unit and D Wing was the facility's only option to deliver the meal cart into the COVID Unit because the exterior entrance had three (3) concrete stairs which the cart could not go up. Continued interview revealed it was important to ensure PPE was used consistently and appropriately per CDC Guidelines to decrease risk for cross contamination and infection control. Further the COVID Unit's census was nineteen (19) with four (4) active COVID-19 positive residents. Interview with CNA #3, on 09/01/2021 at 12:00 PM, revealed she had worked at the facility for four (4) years. Additionally, she said she had been provided training on Infection Control including COVID-19 (how it was spread), PPE (appropriate use), and hand hygiene (correct way to do it and when to do it). Per the interview, the COVID Unit was on Droplet Precautions, and staff working on the unit were required to wear a gown, eye protection, a KN95 mask, and gloves at all times. CNA #3 stated hand hygiene should be performed before donning gloves. Further, she stated the reason she was not wearing eye protection and gloves, when she provided assistance to residents with hand washing in the dining room before meal services, was because she had just came back from lunch and was nervous to help with residents because the SSA Surveyor was watching. However, she stated it was important to protect ourselves, families, and other residents with infection control practices. Per the interview, it was common practice for dietary staff to open the double doors between the COVID Unit and D Wing to deliver the meal cart. CNA #3 stated, after meal services, nursing staff pushed the meal cart back through the double doors and left the meal cart sitting outside the double doors between D Wing and the COVID unit until Dietary staff came to get it. She stated nursing staff did not have supplies to clean the meal cart before it left the COVID Unit; therefore, dietary staff was responsible to clean the cart when it was returned to the kitchen. Interview with CNA #2, on 09/01/2021 at 12:05 PM, revealed she had worked at the facility for one (1) year. Per the interview, she had received training on Infection Control including COVID-19 (how it was spread), PPE (appropriate use), and hand hygiene (correct way to do it and when to do it). Additionally, on 08/31/2021 around noon, she stated she was in between changing her gloves when the SSA Surveyor observed her without gloves on interacting with a resident. CNA #2 stated a resident stopped her, and she interacted with the resident before donning new gloves. Further, she said she should have performed hand hygiene and donned gloves before direct care with a resident. CNA #2 stated hand hygiene and gloves helped decrease the spread of illness. Per the interview, dietary staff delivered the meal cart into the COVID Unit via the double doors between the COVID Unit and D Wing. After the meal service, she stated nursing staff left the meal cart sitting outside the double doors between D Wing and the COVID Unit until dietary staff came to get it. CNA #2 stated nursing staff did not have supplies to clean the meal cart before it left the COVID Unit; therefore, dietary staff was responsible to clean the cart when they got it back to the kitchen. Observation, on 08/31/2021 at 12:17 PM, on A Wing, during lunch meal service, revealed CNA #1 wearing dedicated PPE (a surgical mask and face shield), in the hallway while preparing drinks at the meal cart. Continued observation revealed CNA #1 walked to Resident #4's room and donned a gown and gloves without performing hand hygiene and without donning a respirator mask. The CNA entered the resident's room, setup his/her meal tray on the bedside table (uncovered food), and moved the bedside table to the opposite side of the bed where the resident sat in his/her wheelchair in between the two (2) beds. The resident's urinal was hanging on the bed rail to the right of the resident's bedside table and was one-half (½) full of yellow urine. Per the resident's request, CNA #1 took the urinal to the bathroom and emptied the urinal and returned the urinal to the bedrail. Then, the CNA went to the door doffed gloves and gown, disposed of them in the trash can, entered the bathroom in the resident's room and washed her hands. Next, the CNA exited the resident's room into the hallway, walked down to the food cart, and began preparing another resident's meal tray. She did not change her surgical mask or clean her eye protection. Observation, on 08/31/2021 at 12:20 PM, A Wing, revealed CNA #1 standing in front of Resident #2 and Resident #3's doorway wearing a dedicated surgical mask and eye protection. She donned a gown and gloves without performing hand hygiene and entered the resident's room. Then, CNA #4 handed Resident #2's meal tray into the doorway to CNA #1; CNA #1 setup the resident's meal tray on the overbed table, removing the lid, cutting food, and adding condiments. Additionally, CNA #1 went to the foot of Resident #2's bed and doffed her gloves and donned new gloves, without performing hand hygiene. CNA #4 handed Resident #3's meal tray into CNA #1 who setup the resident's meal tray on the overbed table, removing lids, cutting food, and adding condiments. Further observation revealed CNA #1 came back to the doorway, doffed her gloves, and CNA #4 handed two (2) straws in paper wrappers into CNA #1, who then handed them to Resident #2. Continued observation revealed CNA #1 then doffed her gown and discarded it in the trash can near the door. She entered the bathroom in the resident's room and washed her hands. CNA #1 then exited the room into the hallway; she did not change her surgical mask or clean her eye protection. Interview with CNA #1, on 09/01/2021 at 9:45 AM, revealed she had worked at the facility for three (3) years. Per the interview she had received training in the facility, on Infection Control to include COVID-19, types of isolation, appropriate PPE to wear for each type of TBP, how to properly wear PPE, and hand hygiene. Additionally, she stated when a resident was in isolation, PPE was hung on their door so staff would know they were in isolation. She stated there was usually a sign on the doorway that would notify staff what type of TBP the resident required and what PPE to wear; however, she was not sure why Resident #2 and Resident #3 did not have a sign on the door. Further, after review of the SSA Surveyor's observations, on 08/31/2021 at 12:17 PM and 12:20 PM, CNA #1 stated she thought she had used PPE appropriately when entering and exiting Resident #4's room. She thought she had changed her dedicated mask and cleaned her face shield. CNA #1 stated she thought she used the appropriate mask (surgical mask) when entering Resident #2 and Resident #3's room and performed appropriate hand hygiene before entering and while in the room. Per the interview, she thought she changed her mask and cleaned her face shield when she exited the room. She stated following PPE guidelines was important to ensure infection control practices were followed to reduce the spread of infection. Observation, on 08/31/2021 at 12:25 PM, revealed the route from the COVID Unit to the kitchen included five (5) resident rooms on the D Wing. Interview with the Restorative Nurse, previous Assistant Director of Nursing and Infection Preventionist, on 08/31/2021 at 12:34 PM, revealed she had worked at the facility for three (3) years. Per the interview, the COVID Unit was Droplet Precautions, and all staff on the COVID Unit should always have on PPE to include: eye protection, KN95 mask, gown, and gloves. Continued interview revealed staff should wear dedicated PPE, a gown, mask, and eye protection and change their gloves in between each resident. Additionally, she stated appropriate PPE was important to avoid contracting and spreading COVID. She stated improper use of PPE would increase the risk for cross contamination, and she expected the facility's policy and CDC guidelines to be followed at all times. Per the interview, at no time should staff members on the COVID Unit not be wearing eye protection or gloves in a resident care area. In addition, she stated hand hygiene was expected before and after donning and doffing gloves. Further, she stated the interior double doors separating the COVID Unit and Wing D should not be accessed by staff. She reported the COVID Unit had an exterior entrance for dedicated unit staff to use to access the unit (decrease the risk of cross contaminations). Per the interview, notification/signage should be posted on the COVID Unit interior entrance door so staff and visitors were aware the unit was restricted and to not enter before speaking with a nurse. Continued interview with the Restorative Nurse, previous Assistant Director of Nursing and Infection Preventionist, on 08/31/2021 at 12:34 PM, on 08/31/2021 at 12:34 PM, revealed staff on Wing A should wear dedicated eye protection and surgical mask. Per the interview, isolations rooms should have appropriate PPE available at the door and appropriate notification should be placed on the door so that personnel and visitors were aware of what precaution(s) were necessary. Additionally, she stated staff should change surgical masks when entering and exiting TBP rooms and clean their eye protection to reduce the risk for cross contamination. She also stated PPE should be donned before entering an isolation room. Interview with the Director of Nursing (DON), on 09/01/2021 at 10:26 AM, revealed she had worked at the facility for four (4) years. Per the interview, she was responsible for Infection Control efforts in the facility. She stated she expected facility policies related to infection control and CDC Guidelines to be maintained by all staff. Additionally, she stated she expected hand hygiene to be performed before and after donning and doffing PPE. Per the interview, residents in TBP should have signs on their doors that specified what type of precautions the resident required and what PPE staff should wear in the resident's room. Signage was important for staff because there were different types of isolation, and staff needed the right PPE to decrease risk for infection and cross contamination. The DON stated the specialized COVID Unit should have a bright yellow sign on the interior double doors and tape across the doors to alert staff not to use the door. The only entrance for the COVID Unit was the exterior door. The COVID Unit's meals should be delivered via the exterior doorway, and any reusable dietary equipment should be cleaned prior to leaving the COVID Unit. She stated there should be no through traffic via the interior door between the COVID Unit and Wing D to reduce the risk for cross contamination. Further, she stated the COVID Unit required Droplet Precautions, and staff should wear a gown, a KN95 mask, eye protection, and gloves at all times. Continued interview with the DON, on 09/01/2021 at 10:26 AM, after review of observations by the SSA Surveyor, on 08/31/2021, revealed CNA #4 should have donned gloves before entering Resident #4's room and Therapist #1 and CNA #4 should have changed their face masks and cleaned their eye protection upon exiting Resident #4's room. Additionally, CNA #1 should have performed hand hygiene before donning and doffing PPE with Resident #2, Resident #3, and Resident #4. Further, the DON stated CNA #2 should have had gloves on in a resident care area in the COVID Unit and should have performed hand hygiene before donning gloves. The DON stated CNA #3 should have had on eye protection and gloves while in the resident care area in the COVID Unit and should have performed hand hygiene prior to donning gloves. Interview with Dietary Staff # 1, Dietary Staff #2, and Dietary Staff #3, on 09/01/2021 at 11:50 AM, revealed they delivered the COVID Unit meal cart through the double doors between D Wing and the COVID Unit. Additionally, they stated they picked up the COVID Unit meal cart outside the COVID Unit double doors after meal services. Further, they stated they pushed the meal cart to the kitchen before cleaning the cart with Virex. Interview with LPN #3/Unit Manger A Wing, on 09/01/2021 at 2:48 PM, revealed she was provided training and resources by the facility on Infection Control, including signs and symptoms of COVID; how COVID was transmitted; types of isolation; PPE; and hand hygiene. She stated, for residents who required TBP, PPE supplies were stored on their doors. Additionally, she stated direct care givers knew what type of isolation a resident required by a sign that was in a pocket of the over the door PPE container. The sign would state the type of isolation, i.e. droplet or contact, and the specific PPE required when entering the room. Per the interview, staff should be notified and know the proper PPE required for the different types of TBP to protect themselves and the resident and to reduce the spread of infection. Continued interview with LPN #3/Unit Manger A Wing, on 09/01/2021 at 2:48 PM, revealed Resident #2 was in Droplet Isolation because the resident was a new admit and had not received his/her COVID-19 vaccines. Further, Resident #4 was in Droplet and Contact Isolation because the resident was pending his/her second COVID-19 vaccine and had laboratory confirmation there was Extended Spectrum Beta-lactamase (ESBL, a bacterium) in his/her urine. Further, Resident #3 was in Droplet Isolation because the resident refused his/her COVID-19 vaccine in June 2021. Per the interview, the PPE that staff was required to wear when providing care to the residents was a respirator mask, gown, gloves, and eye protection. She stated staff should perform hand hygiene before donning PPE and after doffing PPE and should not enter the resident's room without all the above PPE, at any time. Observation, on 09/01/2021 at 4:30 PM, A Wing, Resident #2, revealed the call light was on above the resident's door. CNA #5 approached the resident's door wearing a dedicated surgical mask and eye protection. The resident's doorway had a sign in the top pocket of the over door PPE container, Droplet Precautions. CNA #5 did not perform hand hygiene and donned a gown and grabbed two (2) gloves, held them in her hand, and entered the resident's room. Additional observation revealed she entered the bathroom in the resident's room and washed her hands. She then stood at the foot of Resident #2's bed and donned the gloves. Further observations, on 09/01/2021 at 4:45 PM, revealed CNA #5 opened the resident's door, doffed the gown and gloves and washed her hands in the resident's bathroom. She then exited the room into the hallway and did not change her mask or clean her eye protection. Interview with CNA #5, on 09/01/2021 at 4:46 PM, revealed she had worked at the facility for four (4) years. Per the interview, she was unaware of the type of isolation Resident #2 required. However, she had received training on Infection Control, TBP, and PPE. Additionally, she was unable to tell the SSA Surveyor what PPE was required for a resident in Droplet TBP. Continued interview revealed it was important to wear appropriate PPE to not spread infection. Further, she stated she should have washed her hands and donned all PPE before entering the resident's room. Per the interview, she should have changed her mask and cleaned her eye protection after exiting the resident's room. Interview with the Administrator and Regional Consultant, on 09/02/2021 at 1:50 PM, revealed they expected staff to follow Infection Control guidelines (CDC and regulatory). Per the interview, they ensured Infection Control practices were maintained through audit practices in the building, utilizing observations, tracking, and trending. Additionally, they stated they expected hand hygiene guidelines to be followed as well as appropriate use of PPE for TBP's, specific to the isolation type. Both revealed they expected signage to be present on TBP rooms and the COVID Unit. They stated all these infection control practices were important to prevent transmission of disease.

Based on observation, interview, and record review, it was determined the facility failed to ensure medical records were maintained for one (1) of six (6) sampled residents (Resident #1). On Wednesday, 07/28/2021 at 10:00 PM, the facility admitted Resident #1 from an Acute Care Hospital, status post [MEDICAL RECORD OR PHYSICIAN ORDER] Additionally, on Thursday, 07/29/2021 at 1:05 AM, approximately three (3) hours after admission to the facility, Resident #1 was transferred to an Acute Care Hospital for pain management. Hospital records, dated 07/29/2021, revealed on arrival to the hospital, the resident was in significant pain. Additionally, the resident received pain medications at the hospital and was discharged back to the facility at 3:00 AM, with a pain rating of 6/10. However, review of the Electronic Medical Record (EMR) revealed no evidence the licensed nurse documented her assessment of Resident #1 upon re-admission back to the facility. Review of the resident's Controlled Drug Record (CDR) revealed Oxycodone 15 mg (milligrams) was signed out on the CDR, on 07/29/2021 at 5:00 PM and on 07/29/2021 at 11:00 PM. However, the medication was not documented as administered on the electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] The findings include: Interview with the Administrator, on 09/02/2021 at 1:50 PM, revealed there was no policy regarding accuracy of medical records. Review of Resident #1's closed EMR revealed the facility admitted the resident, on 07/28/2021 at 10:00 PM, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Baseline Care Plan, initiated on 07/29/2021 by the Director of Nursing (DON), revealed the resident had pain. The goal stated the resident would have relief or reduction in pain intensity within one (1) hour after receiving an intervention. Interventions included, but were not limited to: administer pain medication per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Progress Note, dated 07/29/2021 at 12:40 PM, completed by Licensed Practical Nurse (LPN) #3, revealed the resident verbalized complaints of pain upon arrival at the facility. However, the ordered pain medication was not made available to the resident, and the resident requested to be sent to the hospital and called 911. However, there was no documented evidence LPN #3 documented a re-assessment of Resident #1 when he/she returned to the facility on [DATE] at 3:04 AM. Interview with LPN # 3, on 09/01/2021 at 6:05 PM, revealed she had worked at the facility for six (6) months and had been a nurse for less than one (1) year. Per the interview, she was assigned to Resident #1, on 07/28/2021 and 07/29/2021 until 7:00 AM. Additionally, she stated it was facility practice to assess the resident and document in the EMR the assessment findings when a resident returned from the hospital. However, she must have forgotten to document her assessment on 07/29/2021. Further, LPN #3 stated the medical record should accurately reflect care and services provided to the resident. Review of Resident #1's CDR, dated 07/29/2021, revealed Oxycodone 15 mg was first signed out on the CDR, on 07/29/2021 at 5:00 PM, by Kentucky Medication Aide (KMA) #1. However, the medication was not documented as administered on the EMAR. Interview with KMA #1, on 09/01/2021 at 12:05 PM, revealed she had worked at the facility for four (4) years. Per the interview, she administered Resident #1 his/her PRN (as needed) Oxycodone when he/she was in pain, on 07/29/2021 at 5:00 PM. Continued interview revealed she forgot to document the administration of Oxycodone on the EMAR on 07/29/2021. However, she stated the medical record should be accurate to ensure standards of practice were met. Further review of Resident #1's CDR, dated 07/29/2021, revealed Oxycodone 15 mg was signed out on the CDR, on 07/29/2021 at 11:00 PM, by LPN #6. However, the medication was not documented as administered on the EMAR. The State Survey Agency (SSA) Surveyor attempted to contract LPN #6, on 09/02/2021 at 9:42 AM; however, she was not available. Interview with the Administrator, on 09/02/2021 at 1:50 PM, revealed she expected the medical record to be accurate with complete documentation of the care and services the resident received. Further, she stated it was important the medical record was accurate to ensure continuity in care.

Based on interview, record review, and review of the facility's policies, it was determined the facility failed to ensure an effective system was in place to obtain Pharmaceutical services, per Physician's orders, to meet the needs of each resident for one (1) of six (6) sampled residents (Resident #1). The facility failed to ensure pain medication was obtained from the pharmacy for Resident #1 in a timely manner. The facility admitted Resident #1 on Wednesday, 07/28/2021 at 10:00 PM from an acute care hospital that sent an invalid paper prescripton for Oxycodone (Schedule II narcotic pain reliever). The On-Call Provider was not notified that Resident #1 was not able to have the pain medication dispensed from the pharmacy, and Resident #1 was transferred to the hospital emergency room (ER), on 07/29/2021 at 1:05 AM, for pain management. The findings include: Review of the facility's policy titled, Controlled Substance Medication Orders, dated 2007, revealed before a controlled substance medication could be dispensed, the pharmacy must be in receipt of a clear, complete, valid prescription from a person lawfully authorized to prescribe. Additionally, written valid prescriptions for controlled substance medication could be faxed to the pharmacy from the facility for dispensing and the original hard copy was then sent to the pharmacy following state and federal regulation. Per the policy, to be a valid controlled medication prescription, some of the requirements included: the resident's name and address (street address of the facility); and printed name, address, and Drug Enforcement Agency (DEA) registration number of the prescriber. Further review revealed the prescriber could fax the valid signed controlled substance prescription to the pharmacy for dispensing. In addition, the practitioner could speak directly to the pharmacist to provide emergency authorization for the pharmacy to supply a small quantity of the Scheduled II medication until the practitioner could provide a valid signed prescription. Per the policy, when a verbal authorization was received by the pharmacist, the pharmacy would contact the facility nurse and provide an authorization to the nurse to access the controlled substance from the emergency supply located at the facility. Further, incomplete prescriptions for controlled substances should not be edited or changed by nursing staff. Continued review of the facility's policy titled, Controlled Substance Medication Orders, dated 2007, revealed written transfer orders for controlled substance medications could only be accepted by the pharmacy for dispensing if all components of a legal, complete prescription was completed and transferred/transmitted to the pharmacy by the prescriber or authorized prescriber's agent. Additionally, new orders for controlled substance medications originating in the facility should contain all required elements and be signed by the prescriber before leaving the facility. The policy stated new orders for controlled substance medications communicated to the nurse verbally by the prescriber via telephone would be entered into the physician's order sheet/telephone order sheet, and the prescriber would prepare a written prescription to fax to the pharmacy or if unable to provide a written prescription, in an emergency situation, verbally communicate the order directly to the pharmacy for a limited quantity. Review of the pharmacy, Hours of Operation/Delivery Window, revealed the new order cut off time, Monday through Friday, was 6:00 PM for a 9:00 AM delivery and 4:30 AM for a 6:00 PM delivery. Review of the facility's Emergency Medication Narcotic Box content list revealed the facility had four (4) Oxycodone 5 milligram (mg) tablets. Review of Resident #1's Hospital Discharge Summary, dated 07/28/2021, revealed the discharge plan included pain control with pain medication including Oxycodone 15 mg tablets, every six (6) hours, as needed (PRN). Review of Resident #1's closed Electronic Medical Record (EMR), revealed the facility admitted the resident, on Wednesday, 07/28/2021 at 10:00 PM, with diagnoses that included Disruption of External Surgical Wound, Pain in Right Leg, Need for Assistance with Personal Care, Muscle Weakness, Dislocation of Right Patella, [CONDITION(S)], Anxiety Disorder, and Major Depressive Disorder. Further review of the record revealed Resident #1 was discharged from the facility on 08/19/2021. Review of Resident #1's EMR revealed a scanned paper prescription from the discharging Acute Care Hospital, dated 07/28/2021: a written order for twelve (12) Oxycodone 5 mg; give three (3) tablets (15 mg), orally, every six (6) hours as needed for severe pain (seven (7) to ten (10) rating on the pain scale). However, there was no documented evidence of the doctor's/prescriber's name, DEA (Drug Enforcement Administration) number, license number, resident name, resident age, or resident address. Review of Resident #1's Medication Administration Record (MAR), dated July 2021, revealed no documented evidence Oxycodone 15 mg, one (1) tablet orally, every six (6) hours PRN for right leg pain, with a start date of 07/28/2021, was administered on 07/28/2021 or 07/29/2021. Review of Resident #1's Progress Note, dated 07/29/2021 at 12:40 PM, by Licensed Practical Nurse (LPN) #3, revealed she input medications orders on the EMR system. However, when faxing the prescriptions to the pharmacy, it was noted the prescriptions were invalid and did not include the resident's name. Further, the On-Call Provider was contacted and directed LPN #3 to attempt to obtain a valid prescription from the discharging hospital, and a facility provider would see the resident in the morning. However, the discharging hospital could not send a valid prescription to the facility/pharmacy until the morning of 07/29/2021 around 8:00 AM. Review of the Hospital Physician Documentation, dated 07/29/2021 at 1:23 AM, revealed Resident #1 presented to the emergency room (ER) with significant complaints of intermittent knee pain. Additionally, the resident verbalized he/she was at the Long Term Care (LTC) facility for a few hours and was informed there was an issue in transition to the LTC facility, and they were out of his/her pain medication. Further, the resident received pain medication and was discharged to the LTC facility, on 07/29/2021 at 2:51 AM. Additional review of Resident #1's EMR, revealed documented evidence the resident verbalized pain, on 07/29/2021 at 12:03 PM, to Physical Therapist #2. However, review of the resident's EMR revealed no pain medication or intervention was provided at the time the resident voiced complaints of pain. Review of the Pharmacy Electronic New Order, dated 07/29/2021 at 12:44 PM, revealed the pharmacy received (approximately fourteen and a half (14.5) hours after the resident was admitted to the facility) an electronically signed prescription for Resident #1; Oxycodone 15 mg, oral tablet, one (1) tablet, by mouth every six (6) hours as needed for pain. Further twelve (12) tablets were dispensed, on 07/29/2021 at 1:56 PM. Review of the Pharmacy Electronic Shipping Manifest, dated 07/29/2021 at 3:56 PM, revealed the facility received Resident #1's STAT Oxycodone 15 mg tablets, twelve (12) each. Further, review of Resident #1's Controlled Drug Record (CDR), dated 07/29/2021, revealed Oxycodone 15 mg was first signed out on the CDR, on 07/29/2021 at 5:00 PM. Interview with LPN #3, on 09/01/2021 at 6:05 PM, revealed she had worked at the facility for six (6) months and had been a nurse for less than one (1) year. Per the interview, she was assigned to Resident #1, on 07/28/2021 and 07/29/2021 until 7:00 AM. Continued interview revealed the Admitting Nurse should ensure controlled medications had the required prescriptions on admission. Additionally, she stated the Admitting Nurse would verify the orders and enter them into the EMR where the orders were automatically transmitted to the pharmacy, and prescriptions for controlled medications would be faxed to the pharmacy. The LPN stated the prescriptions sent with Resident #1 on admission (07/28/2021 at 10:00 PM) were invalid and the pharmacy would not accept them and dispense the resident's pain medications. She stated she contacted the On-Call PA and told him the resident needed a valid prescription from the physician for Oxycodone and was directed to call the discharging hospital. Further, the LPN stated she did not re-contact the On-Call PA when she was unable to obtain a valid prescription from the discharging hospital. She stated she did not call the On-Call Provider, on 07/28/2021 or 07/29/2021, for an order or prescription to obtain medications from the Emergency Medication box. Per the interview, when Resident #1 was informed the facility did not have his/her Oxycodone, the resident stated he/she was in significant pain and wanted to go to the ER for pain management. However, LPN #3 stated she should have called the On-Call PA (Physician's Assistant) back about the required prescriptions for Resident #1's pain medication. RN #1 stated it was important for the facility to ensure their protocol to ensure a resident's pain medication was obtained so the resident was provided pain management, did not have an increase in pain, and to contribute to quality of care and life. Interview with the On-Call PA, on 09/02/2021 at 10:03 AM, revealed, on 07/28/2021, he directed LPN #3 to contact the discharging hospital for a valid prescription for Oxycodone. He stated he did not hear back from the Nurse to see if she had obtained the pain prescriptions from the discharging hospital, and he did not follow-up with the Nurse to see if this happened. Further interview revealed if he had been told a prescription was needed to be sent to the pharmacy related to the resident's Oxycodone, he would have called the Physician to complete the prescription and send them straight to the pharmacy. However, he was not informed that prescriptions were needed for the Oxycodone. Further, the PA stated he expected nursing staff to notify him if a resident's pain medication was not available for administration. Per the interview, it was important that health care professionals ensured pain management in the LTC population because without pain management, residents had the potential to experience impaired comfort. Interview with the contracted Pharmacy Director, on 09/02/2021 at 10:15 AM, revealed review of Resident #1's profile showed the pharmacy did not receive a valid prescription for Oxycodone 15 mg every six (6) hours for pain, PRN. Therefore, the medication was never dispensed from the pharmacy to the facility. Additionally, the Pharmacist stated the pharmacy had no evidence of communication from the facility about the need for the medications. Further interview revealed when a resident was admitted to the facility, controlled medication required a faxed or electronic prescription sent to the pharmacy. Interview with the Director of Nursing (DON), on 09/01/2021 at 11:00 AM, revealed she expected pain medication to be available to residents timely after admission to the facility. Additionally, she stated it was the nurse's responsibility to ensure medications were verified with the On-Call Provider and necessary prescriptions were obtained and sent to pharmacy. The DON stated she expected the nursing staff to contact providers for direction when delivery of a medication was not available. Continued interview revealed it was important for the facility to have processes in place to ensure residents received their prescribed pain medications to ensure pain management and resident comfort. Interview with the Medical Director, on 09/01/2021 at 9:15 AM, revealed he expected nursing staff to call the On-Call Providers of all issues with residents' pain medications. Further, the Medical Director stated he expected a resident's pain medications to be available timely, after admission, and administered per orders. Per the interview, it was important that residents received ordered pain medication to ensure the best care and pain management. Interview with the Administrator, on 09/02/2021 at 1:50 PM, revealed she expected residents with pain to receive pain medication per the Physician's Orders. Additionally, she expected ordered pain medication to be available to residents as timely as possible after admission to the facility. Per the interview, she expected nursing staff to acquire necessary prescriptions from providers for ordered pain medication and to notify providers if the delivery of pain medication was delayed.

Based on interview, record review, and review of the facility's policies, it was determined the facility failed to have an effective system to ensure pain management was provided to residents who required such services. The facility failed to ensure pain medication was available to the resident per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility admitted the resident on 07/28/2021. Hospital discharge records, dated 07/28/2021, revealed the discharge plan included pain control. Additionally, the resident's discharge medication and the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On admission, the facility assessed the resident as having pain, at ten (10) on a scale from one (1) to ten (10), with ten (10) being the most severe. Interview with the licensed nurse who admitted the resident revealed the resident complained of severe pain and asked for pain medication. The On-Call Physician's Assistant was aware the facility needed written prescriptions for Oxycodone ([MEDICATION(S)]), to obtain the medications from the Pharmacy and directed the licensed nurse to obtain the prescriptions from the discharging Acute Care Hospital. Licensed Practical Nurse (LPN) #3 stated on Wednesday, 07/28/2021 between 10:00 PM and 07/29/2021 at 1:00 AM, the resident suffered in pain. The resident stated his/her pain was aching, burning, stabbing, sharp pain multiple times a day. Additionally, on Thursday, 07/29/2021 at 1:05 AM, approximately three (3) hours after admission to the facility, Resident #1 was transferred to an Acute Care Hospital for pain management. Hospital records, dated 07/29/2021 revealed on arrival to the hospital, the resident was in significant pain. Additionally, the medications received at the hospital included [MEDICATION(S)] (nonsteroidal anti-[CONDITION(S)] drug) 60 mg and two (2) [MEDICATION(S)] (narcotic pain reliever) 5 mg-325 mg. The resident was discharged back to the facility at 3:00 AM, with pain rated at a 6/10. On Thursday, 07/29/2021 at 12:03 PM, Resident #1 verbalized pain that interfered/limited functional activity to physical therapy. Interview with Physical Therapist #2 revealed he immediately notified LPN #4/Unit Manager A Wing the resident had verbalized pain. However, pain medication was not made available to the resident, as the facility failed to ensure prescriptions were provided to the pharmacy. Further, there was no documented evidence pain management was provided to Resident #1, at the facility, until 07/29/2021 at 5:00 PM. The findings include: Review of the facility's policy titled, Aspects of Care, undated, revealed medical services would be provided to all residents in a manner to achieve and maintain optimal standards of quality care and professional services; the overall coordination of services would be provided by the facility's medical director. Additionally, clinical services would provide resident care twenty-four (24) hours per day under the direction of the Director of Nursing (DON). Further review revealed clinical services was responsible for the assessment and delivery of nursing needs and the administration of medication. Continued review revealed residents would receive pharmaceuticals ordered by their physician without delay and have their drug regimen monitored by the Interdisciplinary Team (IDT) to prevent adverse incidents. Further, the policy stated the Admissions department would provide a smooth transition for the resident. In addition, notification would be made to the Administrator and all department heads, prior to admission, of the date/time of admission, room number, and initial paperwork. Review of the facility's policy titled, Pain Management, revised 11/06/2019, revealed the facility promoted effective pain management, including initial and ongoing pain assessment, timely response to complaints of pain, the use of appropriate pain relief measures and resident/family education. Additionally, each resident identified with pain would have ongoing assessment, a monitoring system, and a comprehensive person centered plan of care to address pain management to include the resident's goals and preferences. Per the policy, the facility was committed to help each resident attain or maintain their highest reasonable level of well-being and to prevent or manage pain to the extent possible through recognition of pain and circumstances when it could be anticipated; evaluating pain; and management or prevention of pain consistent with professional standards of care and in accordance with the plan of care. Further, a Pain Evaluation would be completed on admission and re-admission for each resident. Continued review of the facility's policy titled, Pain Management, revised 11/06/2019, revealed a Pain Assessment would be completed when there was potential for pain, noting the onset, presence, duration and characteristic of pain. Per the policy, the current pain management plan would be reviewed to determine medication, history of pain, pain characteristics, factors that could precipitate or exacerbate pain, and psychological or psychosocial concerns that could cause or exacerbate pain. Additionally, the facility would determine the resident's goals for pain management and satisfaction with level of pain. Continued review revealed a pain scale for the resident to describe the severity of the pain and for the evaluation of pain relief achieved after treatment would be used. A pain scale of zero (0) to ten (10) would be used with residents who understood the concept; residents who could not understand a numerical scale, would use a visual scale such as Wong-Baker faces to aid in determination of pain severity; residents with advanced Dementia would use the Pain Assessment in Advanced Dementia (PAINAD). Further, the IDT would develop a pain management plan for the resident with pain or potential for pain. Non-pharmacological interventions could be implemented for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The documentation of the administration of pain medication should be completed in the Electronic Medications Administration Record (EMAR). A Pain Evaluation should be completed each shift on all residents and documented in the EMR. Further, when the pain assessment revealed the resident's pain was not under control, the attending provider should be notified. Review of the facility's policy titled, Controlled Substance Medication Orders, dated 2007, revealed before a controlled substance medication could be dispensed, the pharmacy must be in receipt of a clear, complete, valid prescription from a person lawfully authorized to prescribe. Additionally, written valid prescriptions for controlled substance medication could be faxed to the pharmacy from the facility for dispensing and the original hard copy was then sent to the pharmacy following state and federal regulation. Per the policy, to be a valid controlled medication prescription, some of the requirements included: the resident's name and address (street address of the facility); and printed name, address, and Drug Enforcement Administration (DEA) registration number of the prescriber. Further review revealed the prescriber could fax the valid signed controlled substance prescription to the pharmacy for dispensing. In addition, the practitioner could speak directly to the pharmacist to provide emergency authorization for the pharmacy to supply a small quantity of the Scheduled II medication until the practitioner could provide a valid signed prescription. Per the policy, when a verbal authorization was received by the pharmacist, the pharmacy would contact the facility nurse and provide an authorization to the nurse to access the controlled substance from the emergency supply located at the facility. Further, incomplete prescriptions for controlled substances should not be edited or changed by nursing staff. Continued review of the facility's policy titled, Controlled Substance Medication Orders, dated 2007, revealed written transfer orders for controlled substance medications could only be accepted by the pharmacy for dispensing if all components of a legal, complete prescription was completed and transferred/transmitted to the pharmacy by the prescriber or authorized prescriber's agent. Additionally, new orders for controlled substance medications originating in the facility should contain all required elements and be signed by the prescriber before leaving the facility. The policy stated new orders for controlled substance medications communicated to the nurse verbally by the prescriber via telephone would be entered into the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Admission Minimum Data Set (MDS) Assessment, dated 08/04/2021, revealed the resident was assessed to have a Brief Interview for Mental Status (BIMS) score of fifteen (15) of fifteen (15), indicating his/her cognition was intact. Additionally, the resident was assessed to require extensive assistance with Activities of Daily Living (ADL). Further, per the Assessment, the resident had PRN and non-medication interventions; the resident had almost constant pain, rated 10/10, that affected his/her sleep and limited day to day activities Review of the pharmacy, Hours of Operation/Delivery Window, revealed the new order cut off time, Monday through Friday, was 6:00 PM for a 9:00 AM delivery and 4:30 AM for a 6:00 PM delivery. Review of the facility's Emergency Medication Narcotic Box content list revealed the facility had four (4) Oxycodone 5 milligram (mg) tablets. Review of Resident #1's Hospital Discharge Summary, dated 07/28/2021, revealed the resident was admitted to the hospital, on 07/20/2021, for a traumatic wound dehiscence of the right knee and severe pain. Per the Summary, the resident's pain was controlled with pain medication. Additionally, the discharge plan included pain control with pain medication including Oxycodone 15 mg, every six (6) hours PRN. Review of Resident #1's closed Electronic Medical Record (EMR), revealed the facility admitted the resident, on Wednesday, 07/28/2021 at 10:00 PM, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's EMR, revealed a scanned paper prescription from the discharging Acute Care Hospital, dated 07/28/2021: a written order for twelve (12) Oxycodone 5 mg; give three (3) tablets (15 mg), orally, every six (6) hours as needed for severe pain (seven (7) to ten (10) on the pain scale). However, there was no documented evidence of the doctor's name, DEA number, license number, resident's name, resident's age, or resident's address. Review of Resident #1's Admission Assessment, observation on 07/28/2021 at 10:00 PM, and completed by LPN #3, on 07/29/2021 at 3:54 AM, revealed Resident #1 was alert and oriented, to person, place and time. Additional review of the Assessment, revealed the resident had a surgical wound to his/her right knee, with a cast in place. Further review of the Assessment revealed the resident had pain; aching, burning, sharp and stabbing during the evening and night. Per the Assessment, Resident #1 rated his/her pain at 10/10; however an acceptable level of pain was 6/10. Review of Resident #1's Progress Note, dated 07/29/2021 at 12:40 PM, by LPN #3, revealed the resident arrived to the facility by ambulance and was alert and oriented; able to make his/her needs know. Per the note, the resident complained of pain upon arrival at the facility. Additionally, LPN #3, input medications orders on the EMR system; however, when faxing the prescriptions to the pharmacy, it was noted the prescriptions were invalid and did not include the resident's name. Further, the On-Call Provider was contacted and directed LPN #3 to attempt to obtain a valid prescription from the discharging Acute Care Hospital, and a facility provider would see the resident in the morning. However, when LPN #3 contacted the discharging Acute Care Hospital, she was informed a new prescription could not be sent to the facility/pharmacy until the morning of 07/29/2021, around 8:00 AM. The resident requested to be sent to the hospital and called 911. Review of Resident #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's MAR, dated July 2021, revealed no documented evidence Oxycodone 15 mg, one (1) tablet orally, every six (6) hours PRN for right leg pain, with a start date of 07/28/2021, was administered on 07/28/2021 or 07/29/2021. Review of Resident #1's, Emergency Medical Service (EMS) Patient Care Record, dated 07/29/2021 at 1:05 AM, revealed upon arrival to the facility, a nurse advised EMS the patient was new, and there were issues with obtaining the resident's prescription Oxycodone. The record stated because the facility was unable to get the resident's prescribed Oxycodone, the resident called 911 because his/her pain was not being managed appropriately, and the resident could not tolerate the severe pain until morning when the facility's provider would see the resident. Further, Resident #1 was assessed by EMS to be alert and orientated to person, place and time. Per the record, the resident had a cast above his/her right knee to his/her foot and arrived at the Acute Care Hospital, on 07/29/2021 at 1:25 AM. Continued review of Resident #1's Progress Note, dated 07/29/2021 at 1:48 AM, revealed Emergency Medical Services (EMS) arrived at the facility, around 1:15 AM, to transport the resident. Additionally, LPN #3 and EMS staff informed the resident he/she would be better off waiting at the facility until the morning for pain medication, but the resident insisted on being seen at the hospital. Review of the Acute Care Hospital, Physician Documentation, dated 07/29/2021 at 1:23 AM, revealed Resident #1 presented to the emergency room (ER) with complaints of knee pain. The resident was awake and alert and in a hard cast from the knee down (post-operative knee surgery). The resident stated he/she had intermittent pain that feels like razor blades in the right knee. Additionally, the resident verbalized he/she was at the Long Term Care (LTC) facility for a few hours and was informed there was an issue in transition to the LTC facility, and they were out of his/her pain medication. Continued review revealed the resident stated he/she was in significant pain. Further, the resident received two (2) [MEDICATION(S)] 5 mg tablets, orally; and [MEDICATION(S)] 60 mg, intramuscular. Per documentation, the resident's pain was 6/10 after pain management, and the resident was discharged to the facility, on 07/29/2021 at 2:51 AM. Review of Resident #1's, EMS Patient Care Record, dated 07/29/2021 at 3:04 AM, revealed the resident was transported from the Acute Care Hospital to the LTC facility after receiving care in the ER for complaints of leg pain. Additionally, the patient was found to have pain from a past fracture. Further, the resident's pain was rated 2/10 and was released to the LTC facility in good condition. Review of Resident #1's EMR, revealed no documented evidence of a Pain Assessment, until 07/29/2021 at 5:51 AM (approximately three (3) hours after the resident returned from the Acute Care Hospital), by LPN #3. The PAINAD assessment revealed a total score of zero (0). Per the Assessment, the total score ranged from zero (0) to ten (10) points; one (1) to three (3) indicated mild pain; four (4) to six (6) indicated moderate pain; and seven (7) to ten (10) indicated severe pain. Additional review of Resident #1's EMR, revealed no documented evidence of a Pain Assessment, until 07/29/2021 at 12:03 PM, by Physical Therapist #2. Per the Physical Therapy Plan of Treatment, the resident was referred to therapy due to a new onset of decrease in functional mobility, strength, postural alignment, skin integrity, and pain. Further, the resident verbalized pain that interfered/limited his/her activity. Per the assessment, nursing was to address the resident's pain. However, review of Resident #1's EMR revealed no pain medication or intervention was provided at the time the resident voiced complaints of pain. Review of the Pharmacy Electronic New Order, dated 07/29/2021 at 12:44 PM, revealed the pharmacy received (approximately fourteen and a half (14.5) hours after the resident was admitted to the facility) an electronically signed prescription for Resident #1: Oxycodone 15 mg, oral tablet, one (1) tablet, by mouth every six (6) hours as needed for pain. Further, twelve (12) tablets were dispensed, on 07/29/2021 at 1:56 PM. Review of the Pharmacy Electronic Shipping Manifest, dated 07/29/2021 at 3:56 PM, revealed the facility received Resident #1's STAT Oxycodone 15 mg; twelve each. Review of Resident #1's EMR, revealed no documented evidence the resident received pain management at the facility until 07/29/2021 at 5:00 PM. Review of Resident #1's Controlled Drug Record (CDR), dated 07/29/2021, revealed Oxycodone 15 mg was first signed out on the CDR, on 07/29/2021 at 5:00 PM, by Kentucky Medication Aide (KMA) #1. However, the medication was not documented as administered on the EMAR. There was no documented evidence on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Additional review of the EMAR, revealed no documented evidence Oxycodone 15 mg, PRN every six (6) hours, was administered on 07/28/2021. Additional review of Resident #1's EMR revealed no further documented evidence of a Progress Note, until 07/29/2021 at 5:07 PM, fourteen (14) hours after the resident returned from the Acute Care Hospital. Continued review revealed the resident had complaints of pain in his/her right lower extremity. Further, pain management was in place and effective. Further, review of Resident #1's CDR, dated 07/29/2021, revealed Oxycodone 15 mg was signed out on the CDR, on 07/29/2021 at 11:00 PM, by LPN #6. However, the medication was not documented as administered on the EMAR. There was no documented evidence on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Additional review of Resident #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Resident #1's Progress Note, dated 07/30/2021 at 3:55 AM, by Registered Nurse (RN) #3, revealed the resident was in bed with his/her right leg (in a cast) elevated. Additionally, the resident had complaints of pain. However there was no documented evidence of a pain assessment to include descriptors, indicators, intensity, frequency, intervention, and effectiveness of pain treatment. Per the note, at the time the resident complained of pain, it was too soon for the resident to receive pain medication because the order was for every six (6) hours PRN. Further, there was no documented evidence the resident was provided pain management at that time. Further, review of Resident #1's CDR, dated 07/29/2021, revealed Oxycodone 15 mg was signed out on the CDR, on 07/30/2021 at 5:45 AM, by RN #3, approximately one and one-half (1.5) hours after the resident complained of pain. The State Survey Agency (SSA) Surveyor attempted to contact Resident #1, on 08/30/2021, 08/31/2021, 09/01/2021 and 09/02/2021; however, after several phone attempts, Resident #1 was not available to the SSA Surveyor. Interview with the DON, on 09/01/2021 at 11:00 AM, revealed she was not aware, until Thursday, 07/29/2021, that Resident #1 did not receive his/her Oxycodone and was sent to the ER for pain management. Continued interview revealed it was important for residents to receive their prescribed pain medications to ensure optimal pain management and to promote healing and quality of life. Interview with Kentucky Medication Aide (KMA) #1, on 09/01/2021 at 12:05 PM, revealed she worked with Resident #1, on 07/29/2021. Continued interview revealed the resident complained of pain in his/her right knee. She stated Resident #1 told her he/she was not getting his/her prescribed Oxycodone, and the pain medication he/she was receiving was less than effective. Additionally, she stated she received the resident's Oxycodone from pharmacy around 3:00 PM that day. However, she stated she did not administer the medication to the resident until 5:00 PM during medication administration. Further, she stated it was important for residents to get their pain medication to ensure they were not in pain. Interview with LPN #4/Unit Manager, A Wing, on 09/01/2021 at 2:48 PM, revealed she had worked at the facility in her current position for only three (3) months. Per the interview, it was facility practice on admission and re-admission for the afterhours direct care nurse to be responsible to ensure the resident's assessment was documented and the resident's medications were ordered. She stated it was also the nurse's responsibility that the pharmacy received necessary valid prescriptions for controlled substance medications. Additionally, it was the direct care nurse's responsibility to ensure residents received their medications timely and to notify the On-Call Provider as necessary for prescriptions for medication, including STAT or one (1) time orders from the Emergency Medication box. Per the interview, nurses were provided education during floor orientation on the admission/re-admission process, pharmacy process, and pain assessment. Continued interview revealed LPN #3 should have called the On-Call Provider, on 07/28/2021 or 07/29/2021, when she was unable to obtain valid prescriptions from the discharging hospital for Oxycodone. Continued interview with LPN #4/Unit Manager (UM), A Wing, on 09/01/2021 at 2:48 PM, revealed, on 07/29/2021 at 11:00 AM, she attended the Clinical Interdisciplinary Team (IDT) meeting which included but was not limited to the Director of Nursing, Unit Managers, and Therapy. Per interview, the IDT reviewed and discussed what happened in the facility over the past twenty-four (24) hours. However, she stated she did not recall if Resident #1 was discussed in the meeting or if after the meeting the DON came to her and asked her to follow up on Resident #1's prescriptions for controlled substance medications. After the DON directed follow up, PT #2 notified her that Resident #1 was in pain. She stated she realized the resident's Oxycodone had not been received from the pharmacy, and she called the pharmacy, on 07/29/2021 at approximately 12:10 PM. She stated the pharmacy had not received a valid prescription for Resident #1's Oxycodone. The UM stated she called the provider and requested a STAT (immediate) order and for the prescription to be forwarded to the pharmacy for the resident's controlled substance medication. However, she stated she did not think to ask the provider for an Emergency Medication Box one (1) time order because she was focused on getting the medication sent to the facility. Per the interview, it was important for resident's to receive pain medication as ordered by the providers; it was the nurse's responsibility to advocate for residents and ensure pain management was provided to enhance quality of life. Continued interview with LPN #4/Unit Manager (UM), A Wing, on 09/01/2021 at 2:48 PM, revealed Resident #1 should have been provided pain management per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Per the interview, KMA #1 should have documented the administration of Oxycodone on the MAR, on 07/29/2021 at 5:00 PM, and there should have been a documented pain assessment prior to the administration of the medication. Additionally, LPN #6 should have documented the administration of Oxycodone, on 07/29/2021 at 11:00 PM. Further, RN #3 should have documented a thorough pain assessment, on 07/30/2021 at 3:55 AM, when the resident verbalized pain. Continued interview revealed RN #3 should have provided pain management to the resident when he/she verbalized pain, on 07/30/2021 at 3:55 AM. Interview with Physical Therapist (PT) #2, on 09/01/2021 at 4:15 PM, revealed he had worked at the facility for two (2) months. Per the interview, he completed an assessment of Resident #1, on 07/29/2021 around 12:00 PM. Additionally, while he worked with the resident, he/she verbalized pain in both legs; however, he did not get a rating or have the resident describe the pain further. Per the interview, the resident had been asking about medicine that he/she needed and the facility could not supply due to a mix up with pharmacy. PT #2 stated he did not provide the resident with pain management. Further, after the PT finished his evaluation, he passed along the resident's concerns about his/her pain medication and verbalization of pain to the A Wing Unit Manager. Continued interview revealed the resident had a non-removable hard cast on his/her leg due to a wound dehiscence from a previous fall, status post [MEDICAL RECORD OR PHYSICIAN ORDER] Interview with LPN # 3, on 09/01/2021 at 6:05 PM, revealed she had worked at the facility for six (6) months and had been a nurse for less than one (1) year. Per the interview, she was assigned to Resident #1, on 07/28/2021 and 07/29/2021 until 7:00 AM. The LPN stated, on 07/28/2021, it was her first admission at the facility by herself, and she had received limited orientation related to the facility's policies and procedures on admission including pharmacy services. Continued interview revealed she was not aware of the facility's policy related to pain management or medication administration. Additionally, she stated she was aware Resident #1 was in a lot of pain (10/10) immediately on admission, and the resident was requesting his/her pain medication (Oxycodone), which was not available at the facility. Per the interview, she kept the resident informed of the issues she was having with his/her prescription for Oxycodone. LPN #3 stated she realized the prescriptions sent from the discharging Acute Care Hospital were not valid, and the Pharmacy would not accept them and dispense the resident's pain medications. She stated she contacted the On-Call Provider and told him the resident needed a valid prescription from the Physician for Oxycodone, and was directed to call the discharging Acute Care Hospital to get a valid prescription or to see if she could get the resident to hold off until morning when a provider could see the resident. Further interview on 09/01/2021 at 6:05 PM, with LPN #3 revealed she did not notify an On-call supervising nurse about the situation or re-contact the On-Call PA when she was unable to obtain a valid prescription from the discharging Acute Care Hospital. She stated she tried not to call them after hours and awaken them. LPN #3 stated she did not call the On-Call Provider, on 07/28/2021 or 07/29/2021, for an order or prescription to obtain medications from the Emergency Medication box because she had already been told to have the resident wait until morning unless the discharging Acute Care Hospital was able to send the Pharmacy a valid prescription for Oxycodone. Per the interview, Resident #1 was alert and oriented, and when LPN #2 told the resident he/she could wait until morning to see a provider at the facility, or go to the ER for pain management, the resident agreed he/she wanted to go to the ER, and he/she called 911. LPN #3 stated it was facility practice to assess the resident and document in the EMR the assessment findings when a resident returned from the hospital; however, she must have forgotten to document her assessment on 07/29/2021. Per the interview, when the resident returned from the ER, he/she had better pain control than before he/she went to the ER. Per the interview, it was important for residents to receive pain medications per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #3 stated she did not talk to the Unit Manager or DON, on 07/28/2021 or 07/29/2021, about the resident not having a valid prescription for Oxycodone; however, she did pass the information on in shift report to the on-coming nurse. The SSA Surveyor attempted to contract LPN #6, on 09/02/2021 at 9:42 AM; however, she was not available. The SSA Surveyor attempted to contract RN #3, on 09/02/2021 at 9:45 AM; however, she was not available. Interview with the On-Call Physician's Assistant (PA), on 09/02/2021 at 10:03 AM, revealed, on 07/28/2021, he received a call from a facility nurse to verify Resident #1's hospital discharge medications. Additionally, he stated he discussed with the nurse that the resident had pain and to contact the discharging Acute Care Hospital for a valid prescription for Oxycodone. He stated he did not hear back from the Nurse to see if she had obtained the pain prescriptions from the discharging Acute Care Hospital, and he did not follow up with the nurse to see if this happened. Per the interview, if he had been told a prescription was needed to be sent to the pharmacy related to the resident's Oxycodone, he would have called the physician to complete the prescription and send them straight to the pharmacy. However, he stated he was not informed that prescriptions were needed for the Oxycodone. Further, the PA stated he expected nursing staff to notify him if a resident's pain medication was not available for administration. He stated he would never advise nursing staff to have a resident hold on receiving pain medication until morning. Per the interview, it was important that health care professionals ensured pain management in the LTC population because without the pain management, residents had the potential to experience impaired comfort. Interview with the contracted pharmacy's Pharmacy Director, on 09/02/2021 at 10:15 AM, revealed it was the facility's responsibility to coordinate admission times and request STAT medication (facility received within four 4) hours) orders and access to the Emergency Medication box. Additional interview revealed Resident #1's profile showed the pharmacy received an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Therefore, the medications were not dispensed from the pharmacy to the facility until 07/29/2021 at 1:56 PM. Additionally, the Pharmacy Director stated the pharmacy had no documented evidence of communication from the facility about the need for the medications until 07/29/2021 at 12:42 PM. The Pharmacy Director stated Resident #1's new admission prescriptions were not STAT orders and were received on 07/28/2021 after the cut off window (after 9:00 PM) and would have been delivered to the facility, on 07/29/2021 after 3:55 PM. Per the interview, the resident could have potentially experienced pain symptoms without receiving his/her pain medication, Oxycodone. Interview with the Staff Development Coordinator/RN, on 09/02/2021 at 12:00 PM, revealed she did not provide new nurses training on the facility's Admission/re-admission policies or practices. Per the interview, she also did not provide new nurse training on pharmacy policies and practices. She stated the floor nurse who oriented new staff for [TRUNCATED]

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure the Baseline Care Plan was developed and implemented to provide effective and person-centered care for one (1) of six (6) sampled residents (Resident #1). Resident #1's Baseline Care Plan, initiated on 07/29/2021, revealed the resident had pain,with interventions to administer pain medication per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . However, the facility failed to administer medications as directed/ordered. Further, the facility failed to assess the resident's pain before and after the administration of pain medication, as per the Care Plan. On Wednesday, 07/28/2021 at 10:00 PM, the facility admitted Resident #1 from an Acute Care Hospital, status post [MEDICAL RECORD OR PHYSICIAN ORDER] . However, the medications were never dispensed from the Pharmacy and were not administered as directed/per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the EMR revealed the resident was not administered his/her ordered pain medications, as directed per the Baseline Care Plan. The findings include: Review of the facility's policy titled, Baseline Care Plan, undated, revealed the initial Baseline Care Plan ensured care needs were met, utilizing a person centered focus for newly admitted and/or readmitted residents. Additionally, a nurse conducting the admission process would receive and incorporate evaluations and assessments into the Baseline Care Plan. Further, the policy stated the initial Care Plan would be refined by the interdisciplinary team (IDT) for the first forty-eight (48) hours after admission, utilizing input from all disciplinary team members along with the resident. Review of Resident #1's Hospital Discharge Summary, dated 07/28/2021, revealed the resident was admitted to the hospital, on 07/20/2021, with a traumatic wound dehiscence of the right knee and severe pain. Per the summary, the resident's pain was controlled with pain medication. Further review of the hospital discharge records, dated 07/28/2021, revealed the discharge plan included pain control. Additionally, the resident's discharge medication included Oxycodone (a narcotic pain reliever) 15 milligrams (mg) every six (6) hours as needed (PRN). Review of Resident #1's closed EMR (electronic medical record), revealed the facility admitted the resident, on Wednesday, 07/28/2021 at 10:00 PM, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed the resident was discharged from the facility on 08/19/2021. Review of Resident #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Admission Assessment, observation on 07/28/2021 at 10:00 PM, completed by Licensed Practical Nurse (LPN) #3, revealed Resident #1 was alert and oriented to person, place, and time. Additional review of the Assessment, revealed the resident had a surgical wound to his/her right knee, with a cast in place. Further review revealed the resident had pain; aching, burning, sharp and stabbing during the evening and night. Per the Assessment, Resident #1 rated his/her pain at 10/10. However, an acceptable level of pain was 6/10. Review of Resident #1's Electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Baseline Care Plan, initiated on 07/29/2021, revealed the resident had pain. The goal stated the resident would have relief or reduction in pain intensity within one (1) hour after receiving an intervention. Interventions included but were not limited to: Administer pain medication per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Progress Note, dated 07/29/2021 at 12:40 AM, completed by LPN #3, revealed the resident verbalized complaints of pain upon arrival to the facility. However, the ordered pain medication was not made available to the resident, and the resident requested to be sent to the hospital and called 911. Resident #1 was transferred out to the hospital on 07/29/2021 at 1:05 AM for pain management. Review of Resident #1's EMR revealed no documented evidence of a pain assessment, until 07/29/2021 at 5:51 AM, by Licensed Practical Nurse #3, approximately three (3) hours after the resident again returned from the Acute Care Hospital, on 07/29/2021 at 3:04 AM. The PAINAD (Pain Assessment in Advanced Dementia) assessment revealed a total score of zero (0). Per the Assessment, the total score ranges from zero (0) to ten (10) points. One (1) to three (3) indicated mild pain; four (4) to six (6) indicated moderate pain; and seven (7) to ten (10) indicated severe pain. Additional review of Resident #1's EMR revealed no further documented evidence of a Pain Assessment, until 07/29/2021 at 12:03 PM, by Physical Therapist (PT) #2. Further, the resident verbalized pain that interfered/limited his/her activity. Per the assessment, nursing was to address the resident's pain. Review of Resident #1's Controlled Drug Record (CDR), dated 07/29/2021, revealed no documented evidence on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Resident #1's Progress Note, dated 07/30/2021 at 3:55 AM, completed by Registered Nurse (RN) #3, revealed the resident had complaints of pain. However, there was no documented evidence of a pain assessment to include descriptors, indicators, intensity, frequency, intervention, and effectiveness of pain treatment. Review of the Baseline Care Plan, revealed staff were to complete a pain screen on admission and as needed. Further review of Resident #1's CDR, dated 07/29/2021, revealed Oxycodone 15 mg was signed out on the CDR, on 07/30/2021 at 5:45 AM, by RN #3, approximately one and one-half (1.5) hours after the resident verbalized complaints of pain. However, according to the Baseline Care Plan staff would administer pain medication per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #1's MAR, dated July 2021, revealed no documented evidence Tylenol 650 mg was administered to the resident on 07/30/2021. Additionally, Oxycodone 15 mg, one (1) tablet orally, every six (6) hours PRN for right leg pain, with a start date of 07/28/2021, was administered on 07/30/2021 at 5:50 AM. Further, the resident's pain was controlled and the medication was effective after administration on 07/30/2021. Review of Resident #1's Admission Minimum Data Set (MDS) Assessment, dated 08/04/2021, revealed the resident was understood and understood others. Per the Assessment, the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fifteen (15) of fifteen (15), indicating his/her cognition was intact. Additionally, the facility assessed the resident to have no behaviors present. Continued review revealed the resident required extensive assistance with Activities of Daily Living (ADL). Further, the resident had PRN Pain medication and non-medication interventions; the resident had almost constant pain, rated 10/10, that affected his/her sleep and limited day to day activities. Interview with Kentucky Medication Aide (KMA) #1, on 09/01/2021 at 12:05 PM, revealed she had worked at the facility four (4) years. Per the interview, she worked with Resident #1, on Wednesday, 07/28/2021. Additional interview revealed she administered the resident his/her PRN Oxycodone when he/she was in pain. Continued interview revealed per her scope of practice, as a KMA, she was not able to assess a resident's pain before and after administration of pain medication. KMA #1 stated she notified LPN #6 that the resident was in pain and that she had administered pain medication. Per the interview, she forgot to document the administration of Oxycodone on the EMAR on 07/28/2021. Interview with LPN #4/ Unit Manager, A Wing, on 09/01/2021 at 2:48 PM, revealed she had worked at the facility in her current position for three (3) months. Per the interview, the resident should have been provided pain management per the plan of care when the resident was in pain. Continued interview revealed she should have ensured the resident's pain was assessed, and the resident received pain medication, as ordered by the Physician, on 07/29/2021 at 12:00 PM, when PT #2 notified her the resident was in pain. Further, she stated RN #3 should have documented a thorough pain assessment, on 07/30/2021 at 3:55 AM, when the resident verbalized pain. Per interview, RN #3 should have provided pain management to the resident when he/she verbalized pain, on 07/30/2021 at 3:55 AM. Continued interview revealed, it was important for residents to receive pain medication as ordered by their providers. She stated it was the nurse's responsibility to advocate for residents and ensure pain management was provided for quality of life. Interview with LPN #3, on 09/01/2021 at 6:05 PM, revealed she had worked at the facility about six (6) months. LPN #3 stated she was assigned to Resident #1, on 07/28/2021 and 07/29/2021 until 7:00 AM. Per the interview, Resident #1's admission was the first admission she had completed at the facility by herself. She stated she received limited training during her orientation related to the facility's policies and procedures. LPN #3 states she was not aware of the facility's policy related to Baseline Care Plans. However, she was aware Resident #1 was prescribed Oxycodone for pain and was aware the resident was requesting his/her Oxycodone. LPN #3 stated the medication was not available to administer to implement the resident's Baseline Care Plan. The State Survey Agency (SSA) Surveyor attempted to contact LPN #6, on 09/02/2021 at 9:42 AM; however, she was not available. The SSA Surveyor attempted to contact RN #3, on 09/02/2021 at 9:45 AM; however, she was not available. Interview with the On-Call Physician's Assistant (PA), on 09/02/2021 at 10:03 AM, revealed he expected nursing staff to notify him if a resident's pain medication was not available for administration. Additionally, he stated he expected pain medication to be administered per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the Director of Nursing (DON), on 09/01/2021 at 11:00 AM, revealed she expected the Baseline Care Plan to be followed by staff to ensure the resident received the necessary individualized care. Per the interview and per Resident #1's Baseline Care plan, his/her pain medication should have been administered as directed/ordered by the Physician. Interview with the Administrator, on 09/02/2021 at 1:50 PM, revealed she expected a resident's Baseline Care Plan to be followed by staff to ensure care needs were met. Per the interview, she expected pain to be assessed per standards of care. Further, she stated she expected nurses to notify providers if a resident had less than effective pain management.

Based on interview, record review, and review of the Resident Assessment Instrument (RAI) 3.0 User's Manual, it was determined the facility failed to submit the Minimum Data Set (MDS) Assessments to the Centers for Medicare and Medicaid Services (CMS) within the required timeframe for one (1) of twenty-eight (28) sampled resident's (Resident #1). Review of the CMS Submission Final Validation Report, dated 12/12/19, revealed the facility failed to submit Resident #1's Annual MDS Assessment with an Assessment Reference Date of 09/26/19, within the required timeframe. The findings include: Review of the facility's MDS Assessment Completion Policy, revised (MONTH) (YEAR), revealed the facility will conduct and submit resident assessments in accordance with the Resident Assessment Instrument (RAI) Manual including federal and state submission timeframes. Review of the RAI 3.0 User's Manual, Version 1.16, dated (MONTH) (YEAR), Chapter 5 Submission and Correction of MDS Assessments, revealed comprehensive assessments must be transmitted electronically within fourteen (14) days of the Care Plan Completion Date (V0200C2 + 14 days). All other MDS assessments must be submitted within fourteen (14) days of the MDS Completion Date (Z0500B + 14 days). Entry and Death in Facility tracking records, information must be transmitted within fourteen (14) days of the Event Date (A1600 + 14 days for Entry records and A2000 + 14 days for Death in Facility records). Review of Resident #1's medical record revealed the facility admitted the resident on 11/30/18 with [DIAGNOSES REDACTED]. Resident #1's Annual MDS Assessment, revealed an Assessment Reference Date (ARD) date of 09/26/19. Review of the CMS Submission Final Validation Report, dated 12/12/19, revealed the Annual MDS Assessment ARD date was 09/26/19; and the Comprehensive Care Plan (CCP) and Care Area Assessments (CAA) were completed on 10/18/19. However, per the Report, the Assessment was transmitted on 12/12/19, which was more than fourteen (14) days after the CCP was completed. Interview with the MDS Director, on 12/19/19 at 5:00 PM, revealed all sections of Resident #1's Annual MDS Assessment were completed on 10/18/19, when the MDS transmission was supposed to take place. However, further interview revealed MDS Nurse #1 failed to sign the MDS Assessment or she may have signed and the electronic signature did not stay on the document and therefore the Assessment was not transmitted. Further interview with the MDS Director, revealed the process to ensure MDS Assessments were transmitted timely was to run a Monthly Final Validation Report; however, this error was not caught until 12/12/19. Per interview, once the error was identified, the MDS Assessment was transmitted on 12/12/19 to CMS. Post Survey phone interview, on 01/06/19 at 2:34 PM, with MDS Nurse #1, revealed she worked at the facility PRN (as needed), and would fill in if needed to complete MDS Assessments. Continued interview revealed she did not transmit MDS Assessments, as the transmission was the responsibility of the MDS Coordinator. Per interview, her job was to complete the MDS Assessment, CAA and CCP. Further interview revealed prior to the transmission of the MDS Assessment, she signed the CAAS, CCP, and MDS Assessment. However, she stated there were some issues when the facility switched to the new Electronic Medical Record system, as they were having problems with the signatures on the MDS Assessments holding. Interview with the Director of Nursing (DON), on 12/19/19 at 5:30 PM, revealed she did not monitor MDS transmissions. Further interview revealed she was not familiar with the MDS transmission process and did not provide supervision to the MDS Director. Per interview, the MDS Director was supervised directly by the Administrator, and there was also a Regional MDS Coordinator who the facility utilized as a resource for the MDS Director. Interview with the Administrator, on 12/19/19 at 5:43 PM, revealed it was discovered by the MDS Director on 12/12/19, after she ran a CMS Submission Final Validation Report, that MDS Nurse #1's signature was missing from Resident #1's Annual MDS Assessment. Per interview, the document did not transmit on 10/18/19 due to the missing signature. The Administrator stated this may have been due to a problem with the new Electronic Medical Record system. Further, when the error was discovered on 12/12/19, the MDS Assessment was transmitted on that date. Continued interview revealed it was the Administrator's expectation that all MDS Assessments be transmitted timely as per the RAI Manual.

Based on observation, interview, record review, and review of facility Policy, it was determined the facility failed to ensure each resident receives services in the facility with reasonable accommodation of resident needs for two (2) of twenty-eight (28) sampled residents (Residents #25 and Resident #69). Observation on 12/17/19 and 12/19/19, revealed Resident #25 and Resident #69's call lights were out of reach and inaccessible to the residents. The findings include: Review of the facility's Kentucky Resident Handbook and Admission Information Signature Healthcare: KY revised 03/14/2019, revealed the facility will provide general nursing care and treatment to all residents in a non-discriminatory manner as required by federal and state law. Further review revealed this is without regard to race, gender, religion, national origin, veteran status, sexual preference, disability, age, or any other legally protected status. Review of the facility's Answering Call Lights: Guideline Steps Policy, undated, revealed staff are to leave the call light on until the resident's needs are met. The staff are to identify themselves to the resident by their name and address the resident by name. Continued review revealed the staff are to listen to the resident's request, and do what the resident has requested if permitted. If assistance is needed when entering the room, summon help by using the call signal. However, the Policy did not address the need to ensure the call light was in reach of the resident. Observation and inspection of the facility call system on 12/17/19 at 10:15 AM, revealed the call light consisted of a long white cord with a singular push button activation. 1. Review of Resident #25's clinical record revealed the facility admitted the resident on 11/30/18 and readmitted the resident on 03/13/19 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated 12/09/19, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) of nine (9) out of fifteen (15) indicating moderate cognitive impairment. Further review revealed the facility assessed the resident as requiring extensive assist of two (2) persons for bed mobility and toileting; requiring total assist of two (2) persons for transfers; and as did not ambulate. Observation of Resident #25 on 12/17/19 at 11:12 AM, revealed he/she was sitting in the wheelchair which was positioned to the left side of the bed. The resident was wearing a support type glove to the right hand. Further, the call light was in the center of the bed and was not accessible to the resident. Interview with Resident #25 on 12/17/19 at 11:12 AM, revealed staff often placed his/her call light out of reach. Resident #25 stated in order to receive care, he/she had to call out into the hall to get assistance. Continued interview revealed the resident was unable to use his/her right hand with the glove support, but staff would often wheel him/her to his/her room and leave him/her in the wheelchair to the left of the bed. Per interview, he/she was unable to use the call light from that position. During this interview, State Registered Nurse Aide (SRNA) #1 entered the room and explained she was not aware the resident was back in his/her room. SRNA #1 did not identify the call light was out of the resident's reach, and did not ensure it was in reach prior to exiting the room. Further interview with Resident #25, after SRNA #1 left the room, revealed he/she wanted to go to bed, and could not use his/her call light. Resident #25 then called out to staff in the hall that he/she wanted to go to bed. Licensed Practical Nurse (LPN) #1 immediately arrived in the room, moved the resident to the right side of the bed, and placed the call light where he/she could reach it with his/her left hand. Resident #25 was then agreeable to sitting up in the wheelchair for the lunch meal. Continued observation revealed maintenance came into the room and hooked up a longer call light cord at the request of LPN #1. Interview with SRNA #1 on 12/19/19 at 10:13 AM, revealed the call lights should be within reach of the residents while they were in their rooms or in the restrooms. Further interview revealed she did recall on 12/17/19, Resident #25 was in his/her room and sitting in the wheelchair which was positioned on the left side of the bed. Per interview, she should have ensured Resident #25 was positioned on the right side of the bed while in the wheelchair in order for him/her to be able to use his/her left hand to reach the call light since he/she could not use his/her right hand due to pain. Per interview, on that date she should have ensured the call light was in reach prior to exiting the room. Interview with LPN #1, on 12/19/19 at 1:19 PM, revealed on 12/17/19, she did notice Resident #25 was unable to use his/her call bell when he/she had to call out for staff. Per interview, the resident's call light was not within reach when she checked on him/her on that date, and she had a longer cord put on the call light. Further interview revealed if a resident did not have access to his/her call light, that could be a safety issue. Interview on 12/19/19 at 10:42 AM, with the Unit Manager for the unit in which Resident #25 resided, revealed Resident #25 would not be able to use his/her right hand with the [MEDICAL CONDITION] Glove on, and the call light should not be placed to his/her right side. Per interview, the facility did address the issue on 12/17/19 by placing a longer call light cord in the room and on that date staff was instructed to position the call light on the resident's left side at all times. 2. Review of Resident #69's medical record revealed the facility admitted the resident on 12/18/19 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated 10/19/19, revealed the facility assessed the resident as having a BIMS score of zero (0) out of fifteen (15) indicating the resident was unable to complete the interview. Further review of the MDS Assessment, revealed the facility assessed the resident as independent with bed mobility. Continued review of the MDS Assessment, revealed the facility assessed the resident as requiring the assist of one (1) staff for transfers and ambulation; and requiring limited assist of two (2) staff for toileting. Testing of the call light in Resident #69's room (room [ROOM NUMBER]) on 12/17/19 at 10:15 AM, on the locked unit, revealed adequate communication and signaling to display the light directly above the resident's room door. Observation of Resident #69, on 12/17/19 at 10:30 AM, revealed the resident was resting in bed. Further observation revealed the resident's call light was not in plain view, and after searching for the call light, it was found on top of the overhead light above the resident's bed out of reach of the resident. A metallic clip was attached to the call line which would allow placement and securement to the resident's bed linens. Observation of staff on 12/17/19 at 10:45 AM, revealed they were conducting rounds in and out of Resident #69's room. Further observation on 12/17/19 at 11:00 AM, revealed after staff rounds, Resident #69's call light remained in the previous location on the overhead light out of reach, while the resident was resting in bed. The Surveyor attempted an interview with Resident #69, on 12/18/19 at 2:00 PM; however, the interview was unsuccessful due to the resident's cognitive status. Observation on 12/19/19 at 9:00 AM, revealed Resident #69 was in bed with eyes closed. Further observation revealed the resident's call light was directly behind the resident's bed in the floor inaccessible to the resident. Interview with SRNA #1 on 12/19/18 at 2:00 PM, revealed the SRNAs shared responsibility of the residents on the locked unit and she was familiar with Resident #69. Per interview, Resident #69 was actively encouraged to utilize the call system, and at times was capable of using and making specific requests. Further interview revealed having call lights in reach of residents was a facility expectation, and was crucial in the prevention of accidents. Per interview, call lights should always be in reach of the residents in order for them to be able to communicate with staff, and receive the required assistance. Further interview revealed residents who could not reach or find call lights were prone to falls or other potential accidents, especially if the call light cord was lying on the floor. Interview with SRNA #2, on 12/19/18 at 2:15 PM, revealed Resident #69 sometimes used his/her call light. SRNA #2 stated it was the facility's expectation that call lights be in reach of the residents. Per interview, call lights were not to be in the floor as the cord could cause a resident to trip. Further interview revealed call lights should be checked during scheduled rounds for placement and any time care was provided. Interview with SRNA #3, on 12/19/18 at 3:00 PM, revealed call lights should be accessible and visible to the residents. Further Interview revealed the facility provided training and education on call light placement and all staff was responsible for answering and maintaining call lights in resident rooms. Interview with LPN #1, on 12/19/18 at 3:30 PM, revealed she was assigned to Resident #69. Per interview, all residents were to have call lights in reach and accessible for use. She stated when residents were in bed resting, call lights should be pinned to the bed sheet in reach of the resident and not obstructed by sheets or blankets. Per interview, if a resident was sitting in a chair, the call light needed to be placed in view of the resident and in reach. Further interview revealed residents could not receive proper assistance if they could not find or reach their call lights. In addition, she stated there was the potential for falls or accidents if residents could not reach the call lights. Additional interview revealed all staff was responsible for checking call lights to ensure they were in reach prior to exiting any residents' room. Interview with the Director of Nursing, on 12/19/18 at 5:00 PM, revealed it was her expectation for call lights to be in reach, visible, and accessible to residents. Per interview, there was the potential for accidents such as falls if call lights were out of reach, and residents could not call for assistance. Further interview revealed any time a staff member was in a resident's room, they should check to ensure the call light was in reach prior to exiting the room. Interview with the Administrator, on 12/19/18 at 5:15 PM, revealed call lights should be in reach and in plain sight while residents were in their rooms or in the bathrooms. Per interview, if call lights were out of reach, this could prohibit residents from receiving prompt care and assistance, which may lead to falls or other accidents. The Administrator further stated it was her expectation for all staff to be answering and monitoring call lights in resident rooms.

Based on observation, interview, record review, review of the facility's Policies, review of the facility's Investigations, and review of the Manufacturer's Guidelines for the Wander Management System, it was determined the facility failed to have an effective system in place to ensure each resident received adequate supervision and assistive devices to prevent accidents for (2) of sixteen (16) sampled residents (Residents #1 and #6). On 05/04/18, the facility admitted Resident #1, assessed the resident to be at risk for wandering, and provided a wanderguard bracelet (a tracking device designed to prevent persons at risk for wandering from leaving a facility, unless they were accompanied). Staff interviews revealed the resident had a history of [REDACTED]. Staff interviews further revealed on 08/30/18, the resident was exhibiting repeated wandering episodes to the C and D units and staff brought the resident back to the B unit without reporting the wandering behavior to the Charge Nurse, or any staff on the B unit, therefore, the resident's monitoring and supervision was not increased. On 08/30/18, after 7:30 PM, Resident #1 exited the building without staff's knowledge from the C unit dining room exit which had a Wander Alert System. However, the Wander Alert System on this exit door was non-operable at the time of the resident's exit. The resident walked across a two (2) lane highway in sock feet and was found by a stranger greater than one half (1/2) mile from the facility. A facility visitor who had already left the facility between 7:45 PM and 7:50 PM, recognized Resident #1 and called his sister who was visiting at the facility, to alert staff the resident was walking towards a local gas station. Resident #1 was returned to the facility at approximately 7:58 PM and was assessed with [REDACTED]. In addition, the facility failed to ensure a quarterly system inspection of the Wander Management System, by a qualified representative, as per the Manufacturer's Recommendation, to ensure the system's safety and performance of the door alarms in conjunction with the wanderguard transmitters. Per the Manufacturer's Recommendation, Failure to provide regular inspections of the product may result in equipment and/or system failure. There was no documented evidence provided to support the facility's equipment, on all facility exit doors, was checked by a qualified representative prior to Resident #1's elopement on 08/30/18. (Refer to F-659) Furthermore, Resident #6 was assessed by the facility to require total assistance of two (2) persons for bed mobility and transfers per the Quarterly Minimum Data Set (MDS) assessment dated [DATE]. According to the Comprehensive Care Plan dated 03/27/18, Resident #6 was to be transferred with a Hoyer lift (mechanical assistive device used to transfer a person between surfaces by use of electrical or hydraulic power) for all transfers. However, on 09/03/18, Resident #6 was not transferred with a Hoyer lift, as per the Comprehensive Care Plan, and was transferred with a stand and pivot maneuver with one (1) staff member holding on to the back of the resident's clothing to assist the resident to rise into a standing position. Resident #6 sustained a large area of discoloration and swelling to the upper right arm and complained of pain with movement the following morning on 09/04/18. An X-Ray obtained on 09/04/18, revealed the resident sustained [REDACTED].#6. (Refer to F-659) The facility's failure to have an effective system in place to ensure each resident received adequate supervision and assistive devices to prevent accidents has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified on 09/07/18 and determined to exist on 08/30/18. The facility provided an acceptable Allegation of Compliance (AoC) on 09/19/18, with the facility alleging removal of the Immediate Jeopardy on 09/03/18. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on 09/03/18, prior to exit on 09/20/18, with remaining non-compliance at a Scope and Severity of a G while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: 1. Review of the facility's Safety and Supervision of Resident Policy, review date 05/31/18, revealed resident safety, supervision, and assistance to prevent accidents were facility wide-priorities. Continued review revealed staff would ensure the safety and well-being of the residents by making routine resident and environmental checks. Further review of the Policy, revealed routine resident checks by nursing staff involved entering the resident's room and/or identifying the resident elsewhere on the unit to determine if the resident's needs were being met. Additional review of the Policy, revealed the resident-oriented approach to safety addressed safety and accident hazards for individual residents. Further review revealed implementing interventions to reduce accident risks and hazards would include the following: communicating specific interventions to all relevant staff; assigning responsibility for carrying out interventions; and ensuring the interventions were implemented and documented. Review of the Wander Management Transmitters User Guide, copyright (YEAR), revealed the system was designed and intended to work in conjunction with a facility's overall resident security program, including operating policies and procedures. Further review revealed the Wander Management Solution, by itself, cannot prevent the elopement of residents. Continued review revealed it was the responsibility of the facility to establish and facilitate a regular inspection schedule of the system. Additional review revealed the Manufacturer recommended quarterly inspections of the system for safety and performance by a qualified technician. Failure to provide regular inspections of the product would result in equipment and/or system failure. Interview with the Plant Operations Director, on 09/06/18 at 11:20 AM, revealed the facility had Alarm Egress doors which opened to the outside of the building and would alarm and release fifteen (15) seconds after pushing the panic bar. He further stated the facility also had a Wander Alert System and if a resident wearing a wanderguard bracelet walked towards the door, the voice activated alert would state Wander Alert and would state the unit or area of the door which was being activated. Review of Resident #1's Medical Record revealed the facility admitted the resident on 05/04/18 with [DIAGNOSES REDACTED]. Review of Resident #1's Admission Elopement Risk Evaluation, dated 05/04/16, revealed the resident was assessed to be at risk for elopement. The Resident's risk factors included cognitive impairment, independently mobile, poor decision making skills, exit-seeking behavior, wander oblivious to safety needs, and the ability to exit the facility. Review of Resident #1's Comprehensive Care Plan, dated 07/04/18, revealed the resident was at risk for elopement as evidenced by attempts to open exit doors. The goal stated the resident would not elope and would be monitored for whereabouts on an ongoing basis. The interventions included using verbal and if necessary physical cues for redirection related to exit-seeking behaviors; use diversional activities when exit-seeking behaviors occurred including offering food, activities, and one (1) on one (1) company; and wanderguard. Review of the resident's Quarterly Minimum Data Set (MDS) Assessment, dated 08/11/18, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of three (3) out of fifteen (15) indicating the resident was severely cognitively impaired. Additional review of the MDS Assessment, revealed the facility assessed the resident as having no wandering behaviors. Review of Resident #1's (MONTH) (YEAR) Monthly physician's orders [REDACTED]. Review of the Treatment Administration Record (TAR), dated (MONTH) (YEAR), revealed the wanderguard to the resident's ankle was checked for placement and function 08/01/18 through 08/30/18. Further review revealed the wanderguard bracelet was checked the morning of 08/30/18, with no concerns identified. Review of the facility's Event Manager Clinical Summary Report, dated 08/30/18, signed by Licensed Practical Nurse (LPN) #7, under the section titled, Detailed Description, revealed Resident #16's family member came to the nurse's station and told Licensed Practical Nurse (LPN) #7, her brother had called and stated a resident was wandering by the local gas station. LPN #7 immediately told LPN #8, left the facility and drove to get the resident. Further review revealed when LPN #7 pulled to the resident's location, she observed a woman walking with the resident by the road. LPN #7 approached Resident #1 and the resident got into LPN #7's car. Further review of the Event Manager Clinical Summary Report, under the section titled Elopement Specific Information, revealed an Elopement Allegation related to Resident #1 was reported to the Director of Nursing (DON), on 08/30/18 at 7:58 PM by LPN #7. LPN #7 documented the resident was last seen at the nurse's station at 7:09 PM. Per the Report, another resident's family member called a facility visitor and that visitor informed LPN #7, the resident was at the local gas station. Additional review revealed the resident was easily coaxed into the vehicle after offering the resident a snack. LPN #7 documented the resident had a history of [REDACTED]. Continued review revealed the exit doors did not alarm. A search of the building and premises was not completed because the facility did not know the resident was missing. No injuries were noted per the head to toe assessment. The resident had no pain and his/her Vital Signs were stable. Per the Report, the DON, Advanced Registered Nurse Practitioner (ARNP), and Administrator were notified of the elopement on 08/30/18 at 8:07 PM and Resident #1's family was notified on 08/30/18 at 8:30 PM. Review of the Event Manager Clinical Summary Report, dated 08/30/18, signed by the DON, revealed the resident was last seen in the C wing dining room and was reported missing at 7:53 PM. The resident was found a the local gas station. The DON documented the exit location was the C wing dining room, and the door malfunctioned. Further review revealed the resident had a history of [REDACTED]. Review of the facility's Investigation, dated 09/04/18, revealed Resident #1 went outside through the C unit dining room door at approximately 7:30 PM on 08/30/18. The resident was last seen by LPN #7 at approximately 7:15 PM at the nurse's station. Resident #1 was found off grounds by a family member of another resident who notified the facility staff immediately. Resident #1 was returned to the facility by LPN #7 at approximately 7:58 PM. LPN #9, immediately performed an assessment, to include a head to toe skin check, with no injury identified. Further review, revealed the door located on the C unit dining room was found to be malfunctioning. Continued review of the Investigation, revealed the Plant Operations Director inspected the door located on the C unit dining room on 08/30/18, and access panels externally and could not find any visible issues. The Plant Operations Director then removed the panel covers of the access panels and at this point he was able to determine two (2) internal wires had come into contact with each other and had caused the door to malfunction, keeping this door in the open mode. Further review of the Investigation, revealed this would not have been visible during the facility's daily inspections of the doors and the door systems. Additional review revealed the Plant Operations Director repaired the wires immediately and the door became operational and all other doors were re-evaluated to ensure that they were also functioning correctly and were secure, with no further problems noted. Observation on 09/06/18 at 1:15 PM, of the elopement route, revealed Resident #1 would have traveled from the C unit dining room exit door through a pavement walkway, then through the facility's parking lot, which had two (2) stop signs before leaving the grounds. Continued observation revealed the resident would have walked towards a two (2) lane street, before turning left to cross over to a busy two (2) lane highway with no sidewalks which was close to an Interstate to get to the local gas station, where the resident was found. Additional observation further revealed the path was about a fifteen (15) minute walk and greater than a one half (1/2) mile from the facility. Observation of Resident #1, on 09/04/18 at 10:30 AM, revealed the resident was dressed in a green sweat suit. The resident wore non-skid red socks and his/her wanderguard was on his/her left ankle. Interview was attempted during the observation. The resident stated he/she had a friend, but was not sure what happened to him/her. He/she further stated this State Surveyor would not want to talk with him/her, adding, I can't remember anything. Phone interview on 09/06/18 at 3:43 PM, with State Registered Nurse Aide (SRNA) #7, revealed she was assigned to Resident #1 on the B Wing on 08/30/18 from 7:00 AM to 7:00 PM. She stated the last time she saw the resident that evening, he/she was on the C Wing of the facility, near the Nook (Area outside of the C wing dining room area) about 7:00 PM. SRNA #7 stated she and SRNA #15 were clocking out and the resident asked them for ice for his/her pitcher. Continued interview revealed SRNA #7 and SRNA #15 provided the resident with ice and brought the resident back to his/her unit. Per interview, she did not see any other SRNAs on the unit when she brought the resident back, but noticed the nurses sitting at the nurse's station, during shift report. SRNA #7 stated she did not alert anyone the resident was wandering from unit B to unit C. She further stated she probably should have alerted the resident's assigned SRNA. Per interview, she knew the resident had a wanderguard, and staff was to keep an eye out for the resident. Interview with SRNA #15, on 09/06/18 at 4:28 PM, revealed she worked from 7:00 AM to 7:00 PM, on the B Wing the day Resident #1 exited the facility. SRNA #15 stated she helped provide care for the resident that day and the resident stayed in his/her room for most of the day. She further stated the resident's behaviors on a daily basis included sitting in the lobby area, roaming around the facility, or walking up and down the hallways and looking out the doors. Continued interview revealed Resident #1 was standing in the C unit dining area, when she was leaving the building about 7:00 PM. Per interview, SRNA #7 and SRNA #15 walked the resident back to the B Wing where the resident resided, and provided the resident with ice, per his/her request. She stated she left the resident on the B unit, but did not see any SRNAs on the unit. Per interview, it was change of shift and the nurses were in the process of giving shift report. Further interview revealed she did not alert staff the resident was wandering from one (1) unit to the next. SRNA #15 stated she should have alerted staff the resident was found on the C unit. Phone Interview with SRNA #2, on 09/05/18 at 9:09 PM, revealed she clocked in a few minutes before 7:00 PM on 08/30/18, on the D unit, and a few minutes later she noticed Resident #1 was on her unit. SRNA #2 stated she walked the resident back to the B unit where the resident resided. Per interview, she guided the resident to the nurse's station and left the resident with a cookie. She stated the resident was again found on the D unit around 7:15 PM. Per interview, she gave the resident a glass of water and brought him/her back to the B unit. SRNA #2 stated she saw the resident again around 7:30 PM, near the Nook, an area outside the C unit dining room, and he/she was walking towards her unit. She stated she was giving another resident a shower a the time, so told the resident to go back to his/her unit. Per interview, she did not tell the nurse or the resident's SRNA the resident was wandering to the D unit of the facility, but stated she should have as there was the potential for harm including falls with injuries, if a resident who was was wandering exited the facility without staff's knowledge. Phone Interview with SRNA #13, on 09/06/18 at 5:16 PM, revealed she was assigned to care for Resident #1 on the evening the resident eloped. SRNA #13 stated she reported to work at 7:00 PM that evening on the B unit. SRNA #13 stated after she received report she began her rounds with SRNA #12, and shortly afterward SRNA #12 was pulled to assist SRNA #14 with a resident on the Hospice Unit. SRNA #13 stated the last time she saw Resident #1 prior to him/her exiting was at 7:00 PM, by the nurse's station. She stated she was unaware the resident was wandering from the B unit that evening, and if she had known, she would have walked with the resident, redirected the resident to the television room, and kept a closer eye on the resident. Per interview, she did not hear a door alarm that evening, or the wanderguard voice alert. Phone Interview with SRNA #14, on 09/05/18 at 4:18 PM, revealed she worked the evening Resident #1 eloped. SRNA #14 stated she worked the Hospice Unit, which was a side hall on the B unit. SRNA #14 further stated she last saw Resident #1 on 08/30/18 prior to the elopement at 7:10 PM, standing at the B unit nurse's station. Per interview, the resident was wearing a blue top and tan colored khaki pants. SRNA #14 stated the resident had on socks and was not wearing any shoes. SRNA #14 further stated she did not hear an alarm when the resident exited the building or a wanderguard voice alert. Per interview, it was dangerous for this resident to exit the facility without staff's knowledge as the resident could have been hit by a car, or injured him/herself. Phone Interview with SRNA #12, on 09/06/18 at 5:49 PM, revealed she reported to the B unit, a little bit prior to her shift at 7:00 PM on 08/30/18. SRNA #12 stated she teamed up to work with SRNA #13 to provide care for the residents on the unit. SRNA #12 further stated the last time she saw Resident #1 on 08/30/18 prior to the resident leaving the building, was around 7:15 PM at the B unit nurse's station. Continued interview revealed she was asked by SRNA #14, to assist her on the Hospice unit. SRNA #12 stated while caring for the residents on the Hospice Unit, a family member of another resident yelled that her brother found Resident #1 walking towards the gas station. Per interview, she did not hear a door alarm that evening, or a wanderguard voice alert. Interview with Resident #16's son, on 09/06/18 at 1:11 PM, revealed he left the facility, on 08/30/18 between 7:15 PM and 7:30 PM. He stated he was at the stop sign on the main road and recognized Resident #1 who was walking along the guardrail. Continued interview revealed he noticed the resident was wearing black pants, a light blue top, and red non-slip socks. He stated he did not observe shoes on the resident. Resident #16's son stated the resident walked slow which probably meant the resident had been gone from the facility for awhile. He stated, it was not safe, what if the resident turned left and went under the rail road tracks or went across the highway? Interview with Resident #16's daughter, on 09/06/18 at 11:22 AM, revealed her brother left the facility to go home while she stayed with Resident #16 on 08/30/18. Per interview, her brother called that evening and told her, there was someone who may be a resident by the gas station, halfway across the road, and there was a good Samaritan with the resident (time unknown). Resident #16's daughter stated she ran out and told LPN #7. Per interview, LPN #7 then rushed out of the facility and brought the resident back. Phone Interview with LPN #7, on 09/05/18 at 12:00 PM, revealed she was assigned to Resident #1 the evening of the resident's elopement. LPN #7 stated she recalled seeing the resident at the beginning of her shift, around 7:00 PM or 7:10 PM. LPN #7 stated she did not see the resident after that due to administering medication on the unit. Continued interview revealed later on during the evening Resident #16's family member told her a facility resident was walking to the gas station. LPN #7 stated she told LPN #8 she was leaving because a resident had left the facility, and then drove to find the resident down the road by the gas station with a stranger. Further interview revealed the stranger stated she pulled over because the resident was wandering, appeared to be lost, and she was worried the resident would get hit by a car. LPN #7 stated the door alarm exiting to the outside of the building did not go off that night to alert staff the resident exited the facility. Interview with LPN #8, on 09/05/18 at 11:31 AM, revealed she was familiar with Resident #1's wandering behavior. Per interview, the resident would often walk between the B Wing and the D Wing, and would sometimes carry a suite case, often stating he/she was waiting for the bus. However, LPN #8 did not know if the resident was exhibiting this behavior on the evening of the elopement. LPN #8 stated she worked the day shift on 08/30/18, and she last saw the resident during shift change, at around 7:00 PM that evening. She stated the resident was at the nurse's station and asked her to fill up his/her cup with water. LPN #8 stated LPN #7 alerted her the resident was out of the facility that evening. She further stated LPN #7 received the information from Resident #16's family member. Continued interview with LPN #8 revealed she did not hear any alarms or wanderguard voice alert when the resident left the building. Additional interview with LPN #7, on 09/05/18 at 12:00 PM, revealed when she returned to the facility with the resident around 7:55 PM, at the A unit Ambulance Entrance Door, the door alarm sounded, and the doors locked as they should. Per interview, Registered Nurse (RN) #3 put the code in to turn the door alarm off. LPN #7 stated she checked the resident's wanderguard to see if it was working with the transmitter, and it was working. Further interview revealed staff did not alert her of the resident's wandering behavior on 08/30/18 prior to the elopement. Interview with Unit Manager (UM)/LPN #3, on 09/07/18 at approximately 12:45 PM, revealed she worked B Wing, the unit in which Resident #1 resided. She stated the residents were assessed upon admission, quarterly, and as needed for elopement risk. Continued interview revealed the residents who were at risk for wandering were provided wanderguards to monitor the residents whereabouts and to alert staff when the resident got close to a door with a wander alert system. UM/LPN #3 stated the residents' wanderguard bracelets were checked every shift by using a box and running it across the wanderguard to ensure the wanderguard was working. She further revealed the nurses documented checking the wanderguards on the TAR. However, she stated staff should not rely on the wanderguard system to ensure the safety of the residents. Per interview, Resident #1 did not like the noise of the alarm and would often walk away from the door when it alarmed. Continued interview with the UM/LPN #3, revealed Resident #1 was known to wander and this was not a new behavior for the resident. Per interview, staff was to re-direct the resident when he/she wandered and offer the resident water, juice, and snacks such as oatmeal or cookies. She further stated if those methods did not work, staff was to toilet the resident or try to find out what the resident needed. Additional interview revealed if the resident continued to wander, staff was to wander with the resident. She stated staff from the other units should have communicated with the nursing staff on the B unit to let them know the resident was wandering to their units in order for staff to increase supervision and monitoring of this resident on 08/30/18. Continued interview revealed proper supervision and monitoring residents at risk for elopement was important for their safety. Interview with the DON, on 09/07/18 at 3:46 PM, revealed on 08/30/18, LPN #8 called her around 7:53 PM, to inform her Resident #1 eloped. She stated she arrived to the facility shortly thereafter to check on the resident and to find out what happened. She acknowledged when Resident #1 was wandering to other units and staff brought the resident back to the B unit on 08/30/18, prior to the elopement, the B unit staff should have been notified of the resident's behavior. She further acknowledged this would be important in order to increase the resident's supervision and monitoring as the facility had assessed the resident to be at risk for elopement. Continued interview with the DON, revealed staff should not rely on the Wander Alert System to protect the residents. She further stated there were interventions in place per the resident's care plan which should have been followed. The DON stated, I understand the seriousness of someone exiting the facility. She stated the potential for harm could be death. Interview with Dietary Aide #14, on 09/04/18 at 2:00 PM, revealed her Supervisor informed her Resident #1, who was sitting in the C unit dining room earlier in the evening, was found by a visitor walking towards the gas station. Dietary Aide #14 stated she did not hear an alarm go off that evening or a wanderguard voice alert. She stated if the resident had a wanderguard on, it should have alerted staff when the resident walked to the door. However, further interview revealed after she was told the resident exited the facility, she started checking doors and found the door to the back of the C unit dining room was set on green which indicated the door never reset after it was last opened, meaning the door would not voice command if someone who had a wanderguard walked by. Dietary Aide #14 stated she told her Supervisor the door was in bypass mode and was not functioning properly, meaning anyone could go in and out the door undetected including residents with wanderguards. Interview with Dietary Aide Supervisor #15, on 09/05/18 at 10:53 PM, revealed he saw Resident #1 sitting in the C dining room area, around 7:30 PM, but could not be sure of the time. He stated he did not know the resident very well, but had often seen the resident wandering about the facility. Per interview, Dietary Aide #14 had checked the dining room doors after she heard about the elopement and informed him the C unit dining room exit door to the outside was not functioning properly as it was in bypass mode. He stated he stationed himself at the door until management came in to check the doors. Interview with the Assistant Maintenance Director, on 09/06/18 at 2:30 PM, revealed he checked the facility doors to ensure the egress system worked, including the doors, locks, alarms, and the voice activated wanderguard system every morning with the Plant Operations Director. Per interview, there was no concerns with the door alarms when checked on the morning of 08/30/18. Further interview revealed maintenance did not call the Technicians to check the wander alert system unless there was a known issue with the system. Interview with the Plant Operations Director, on 09/06/18 at 2:01 PM, revealed he checked all of the facility doors including the C unit dining room doors the morning of 08/30/18 with no concerns noted. Per interview, he received a call from the Administrator around 8:39 PM to alerted him Resident #1 exited the facility through the C unit dining room doors. Continued interview revealed he called his supervisor and the Wander Alert System Manufacturer, and immediately came to the facility, adding anytime something happens with the facility doors it was critical. The Plant Operations Director stated he believed the C unit diningroom door malfunctioned sometime between his daily inspection at approximately 8:00 AM on the day of the incident and approximately 7:30 PM that evening, when the resident was discovered missing. He stated upon arrival to the facility the evening of 08/30/18, the exterior mounted entrance box with the push button on the C unit dining room exterior door had malfunctioned. He further stated the wiring had come loose inside the electrical box and completed a circuit, which in turn allowed the door to open freely and this closed circuit caused the wanderguard alarm on the door to become inoperative. Per interview, when he opened the box he noticed the wires were connected, and the wires should not have been connected as this put the system in a bypass mode. Further interview with the Plant Operations Director, revealed the bypass mode would allow anyone with a wanderguard to go through the door undetected. Per interview, this also meant the door would not lock and the egress system would not alarm. Continued interview revealed he pulled the wires apart and as soon as he did that, the door locked. He stated the wanderguard system box with the push button on the outside of the building had damaged wires due to the elements/weather. Further interview with the Plant Operations Director, revealed prior to this incident, he contacted the Wander Alert System Technicians only when he had a concern with the equipment, not for an inspection to check the inside wiring of the door system for weather damage. Further interview with the Plant Operations Director, on 09/06/18 at 2:01 PM, revealed he did not call the wanderguard system manufacturer to have the Wander Alert System checked quarterly, as per the manufacturer's recommendations. Review of the Service Call Job Form, dated 09/04/18, revealed a service field representative checked the C unit of the facility's dining room and determined the outside bypass button malfunctioned, causing the bypass to stay on. Continued review revealed the button was removed from the system making the door exit only. Additional review revealed all other doors tested ok. Phone Interview with the Manufacturer's Technician for the Wander Alert System, on 09/11/18 at 2:10 PM, revealed he checked the facility's doors on 09/04/18 and determined the C-unit dining room door experienced weather damage and thus was stuck in the bypass mode, which allowed a resident with a wanderguard to walk through without being detected. He further stated the facility's Wander Alert System came with the recommendation to have the system checked quarterly by a qualified technician. He revealed this was important because the technicians could provide a comprehensive inspection. Continued interview revealed the comprehensive inspection included inspecting the systems voltage and wiring to ensure there were no breaks in the wiring. He stated he was not certain when the last time the facility had a comprehensive inspection, adding it would have been important to have an inspection to detect any problems before they occurred. Further interview with the DON, on 09/07/18 at 3:46 PM, revealed the facility identified the C unit dining room door as the door the resident exited that evening and also identified the door was not working, meaning the egress alarm was not sounding and the voice command wanderguard system was not sounding due to the door being in the bypass mode. The DON stated the facility shoul

Based on observation, interview, record review, review of the facility's Policies, and review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, it was determined the facility failed have an effective system to provide services in accordance with each resident's written Comprehensive Plan of Care for two (2) of sixteen (16) sampled residents (Residents #1 and #6). Resident #1's Comprehensive Care Plan, dated 07/04/18, revealed the resident was at risk for elopement with interventions to be implemented when the resident exhibited exit seeking behaviors including offering food, activities, one (1) on one (1) company; and a wanderguard (a tracking device designed to prevent persons at risk for wandering from leaving a facility, unless they were accompanied). Staff interviews revealed on 08/30/18, the resident was exhibiting repeated wandering episodes from the B unit, where the resident resided, to the C and D units. Staff interviews further revealed the B unit Nurses and SRNAs were not informed of the resident wandering to the other units by the staff bringing the resident back to the B unit, in order for the resident's elopement Care Plan to be implemented. On 08/30/18, after 7:30 PM, Resident #1 exited the facility without staff's knowledge through the C unit dining room exit door which had a Wander Alert System. However, the Wander Alert System on this exit door malfunctioned at the time of the resident's exit, and neither the egress alarm or the voice activated Wander Alert was activated. Resident #1 walked across a two (2) lane highway in sock feet and was found by a stranger greater than one half (1/2) mile from the facility. A facility visitor who had just left the facility between 7:45 PM and 7:50 PM, identified Resident #1, and called his sister who was visiting at the facility, to alert staff the resident was walking towards a local gas station. Resident #1 returned to the facility at approximately 8:00 PM and was assessed with [REDACTED]. Additionally, Resident #6's Comprehensive Care Plan dated 03/27/18, revealed the resident was to be transferred per Hoyer lift (mechanical assistive device used to transfer a person between surfaces by use of electrical or hydraulic power). However, on 09/03/18, Resident #6's Comprehensive Care Plan was not followed and the resident was transferred with a stand and pivot maneuver by one (1) staff member. The next morning, on 09/04/18, Resident #6 was noted to have a large area of discoloration and swelling to the upper right arm and pain with movement. An X-Ray obtained on 09/04/18, revealed Resident # 6 sustained a Right Humerus Fracture. Actual harm was determined to exist on 09/03/18 related to Resident #6. (Refer to F-689) The facility's failure to have an effective system in place to ensure services are provided in accordance with each resident's written Comprehensive Plan of Care has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) was identified on 09/07/18 and determined to exist on 08/30/18. The facility provided an acceptable Allegation of Compliance (AoC) on 09/19/18, with the facility alleging removal of the Immediate Jeopardy on 09/03/18. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on 09/03/18, prior to exit on 09/20/18, with remaining non-compliance at a Scope and Severity of a G while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's Comprehensive Care Plans Policy, revised 07/19/18, revealed a person-centered Comprehensive Care Plan including measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs would be developed for each resident. Further review of the Policy, revealed the facility would assist the resident to meet their needs, goals and preferences. Review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, dated (MONTH) (YEAR), revealed the Comprehensive Care Plan is an interdisciplinary communication tool and must include measurable objectives and time frames and must describe the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Further review revealed the services provided or arranged must be consistent with each resident's written Plan of Care. 1. Review of the facility's Care of Wandering Resident Guidelines, revised 06/26/18, revealed the Guidelines for the plan of care for wandering residents would include: provide safety within the facility; reduce risk from exit seeking behavior; identify, decrease or eliminate stressors that triggered wandering; and increase supervision as deemed necessary by the interdisciplinary team. Review of the facility's Safety and Supervision of Resident Policy, review date 05/31/18, revealed staff would implement interventions to reduce accident risks and hazards. Further review revealed interventions would include the following: Communicating specific interventions to all relevant staff, assigning responsibility for carrying out interventions, and ensuring the interventions were implemented Review of Resident #1's Medical Record revealed the facility admitted the resident on 05/04/18 with [DIAGNOSES REDACTED]. Review of the resident's Admission Elopement Risk Evaluation, dated 05/04/16, revealed Resident #1 was assessed to be at risk for elopement with risk factors including cognitive impairment, independently mobile, poor decision making skills, exit-seeking behavior, wander oblivious to safety needs, and the ability to exit the facility. Review of Resident #1's Comprehensive Plan of Care, dated 07/04/18, revealed the resident was at risk for elopement as evidenced by attempts to open exit doors. The Care Plan goal stated the resident would not elope and would be monitored for whereabouts on an ongoing basis. The interventions included the following: use verbal and if necessary physical cues for redirection related to exit-seeking behaviors; use diversional activities when exit-seeking behaviors occurred including offering food, activities, and one (1) on one (1) company; and a wanderguard. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 08/11/18, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of three (3) out of fifteen (15) indicating the resident was severely cognitively impaired. Continued review of the MDS Assessment, revealed the resident assessed the resident as not exhibiting wandering behaviors within the review period. Review of the facility's Event Manager Clinical Summary Report, dated 08/30/18, signed by Licensed Practical Nurse (LPN) #7, under the section titled, Detailed Description, revealed Resident #16's family member came to the nurse's station and informed Licensed Practical Nurse (LPN) #7, her brother called and stated a resident was wandering by the local gas station. LPN #7 immediately informed LPN #8, left the facility and drove to get the resident. Continued review revealed when LPN #7 pulled to the resident's location, she observed a woman walking with the resident by the road. LPN #7 approached Resident #1 and the resident got into LPN #7's car. Further review of the Event Manager Clinical Summary Report, under the section titled Elopement Specific Information, revealed an Elopement Allegation involving Resident #1 was reported to the Director of Nursing (DON), on 08/30/18 at 7:58 PM by LPN #7. Per the Report, the resident was last seen at the nurse's station at 7:09 PM. Another resident's family member called a facility visitor and that visitor informed LPN #7, the resident was at the local gas station. The resident was easily coaxed into the vehicle after offering the resident a snack. Per the Report, the resident had a history of [REDACTED]. The exit doors did not alarm and a search of the building and premises was not completed because the facility did not know the resident was missing. No injuries were noted to the resident per the head to toe assessment, and the resident did not complaint of pain. Per the Report, the DON, Advanced Registered Nurse Practitioner (ARNP), and Administrator were notified of the elopement on 08/30/18 at 8:07 PM, and Resident #1's family was notified on 08/30/18 at 8:30 PM. Observation of Resident #1, on 09/04/18 at 10:30 AM, revealed the resident wore non-skid red socks and his/her wanderguard was on his/her left ankle. Interview was attempted during the observation, and the resident stated he/she had a friend, but was not sure what happened to him/her. Resident #1 further stated this State Surveyor would not want to talk with him/her, adding, I can't remember anything. Phone interview on 09/06/18 at 3:43 PM, with State Registered Nurse Aide (SRNA) #7, revealed she worked the B unit, and was assigned to Resident #1 on 08/30/18 from 7:00 AM to 7:00 PM. Per interview, the last time she saw the resident that evening, he/she was on the C unit of the facility, near the Nook (Area outside of the C unit dining room area) about 7:00 PM. SRNA #7 revealed as she and SRNA #15 were clocking out, the resident asked them for ice for his/her pitcher. Per interview, SRNA #7 and SRNA #15 walked the resident back to the B unit. However, SRNA #7 stated she did not see other SRNAs on the unit and the nurses were sitting at the nurse's station, during shift report. SRNA #7 revealed she failed to alert anyone the resident was wandering from unit B to unit C. Per interview, she knew the resident had a wanderguard, and was care planned for wandering, and she should have alerted the B unit staff of the resident wandering to other units. Interview with SRNA #15, on 09/06/18 at 4:28 PM, revealed she worked from 7:00 AM to 7:00 PM, on the B unit and helped provide care for Resident #1 the day the resident exited the facility. She stated Resident #1 was standing in the C unit dining area, when she was leaving the building about 7:00 PM. She further stated SRNA #7 and SRNA #15 walked the resident back to the B Wing where the resident resided, and provided the resident with ice, as per his/her request. She stated she did not see any SRNAs on the unit, and the nurses were busy in the process of giving shift report. Per interview, the care plans were important because they informed staff of how to provide care for the resident. She stated she did not alert staff the resident was wandering from one (1) unit to the next on 08/30/18, but she should have alerted the B unit staff, the resident was found on the C unit, in order for staff to follow the resident's care plan related to redirection; use of diversional activities; and, one (1) on one (1) company. Phone Interview with SRNA #2, on 09/05/18 at 9:09 PM, revealed she clocked in a few minutes before 7:00 PM on 08/30/18, on the D unit, and a little while later noticed Resident #1 was on her unit. SRNA #2 revealed she walked the resident back to the B unit, guided the resident to the nurse's station and left the resident with a cookie. Per interview, the resident was again found on the D unit around 7:15 PM. SRNA #2 stated she gave the resident a glass of water and brought him/her back to the B unit. Per interview, she saw the resident again around 7:30 PM, near the Nook, an area outside the C unit dining room, and he/she was walking towards her unit. Continued interview revealed she was giving another resident a shower a the time, so told the resident to go back to his/her unit. SRNA #2 revealed she did not tell the nurse or the resident's SRNA the resident was wandering to the D unit of the facility, but stated she should have as there was the potential for harm including falls with injuries, if a resident who was wandering exited the facility without staff's knowledge. Phone Interview with SRNA #13, on 09/06/18 at 5:16 PM, revealed she was assigned to care for Resident #1 on the evening of 08/30/18. SRNA #13 stated she arrived to work at 7:00 PM that evening on the B unit, and after receiving report she began her rounds with SRNA #12. Per interview, the last time she saw Resident #1 prior to him/her exiting was at 7:00 PM, by the nurse's station. She stated she was unaware Resident #1 was wandering from the B unit that evening, and had she known, she would have walked with the resident, redirected the resident to the television room, and kept a closer eye on the resident, as per the Care Plan. Phone Interview with LPN #7, on 09/05/18 at 12:00 PM, revealed she was assigned to Resident #1 the evening of the resident's elopement, and she recalled seeing the resident at the beginning of her shift, around 7:00 PM or 7:10 PM. She revealed staff did not alert her of the resident's wandering behavior on 08/30/18 prior to the elopement, in order for the resident's care plan related to elopement to be implemented. Interview with Unit Manager (UM)/LPN #3, on 09/07/18 at 12:45 PM, revealed she worked B unit, the unit in which Resident #1 resided. Continued interview revealed the residents who were at risk for wandering were provided wanderguards to monitor the residents whereabouts and to alert staff when the resident got close to a door with a wander alert system. However, she stated staff should not rely on the wanderguard system to ensure the safety of the residents. Additional interview with the UM/LPN #3, revealed Resident #1 was known to wander and this was not a new behavior for the resident. She stated staff was to re-direct the resident when he/she wandered and offer the resident water, juice, and snacks such as oatmeal or cookies. Per interview if those methods did not work, staff was to toilet the resident or try to find out what the resident needed. Further interview revealed if the resident continued to wander, staff was to wander with the resident. She revealed staff from the other units should have communicated with the nursing staff on the B unit to let them know the resident was wandering to their units in order for staff to implement the resident's elopement care plan on 08/30/18. Interview with the Social Service Director (SSD), on 09/07/18 at 3:36 PM, revealed she developed the care plans related to behaviors and developed Resident #1's Comprehensive Care Plan related to wandering. Continued interview revealed the resident at times, may loose sight of where his/her room may be and often needed assistance to return to his/her room. She stated staff should always be aware of where the resident was located in the building as the resident was cognitively impaired. Further interview with the SSD, revealed it was important for staff to follow the resident's care plan because it was a reference to providing care. Per interview, Resident #1's Comprehensive Care Plan should have been followed on 08/30/18, for the resident's safety. Interview with the DON, on 09/07/18 at 3:46 PM, revealed on 08/30/18, LPN #8 called her around 7:53 PM, to report Resident #1 eloped. The DON acknowledged when Resident #1 was wandering to other units and staff brought the resident back to the B unit on 08/30/18, prior to the elopement, the B unit staff should have been notified of the resident's behavior. She further acknowledged this would be important in order to increase the resident's supervision and to implement the resident's Care Plan related to diversional activities to prevent the wandering behaviors. The DON revealed staff should not rely on the Wander Alert System to protect the residents. Interview with the Administrator, on 09/07/18 at 5:07 PM, revealed the Administrator acknowledged residents assessed to be an Elopement Risk, should be supervised and monitored for safety, even though they were wearing the wanderguard bracelet. Further interview with the Administrator, revealed it was her expectation that the facility's policies and the resident's care plans be followed for residents at risk for elopement. 2. Review of the facility's Mobility Policy, reviewed 07/11/18, revealed the therapy department would complete the resident's initial screening for mobility. Staff would provide all adaptive equipment as required while encouraging the resident to continue to perform at his/her present level of mobility. Further review of the Policy, revealed the Plan of Care would reflect the resident's current level of function, necessary interventions, goals and duration of these goals. Review of Resident #6's medical record revealed the facility admitted the resident on 03/07/18 with [DIAGNOSES REDACTED]. Review of Resident #6's Comprehensive Care Plan, dated 03/27/18, revealed the resident was at risk for falls related to: use of anti-anxiety medication; inability to ambulate; bowel and bladder incontinence; and requiring the use of the Hoyer Lift for transfers. The Care Plan goal stated the resident would have no falls resulting in significant injury. The interventions included: provide assistance of two (2) staff and Hoyer Lift for all transfers; keep resident's bed in lowest position with brakes locked; fall mats at bedside; perimeter defined mattress to resident's bed; staff to refer resident to therapy as needed; discover root cause of falls; administer medications as ordered; and notify physician and family of any falls. Review of Resident #6's Quarterly Minimum Data Set (MDS) Assessment, dated 08/25/18, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) Score of a four (4) out of fifteen (15) indicating severe cognitive impairment. Continued review of the MDS Assessment, revealed the facility assessed the resident to require extensive assistance of two (2) staff for bed mobility, total assistance of two (2) staff for transfers and as ambulation not occurring. Review of the Event Manager Clinical Summary Report, dated 09/04/18 at 06:37 AM, completed by Licensed Practical Nurse (LPN) #1, for the event which occurred on 09/04/18, revealed State Registered Nurse Aide (SRNA) #2 and SRNA #3 called her to Resident #6's room to observe a large bruise and swelling to the resident's upper right arm as the resident complained of pain with repositioning. Continued review of the Report, revealed LPN #1 assessed Resident #6 and learned from SRNA #2 and SRNA#3, the resident was improperly transferred to bed the night of 09/03/18, by SRNA #1 without the use of a Hoyer Lift. Additional review of the Report, revealed LPN #1 contacted the on-call Physician, Resident #6's family and the Director of Nursing (DON) for further instructions. Review of the facility's Incident/Accident Report, dated 09/04/18, completed by LPN #1, revealed an incident/accident occurred on the evening of 09/03/18 when one (1) SRNA transferred Resident #6 from the Broda Chair to the bed without the assistance of an additional staff member and use of the Hoyer Lift as per the resident's Plan of Care. Per the Report, on 09/04/18, during routine care, Resident #6 complained of upper right arm pain with repositioning and a large area of discoloration and swelling was noted to the area. Additional review of the Report, revealed the Advanced Registered Nurse Practitioner (ARNP) was notified by LPN #1 with new orders received to obtain a mobile X-Ray of the resident's arm. Review of the Radiology Report, dated 09/04/18, revealed Resident #6's X-Ray showed a [MEDICAL CONDITION] of the Right Humerus. Interview with Resident #6, on 09/13/18 at 12:00 PM, revealed the resident was unable to recall the events surrounding the injury to his/her arm. Resident #6 stated his/her right arm would hurt a great deal with repositioning and care, but felt better when he/she would lie still. Per interview, staff usually transferred him/her utilizing the stand and pivot maneuver with two (2) staff to assist. Per interview, staff used the Hoyer Lift for transfers in the past, but not all the time. Further interview revealed he/she was not certain what happened to his/her arm, only that he/she she must have landed in the bed wrong. Phone interview with SRNA #4, on 09/17/18 at 6:27 PM, revealed she worked from 7:00 AM to 7:00 PM, the day prior to staff finding Resident #6's bruise. Per interview, when she reported to work the next day, SRNA #3 showed her the bruise on the resident's arm and told her, SRNA #1 transferred the resident by herself the prior evening, and the bruise may have come from the transfer. Further interview with SRNA #4, revealed she talked to the resident who stated, that girl picked me up, though the resident did not provide a name. Per interview, Resident #6 was care planned to be transferred by the Hoyer Lift with the assist of two (2) staff. Phone interview with SRNA #5, on 09/18/18 at 3:44 PM, revealed she worked the 7:00 AM to 7:00 PM shift on 09/03/18, and when she reported to work the next day on 09/04/18, around 3:00 PM, Resident #6's arm was bruised and swollen. SRNA #5 revealed she asked the resident what happened and the resident stated, someone shoved a pole into my back, someone dropped me and that girl picked me up. SRNA #5 further revealed the resident did not say which girl. SRNA #5 further stated the resident's legs/feet were contracted and she would be afraid not to use the Hoyer Lift to transfer Resident #6, as per the Care Plan. Phone interview with SRNA #3, on 09/14/18 at 10:55 AM and on 09/15/18 at 7:34 PM, revealed she worked on the D Unit 09/03/18 from 7:00 PM until 09/04/18 at 7:00 AM. Per interview, she worked with SRNA #1, SRNA #2 and LPN #1 during that shift. Continued interview revealed at approximately 8:30 PM, on 09/03/18, SRNA #1 requested assistance to transfer Resident #6 from the Broda Chair to bed. SRNA #3 stated she told SRNA #1 she would assist her with transferring Resident #6 to bed when she finished providing care for her assigned resident. Further interview with SRNA #3, revealed Resident #6 was supposed to be transferred per Hoyer Lift with the assistance of two (2) people as outlined in the Care Plan. However, SRNA #3 stated when she went to provide assistance to SRNA #1 she observed SRNA #1 at the nurse's station and Resident #6 was already in his/her bed. Phone interview with SRNA #2, on 09/17/18 at 8:24 PM and 09/19/18 at 2:40 PM, revealed SRNA #3 told her that SRNA #1 transferred the resident to bed without assistance. SRNA #2 stated the resident was care planned to be a two (2) person assist with a Hoyer lift. Phone interview with SRNA #1, on 09/18/18 at 2:00 PM, revealed she was scheduled to work the D-Unit on 09/03/18 from 7:00 PM until 11:00 PM. Further interview revealed she requested assistance from SRNA #3 to transfer Resident #6 to bed at approximately 8:30 PM, but SRNA #3 walked off. SRNA #1 stated she assisted Resident #6 into his/her room, pushed the Broda Chair parallel to the resident's bed, kneeled in front of the resident while wrapping her arms around the resident's lower torso and grabbed the waistband of the resident's pants while lifting the resident to his/her feet to stand. She further stated, once Resident #6 was in a standing position, she grabbed his/her legs to swing them over into the bed and placed her hand under the resident's head to position the resident correctly. Further interview with SRNA #1, revealed she understood the importance of following the Comprehensive Care Plan, but said she wasn't really sure why the resident was care planned for a Hoyer Lift. SRNA #1 stated most of the time staff used the stand and pivot maneuver she had just described to transfer Resident #6, and she felt she could safely transfer the resident by herself without the use of the Hoyer Lift. Additional interview with SRNA #1, revealed she did not believe she caused any harm to Resident #6, but she was terminated by the facility. Phone interview with LPN #1, on 09/13/18 at 9:30 AM and 09/15/18 at 7:44 PM, revealed SRNA #2 and SRNA #3 told her SRNA #1 had transferred Resident #6 to bed on the evening of 09/03/18, by herself and without the Hoyer Lift, which required the assistance of two (2) staff. Per interview, LPN #1 reported this additional information to the DON because this was a safety issue. LPN #1 acknowledged SRNA #1 should have followed Resident #6's Care Plan related to transfers for the safety of the resident. Interview on 09/19/18 at 4:50 PM, with the Unit Manager (UM)/ LPN #2 of the D-Wing Unit where Resident #6 resided, revealed the Comprehensive Care Plan and SRNA Care Plans included interventions for transfer technique. Per interview, SRNA #1 had not followed the Care Plan for Resident #6 when she transferred the resident on 09/03/18, and the resident sustained [REDACTED]. Interview with the Director of Nursing (DON) on 09/19/18 at 5:24 PM, revealed it was her expectation that staff follow the Comprehensive Care Plan. The DON acknowledged Resident #6 was transferred with a manual lift of one (1) staff member on 09/03/18; however, the resident was care planned to be assisted with transfers per two (2) persons and a Hoyer lift. The DON acknowledged Resident #6 sustained a Fracture, and stated the facility needed to provide education to the nursing staff related to transfers as per the Care Plan. Interview with the Administrator on 09/19/18 at 5:52 PM, revealed she could not explain Resident #6's Fracture, other than he/she was transferred with the assist of one (1) staff, instead of being transferred as outlined in the Comprehensive Care Plan. Continued interview revealed it was important for the safety of residents and staff for the Care Plan to be followed related to transfer technique. The facility provided an acceptable credible Allegation of Compliance (AoC) on 09/19/18, with the facility alleging removal of the Immediate Jeopardy on 09/03/18. Review of the AoC revealed the facility implemented the following: 1. On 08/30/18, a head to toe assessment was completed by the nurse. The resident's Code Alert (wanderguard bracelet) was checked to ensure it was in place and functioning. Resident #1 received a room change and was placed on the secured unit. Resident #1 was placed on fifteen (15) minute checks by the DON. 2. On 08/31/18, Social Services visited the resident for three (3) days then weekly for two (2) weeks to assess for psychosocial harm or any changes in behavior. 3. All residents were re-assessed for elopement potential 08/30/18 through 08/31/18, by the Director of Nursing, Minimum Data Set (MDS) Coordinator, Social Services, or the Unit Managers following the occurrence. One-hundred percent (100 %) of residents in the facility received new elopement assessments. 4. Three (3) residents that were re-assessed 08/30/18 through 08/31/18, based on new or recent changes, were identified as elopement risk, by the Unit Manager, DON, MDS nurse, and/or Social Service staff. These residents received Code Alert bands placed by the Unit Managers and the resident's information was placed in the Elopement Binder by Social Services. 5. The Comprehensive Care Plan and SRNA Care Plans were updated 08/30/18 through 08/31/18, to show risk of elopement by the DON, Unit Managers, Social Service staff, and the MDS Nurse. All Care Plans were reviewed or updated by the MDS Nurse, Director of Nursing, Social Services, or Staff Development Coordinator, for any changes found on elopement assessment. 6. On 08/30/18, all wander guards were checked by the Unit Managers and Director of Nursing for all residents who were currently utilizing the wander guard system and all were secured and functioning properly. 7. The wander guards expiration dates were monitored daily by the Unit Managers and the Director of Nursing and the wander guards were changed according to the expiration date and this will be ongoing. 8. Starting 08/30/18, the DON would monitor daily for two (2) weeks, then decrease to Monday-Friday for three (3) months to determine if there were any new behaviors related to wandering. This would be monitored through Event Manager, and Twenty-four (24) Hour Clinical Summary Report, which will be compared to the Care Plan to make sure the interventions were appropriate and working. On-going audits will be completed to review for any exit seeking behaviors or elopement by Management including the Administrator, Director of Nursing, Unit Managers, Staff Development Coordinator, and Regional Nurse Consultant. Management would be onsite daily to visually monitor any exit seeking behaviors, ensure the Care Plan interventions were being implemented, and monitor for new admissions and re-admissions which were at risk for elopement, 9. Starting 08/30/18, the Administrator will have oversight related to staff questionnaires, door checks, code alert audits, new admit and re-admit elopement audits, Twenty-four (24) Hour Clinical Summary audits, Events in Event Manager audits, and code green drills. This was completed daily for two (2) weeks, then decreased to Monday-Friday for three (3) months for compliance. 10. On 08/31/18, the Regional Nurse Consultant reviewed the last thirty (30) days of Notes, documentation, and Events for exit seeking behaviors and/or elopement. No new exit seeking behaviors were identified. 11. On 08/30/18, the Plant Operations Director and Administrator, checked all exit doors to ensure all doors were locked and secure and the delayed egress and wanderguard system were functioning properly. The door located in the C unit dining room was found to be malfunctioning. The Plant Operations Director inspected the door and accessed panels externally and could not find any visible issues. The Plant Operations Director then removed the panel covers of the access panels and at this point he was able to determine that two (2) internal wires had come into contact with each other and had caused the door to malfunction. The wires on the access panel to the C unit dining room door were pulled apart and the door became operational. All other doors were re-evaluated to ensure they were functioning correctly and were secured. All doors were found to be secure and no further issues were discovered. 12. All doors were checked for proper function every hour by a member of the nursing staff, department managers or plant operations 08/30/18 through 09/02/18. The Regional Director of Plant Operations validated all doors and Alert Code systems were functioning properly and according to design. 13. On 08/31/18, the TELS system (computerized system utilized to ensure the facility doors were checked) was reviewed by the Plant Operations Director, and the Signature Clinical Consultant, to ensure the facility's doors were checked daily for the last thirty (30) days. The doors checked included the egress, and the Wanderguard system. Additionally, the operation of the magnetic door locks were checked, verifying the system code and keypad operations, and validating the doors stayed locked and alarms sounded when a resident transmitter was nearby. This included the use of a wanderguard to ensure the system activated properly. 14. The Plant Operations Director called RF Technology (the manufacturer) of the facility's Wander Alert System on 08/30/18, to request they send a Technician to inspect the door systems to ensure they were functioning properly. RF Technology confirmed they would send a technician to ensure the doors were working properly. The Facility will follow the Manufacturer's Recommendation's for quarterly inspections of the door systems. 15. An elopement drill was completed by the Plant Operations Director, 08/29/18 through 08/31/18, and the drill was reviewed by the Administrator. There were no issues with the drill. Elopement drills will continue weekly for f

Based on interview, record review, and review of the facility's policies, it was determined the facility failed to have an effective system in place to ensure staff provided immediate basic life support, including Cardiopulmonary Resuscitation (CPR) prior to the arrival of emergency medical personnel, as per physician's orders [REDACTED].#1). On [DATE], Resident #1 was admitted to the facility with an Advance Directive/Informed Consent Form, which stated, Full Code. On [DATE], per staff interview and record review, at approximately 5:45 PM, Registered Nurse (RN) #1 observed Resident #1 to be unresponsive and cold to the touch with absence of respirations and heartbeat. RN #1 was not knowledgeable of the facility's protocol when a resident was found unresponsive and called out to Licensed Practical Nurse (LPN) #1, who came to the resident's room. However, neither RN #1 or LPN #1 immediately checked the resident's code status. RN #1 then overhead paged for a nurse from other units to call Unit B Hall immediately. Staff interviews revealed RN #1 subsequently called the Director of Nursing (DON) at approximately 6:07 PM and the DON directed her to check the resident's chart for code status. After RN #1 identified the resident was a Full Code, 911 was called, and CPR was initiated at approximately 6:08 PM, approximately twenty-three (23) minutes after the resident was found with absence of respirations and heartbeat. RN #1 performed three (3) to five (5) chest compressions, and then stopped CPR. Review of the Emergency Medical Response Report revealed Emergency Medical Services (EMS) received a call on [DATE] at 6:08 PM and arrived on scene at 6:14 PM to find Resident #1 in [MEDICAL CONDITION] with no efforts at CPR or oxygenation. EMS transported Resident #1 to the Hospital where the resident was pronounced dead on [DATE] at 6:53 PM. The facility's failure to have an effective system in place to ensure staff provide immediate basic life support, including Cardiopulmonary Resuscitation (CPR) prior to the arrival of emergency medical personnel, as per physician's orders [REDACTED]. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified on [DATE] and determined to exist on [DATE]. The facility provided an acceptable credible Allegation of Compliance (AoC) on [DATE], with the facility alleging removal of the Immediate Jeopardy on [DATE]. However, the State Survey Agency (SSA) determined the Immediate Jeopardy was not removed on [DATE] as alleged. Through record review, the SSA identified discrepancies regarding code status related to Advance Directives, physician's orders [REDACTED]. The facility made corrections and conducted another audit on [DATE]. Therefore, the SSA determined the Immediate Jeopardy was not removed until [DATE]. Non-compliance remains at a Scope and Severity of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's Cardiopulmonary Resuscitation Policy, undated, revealed CPR would be attempted for any resident who was found to have no palpable pulse and/or no discernible respirations, unless there was a written physician's orders [REDACTED]. Continued review revealed if a resident was found unresponsive and without respirations, a licensed staff member who was certified in CPR would promptly initiate CPR for residents who had requested CPR in their Advance Directive; for residents who had not formulated an Advance Directive; and for residents who did not have a valid DNR order; or unless it would pose a danger to self or others to initiate CPR. Further review revealed CPR would be continued by the facility staff until EMS arrived to assume responsibility for providing CPR. Review of the facility's Advance Directives Procedure Policy, revised on [DATE], revealed upon admission to the facility, the admitting department would inform the resident that he/she had the right to accept or refuse medical treatment and the right to formulate an Advance Directive. Continued review revealed if the resident or resident's representative stated the resident had completed an Advance Directive, it should be documented in the resident's medical record. Review of Resident #1's medical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Advance Directive/Informed Consent Form, signed by the resident's son on [DATE], revealed Full Code, indicating in the event the resident experienced a cardiopulmonary arrest, the resident wanted Cardiopulmonary Resuscitation (CPR) performed. Review of Resident #1's physician's orders [REDACTED]. Review of the resident's Baseline Care Plan, dated [DATE], revealed the resident and family had elected Full Code. Review of Resident #1's Progress Note, dated [DATE] at 6:28 PM, signed by RN #1, revealed RN #1 entered the resident's room to pick up the dinner tray, and the resident was noted to be unconscious and did not respond to word or touch. Per the Note, Resident #1's skin was cold and his/her eyes were open. Further review of the Note, revealed RN #1 placed the resident in a lying position and started CPR; and LPN #1 quickly replaced RN #1 in order for RN #1 to call 911 and the family. Per the Note, CPR continued and EMS arrived and took over life resuscitation attempts. Review of the facility's Investigation Report, completed by the Administrator, dated [DATE], revealed Resident #1 was given his/her dinner tray at approximately 5:15 PM on [DATE] by RN #1. RN #1 returned to the resident's room at approximately 5:45 PM and found Resident #1 cold, with his/her eyes open, unresponsive, and CPR was initiated. EMS was called and the resident was transported to the hospital where he/she later expired. Continued review of the Investigation Report, revealed an interview was conducted with RN #1 who revealed she initiated CPR to Resident #1 after speaking with the DON by phone, and being instructed to do so. Further review revealed RN #1 stated she initiated CPR, but became confused and called the resident's son to inform him of the resident's condition. Per the Report, while RN #1 was on the phone with the resident's son, EMS arrived and took over CPR and transported the resident to the hospital. There was no timeline of events with the investigation. Review of RN #1's written Statement, undated, revealed she was picking up dinner trays around 5:45 PM, when she walked into Resident #1's room and noted the resident's head to be slightly turned with his/her eyes and mouth open, and the resident's skin looked yellow and waxy; she touched the resident's arm which was cold. The Statement revealed she realized something was wrong so she felt the resident's neck for a pulse and there was none. Per the Statement, RN #1 looked at the resident's dinner tray and saw the resident had only taken three (3) bites out of his/her hamburger. RN #1 did a sweep of the resident's mouth and did not find any food. The Statement revealed RN #1 did not have her stethoscope with her so she put her head on the resident's chest and heard no breathing so she went out into the hall and called for LPN #1 who came to the resident's room and examined the resident. LPN #1 asked RN #1 if the resident was a Full Code at which time RN #1 asked LPN#1 to stay with the resident so she could call the DON and ask her what needed to be done. The Statement revealed while RN #1 was walking to the phone to call the DON, she passed SRNA #1 and SRNA #2 and asked them to go and clean the resident for the funeral home. Further review of RN #1's Statement, revealed she called the DON and informed her Resident #1 had passed and the DON asked if the resident was a Do Not Resuscitate (DNR). RN #1 looked at the resident's chart and saw Full Code and the DON instructed her to call a code and start CPR. Per RN #1's statement, she hung up the phone, got the crash cart, and took it to the resident's room where the SRNAs were cleaning the resident up. She donned gloves, walked over to the resident, and started to do CPR, and as she was performing chest compressions, she (RN #1) suddenly choked and didn't know what to do. Per the Statement, she knew the DON told her to do CPR, but the DON had not seen the resident in this condition and she (RN#1) felt it was too late. The Statement revealed the SRNAs were watching her and she felt it was disrespecting the resident by performing CPR when the resident was already too far gone. Per the Statement, RN #1 felt she needed to call the resident's son so she left the room and honestly did not know what to do next. Continued review of the Statement, revealed RN #1 went back to the desk and called for another nurse on another unit and then called the resident's son and broke the news. She told the son that she was going to do CPR, but felt it was too late and the son stated he understood and was glad the resident did not suffer. Per the Statement, while on the phone with the son, EMS arrived and came to the nurse's station and RN #1 informed the son she needed to get off the phone because EMS was there to take the resident to the hospital. The Statement revealed RN #1 followed EMS to the resident's room and EMS saw the Full Code on the chart and proceeded to start CPR. RN #1 worried for a moment she might be wrong and the resident had not died , and as she (RN#1) stood back and watched EMS, she didn't really know what to do. Additional review of the Statement, revealed RN #1 thought the resident might recover so she left the room and went to call the son back to inform him EMS was taking the resident to the hospital and the hospital could help the son with any arrangements that needed to be made. Interview on [DATE] at 6:20 PM with RN #1, revealed she was the nurse assigned to Resident #1 on [DATE], and at approximately 5:15 PM on that date, Resident #1 was in bed when she walked in the resident's room to deliver his/her dinner meal tray. RN #1 stated after the meal trays had been passed to other residents, she began to pick-up meal trays for those residents who were finished eating. She stated she entered Resident #1's room at approximately 5:45 PM to pick up the resident's dinner tray and noticed his/her eyes were slightly open. Per interview, she reached down and touched the resident who was cold to the touch. She did not have her stethoscope with her, so she put her head on the resident's chest to see if he/she was breathing. RN #1 stated the resident was not breathing, so she checked his/her mouth because she saw there was about three (3) bites missing out of the hamburger on the meal tray. RN #1 further stated she did not find anything in the resident's mouth, and she then checked the resident's pulse and noted there was no pulse. Per interview, RN #1 went to the door and yelled down the hall for LPN #1, who came to the room. RN #1 stated she told LPN #1 she thought the resident had passed away and asked LPN #1 what she should do. Per interview, LPN #1 told her she needed to call the DON, and she and LPN #1 then headed to the nurse's desk because neither one of them knew the facility's protocol for finding a resident unresponsive. Further interview with RN #1, revealed she and LPN #1 passed SRNA #1 and SRNA #2 in the hall on the way to the nurse's station and told them Resident #1 had passed away and asked them to go to the resident's room and make him/her presentable. RN #1 stated she went to the nurse's station and called Unit A and Unit D to find out what the protocol was for finding a resident unresponsive and no one answered the phone so she overhead paged for a nurse from Unit A or Unit D to call Unit B Hall immediately. Per interview, LPN #2 returned the call and asked RN #1 about the resident's code status. RN #1 stated she was looking in the chart and saw a sticker that said Full Code, then informed LPN #2 the resident was a Full Code. Per interview, LPN #2 told RN #1 you are supposed to code {him/her}. Interview on [DATE] at 3:05 PM with LPN #2, who worked the 7:00 AM to 7:00 PM shift as needed at the facility, and was working the evening of [DATE] on A Wing Rehab Unit passing medications when she heard an overhead page for an RN or LPN to call B Wing immediately. LPN #2 stated she responded to the page, and RN #1 answered the phone. LPN #2 further stated RN #1 asked her of it took two (2) nurses to pronounce a resident dead. Further interview revealed she told RN #1 she did not know, but she would check with another nurse. LPN #2 stated RN #1 told her no that's ok and hung up the phone. LPN #2 further stated RN #1 never said anything to her about Resident #1's code status. Per interview, later that night, she heard RN #1 did not perform CPR on a resident that was a Full Code. Additional interview with RN #1, on [DATE] at 6:20 PM, revealed she was in a panic mode and called the DON and was told to go do a code at which time RN #1 informed the DON, the resident was already dead. RN #1 stated the DON said I don't care, call 911 and go do CPR. RN #1 further stated she called 911, hung up the phone, and grabbed the code cart, but she left it outside the resident's room. Per interview, when RN #1 walked into the resident's room, SRNA #1 and SRNA #2 had the resident lying flat in the bed and were cleaning the resident. RN #1 stated she put on gloves and told the SRNAs the DON told her to do CPR on the resident. RN #1 further stated she pushed on the resident's chest about three (3) or four (4) times and stopped. Continued interview with RN #1, revealed the resident was cold and she felt like it was wrong to continue with CPR because it had been about twenty (20) minutes since she found the resident unresponsive. RN #1 stated she stopped CPR, went to the nurse's station, and called the resident's son to inform him she thought the resident had passed away. Continued interview with RN #1, revealed after she left the resident's room, nobody was performing CPR on the resident. Further interview with RN #1, revealed once she initiated CPR, she should have continued CPR until EMS arrived. Review of LPN #1's written Statement, dated [DATE], revealed on Sunday, [DATE] at approximately 5:30 PM, RN #1 asked LPN #1 to go check Resident #1 because RN #1 wanted LPN #1 to verify the resident had passed away. Per the Statement, LPN #1 went to the resident's room and the resident was in an upright position, the resident's arms were limp to his/her side, and his/her eyes were closed. The resident was not breathing because the resident's chest was not moving and the resident was cold to the touch. Per LPN #1's Statement, RN #1 told her to get the SRNA to clean the resident. Additional review of the Statement, revealed at approximately 6:30 PM, she saw RN #1 at the nurse's station and RN #1 reported to LPN #1 she had started CPR, called 911, called the family, and called the DON. Per LPN #1's Statement, at approximately 7:30 PM, she was at the nurse's station and overheard RN #1 speaking to the triage call center. The Statement revealed LPN #1 heard RN #1 state that LPN #1 had performed CPR on the resident while RN #1 called 911. Per the Statement, that was not true and she (LPN #1) reported what she had seen and heard to the C Wing Unit Manager. Interview on [DATE] at 12:15 PM, with LPN #1, revealed she was passing medications on B Wing South Hall on [DATE] at approximately 5:30 PM, when RN #1 called out to her. She stated RN #1 told her a resident had died and she wanted her to check the resident. LPN #1 stated she entered Resident #1's room and observed the resident sitting up in the bed with eyes slightly open, and chest not moving. LPN #1 further stated she touched the resident's hand which was cold. Per interview, neither she or RN #1 checked to see if Resident #1 had a pulse or respirations. LPN #1 stated she and RN #1 left the room to go to the nurse's station to call the DON. Per interview, no one was performing CPR on the resident at this time. LPN #1 stated as she and RN #1 were walking to the nurse's station they passed SRNA #1 and SRNA #2 in the hall and RN #1 instructed the SRNAs to clean the resident. Further interview with LPN #1, revealed she went back to her unit to finish passing medications while RN #1 called the DON. Per interview, at around 7:30 PM she overheard RN #1 talking to the triage center on the phone and overheard RN #1 state that LPN #1 was performing CPR to the resident while she (RN#1) was calling 911. LPN #1 stated that was not the truth, and she never layed hands on the resident. LPN #1 further stated she and RN #1 should have checked Resident #1's chart for code status, and should have called a code blue when the resident was observed to be unresponsive. Per interview, RN #1 should have grabbed the crash cart and started CPR on the resident immediately and continued CPR until EMS arrived. Review of the C Wing Unit Manager's written Statement, dated [DATE], revealed LPN #1 approached her and informed her she did not help RN #1 start CPR on Resident #1. Review of State Registered Nurse Aide (SRNA) #1's Statement, dated [DATE], revealed a nurse told SRNA #1 and SRNA #2 to go clean up Resident #1 because he/she had passed. The Statement further revealed while SRNA #1 and SRNA #2 were cleaning the resident, RN #1 came into the resident's room and stated the resident was a Full Code and she had called the ambulance, but was not going to waste the crash cart. Per SRNA #1's Statement, RN #1 left the room and called the resident's family. The Statement further revealed the ambulance arrived and SRNA #1 left the room. Interview on [DATE] at 4:10 PM, with SRNA #1, revealed on [DATE], sometime between 5:45 PM and 6:15 PM, she heard someone page we need an RN on B wing. Per interview, not long after that, LPN #1 came up to her and said, go clean up Resident #1 because the resident just passed. SRNA #1 stated after she and SRNA #2 cleaned the resident and was changing the resident's gown, RN #1 came into the room and told them the resident was a Full Code. SRNA #1 stated she expected to see RN #1 perform CPR on the resident, but instead RN #1 just did three (3) taps on the resident's chest and told them the resident was not going to come back, he/she was eighty (80) years old, and was hospice. Further interview revealed RN #1 told them, I'm not going to waste my crash cart. SRNA #1 stated RN #1 then left the resident's room, and a few minutes later, while she and SRNA #2 were still in the resident's room, EMS arrived. Continued interview with SRNA #1, revealed Resident #1 wasn't cold when she and SRNA #2 were cleaning the resident. SRNA #1 stated RN #1 should have brought the crash cart into the resident's room and performed CPR until EMS arrived since the resident was a Full Code. Per interview, staff did not perform CPR on Resident #1 after RN #1 left the room, and she left the room after EMS arrived. Review of SRNA #2's Statement, dated [DATE], revealed at supper time RN #1 approached SRNA #2 and SRNA #1, and told them Resident #1 had passed and needed to be cleaned up. Per SRNA #2's Statement, she and SRNA #1 were cleaning the resident when RN #1 walked into the room and said Resident #1 was a Full Code, but she didn't see the resident coming back. Per the Statement, RN #1 brought the crash cart down the hall, but didn't call a code. SRNA #2's Statement revealed RN #1 stated she wasn't going to waste the crash cart. SRNA #2's Statement further revealed RN #1 did five (5) chest compressions and said the resident was not coming back and walked out of the resident's room, went to the nurse's station, and got on the phone. Per SRNA #2's Statement, when the ambulance arrived she left the resident's room. Interview on [DATE] at 4:04 PM, with SRNA #2, who was assigned to Resident #1 on [DATE], revealed on that date between 6:10 PM and 6:15 PM, LPN #1 informed her Resident #1 had passed and needed to be cleaned. SRNA #2 stated she went to get linens and when she passed the nurse's station she saw RN #1 at the desk talking on the phone. SRNA #2 stated while she and SRNA #1 were cleaning the resident, RN #1 came in the resident's room and told them the resident was a Full Code and she needed to perform CPR. Per interview, RN #1 left the crash cart in the hall outside the resident's room, performed about five (5) chest compressions, stopped CPR, left the room, and stated she didn't want to waste the crash cart on the resident because she didn't see the resident coming back. SRNA #2 stated she and SRNA #1 stayed in the resident's room and were gathering up the resident's belongings for the family when EMS arrived and took the resident to the hospital. Further interview revealed Resident #1 wasn't cold when she and SRNA #1 were cleaning the resident. SRNA #2 stated RN #1 should have brought the crash cart into the resident's room and performed CPR until the ambulance arrived. SRNA #2 verified staff did not perform CPR on Resident #1 after RN #1 left the room, and she (SRNA #2) left the room after EMS arrived. Review of the DON's Statement, dated [DATE], revealed RN #1 called her at 6:07 PM and stated Resident #1 had passed away. The DON asked RN #1 if Resident #1 was still in the facility and RN #1 stated yes. Continued review of the Statement, revealed the DON instructed RN #1 to get off the phone and perform CPR immediately, call a code blue, and call 911 because the resident was a Full Code, at which time RN #1 stated it was too late. Per the DON's Statement, she told RN #1 she didn't care if RN #1 thought it was too late, she needed to begin CPR now. Further review of the Statement, revealed RN #1 called the DON back at 6:21 PM, stating EMS had arrived, hooked the resident up to the compression machine, and took the resident out of the facility. Per the Statement, the DON asked RN #1 if she performed CPR and RN #1 stated she did. Interview on [DATE] at 3:03 PM, with the DON, revealed she received a call from RN #1 on [DATE] at 6:07 PM, stating Resident #1 had passed away. The DON stated she directed RN #1 to check the resident's code status. Per interview, when RN #1 identified the resident's code status was Full Code, she informed RN #1 she had to perform CPR. The DON stated RN #1 told her it's too late, and she (DON) instructed RN #1 to perform CPR because Resident #1 was a Full Code and to call EMS. The DON further stated, RN #1 called back at 6:21 PM and informed her EMS had arrived and the resident was on the way to the Hospital emergency room (ER). Continued interview with the DON, revealed approximately six (6) to seven (7) minutes later, SRNA #2 called and stated I've never seen a nurse start CPR and not keep going. The DON further stated SRNA #2 informed her RN #1 only did four (4) to five (5) chest compressions and stopped. Further interview revealed approximately one (1) hour later, LPN #1 called her and told her RN #1 had lied and reported LPN #1 performed CPR while RN #1 was making phone calls. Per interview, LPN #1 informed the DON she never touched the resident. Additional interview revealed RN #1 should have checked the resident's code status, then immediately initiated CPR and continued CPR until EMS arrived and transported the resident to the hospital. Review of Resident #1's Emergency Medical Response Report, dated [DATE], revealed EMS received a call on [DATE] at 6:08 PM and arrived on scene at 6:14 PM to find Resident #1 in [MEDICAL CONDITION]. The Report revealed the resident was in arrest for an unknown amount of time with no efforts at CPR or oxygenation and the resident was unresponsive, warm to touch, and no lividity was noted. Further review of the Report, revealed on EMS arrival, the nurse was at the nurse's station with no efforts being made for CPR, no one was with the resident, and the resident appeared to have been dressed and posed. The Report further stated a right [MEDICAL CONDITION] tracheal tube and intraosseous line was placed, [MEDICATION NAME] (medication used as a heart stimulant), [MEDICATION NAME] (medication to relax muscles), and [MEDICATION NAME] (opioid antagonist) was given enroute and the Lucas Device was used for compressions. Per the report, EMS departed the scene at 6:34 PM and CPR was discontinued at 6:55 PM. Review of Resident #1's Hospital emergency room documentation, dated [DATE], revealed Resident #1 arrived at the hospital on [DATE] at 6:42 PM, unresponsive with [DIAGNOSES REDACTED]. Further review revealed upon arrival to the Emergency Department, Resident #1 was administered intravenous (IV) fluids at 6:41 PM, [MEDICATION NAME] one (1) milligram (mg) IV at 6:42 PM, at 6:45 PM, at 6:48 PM and at 6:51 PM with no change in condition. Continued review revealed time of death was 6:53 PM. Interview, on [DATE] at 11:40 AM, with Resident #1's Attending Physician (AP), revealed he was informed on [DATE] Resident #1 had expired. Per interview, he was aware the resident had been admitted to the facility on [DATE] with a Full Code status, but was not aware there was a delay in initiating CPR and was not aware CPR had been initiated and stopped after only three (3) to four (4) chest compressions. Continued interview with the AP, revealed in the event a nurse found a resident unresponsive, he expected the nurse to follow the protocols outlined by the facility's policies, and per the American Heart Association's (AHA) recommendations, and initiate CPR. Further interview revealed he expected CPR to be initiated in timely manner because the longer the delay, the less likely CPR would be successful. Per interview, he expected the resident's choices to be honored in regards to Advance Directives and code status. Continued interview with RN #1, on [DATE] at 6:20 PM, revealed she had been a nurse for fifteen (15) years and had worked codes in the hospital setting, but had only been working at the facility for two (2) months before the incident where she found Resident #1 unresponsive. She stated she had not been oriented related to how to initiate a code; how to use the crash cart; or how to complete code documentation after a code during orientation at the facility. RN#1 stated she had asked both the Administrator who was a nurse, and the DON for the facility's protocol for conducting a code after hire. However, RN #1 stated she was told by the DON, the Staff Development Coordinator (SDC) would get RN #1 the information whenever she had time. Per interview with RN #1, she could not remember the date in which she had asked the Administrator or the DON for the training on how to conduct a code. Review of RN #1's training submitted by the facility revealed there was no documented evidence the facility trained RN #1 on the facility policies and procedure related to codes. Review of RN #1's Basic Life Support Card, revealed it was issued ,[DATE] verifying successful completion of the cognitive and skills evaluation in accordance with the curriculum of the American Heart Association Basic Life Support (CPR and AED) Program. Interview on [DATE] at 7:35 PM, with Staff Development Coordinator (SDC) #1, revealed she was responsible for providing orientation to new staff and conducting in-services and education to all staff. The SDC stated new licensed nursing staff had three (3) to four (4) days of classroom orientation which covered information about the company and its policies. She stated new licensed nursing staff watched videos on hand washing, infection control, falls, wounds, weights, and there was also a skills check off prior to staff working the floor. Per interview, during orientation she went over the CPR policy, where the crash cart was located and the contents of the cart. Continued interview revealed mock code drills were conducted once a month, but she did not conduct a mock code during new hire orientation. The SDC stated during orientation staff watched a slide presentation which included how to announce a code; how to run a code; and where to find code paperwork and complete the code paperwork. Per interview, she did not provide new hire orientation to RN #1. However, she stated all nurse's in the facility were required to be CPR certified and RN #1 should have known how to conduct a code and perform CPR. Further interview revealed once CPR was started, it should not be stopped until EMS arrived and assumed care of the resident. Interview on [DATE] at 9:45 AM with SDC #2, who no longer worked at the facility, revealed she had been employed by the facility for six (6) months and two (2) of those months she worked as the SDC. She stated during her time at the facility as SDC, she was given a notebook by SDC #1 and told to go through the notebook with new hires. Per interview, she was not given any training on what her role or duties were as SDC. Continued interview revealed she was not given any orientation on hire on how to call a code, conduct a code, or how to use the crash cart and complete the code paperwork after a code. Per interview, the only thing related to codes she received in her three (3) day orientation, was a sheet of paper located in the orientation packet that went over the steps for CPR. Further interview revealed no one conducted mock code drills with new hires during orientation. Additional interview with SDC #2, revealed she remembered she had oriented RN #1 and at that time, the orientation included information about the company, company policies, skills check offs including vital signs, weights, medication administration, how to care for gastrostomy-tubes and tracheotomies, and other nurse related tasks. Per interview, SDC #2 did not recall covering information with new hires related to how to conduct a code or covering code status. SDC #2 stated the DON and Administrator just assumed that if you were a nurse you knew how to conduct a code and perform CPR. Ongoing interview with SDC #2, revealed if a resident was a Full Code she would expect any staff member who was CPR certified to perform CPR until EMS arrived and assumed care of the resident. Per interview, resident's Advance Directives should be honored. Continued interview with the DON, [DATE] at 3:03 PM, revealed she expected staff to follow the facility's CPR and Advance Directives Policy. Per interview, she expected all new licensed staff to receive training on where to find code status in the chart, how to use the crash cart, how to call a code, and how to complete code paperwork during orientation by the SDC. She further stated RN #1 should have received this training during orientation. Interview on [DATE] at 3:33 PM, with the Administrator, revealed she was notified on [DATE] by the DON, Resident #1 had passed and there may have been a delay in CPR. Per interview, RN #1 failed to immediately verify the resident's code status by looking in Resident #1's chart and failed to initiate CPR in a timely manner. In addition, she stated RN #1 failed to continue CPR until EMS arrived at the facility to assume care of the resident. She stated it was her expectation that staff follow facility's policy related to Advance Directives and CPR. The Administrator further stated Resident #1 had an Advance Directive for Full Code on admission, and the resident's wishes should have been honored by the facility and the staff. Further interview revealed it was her expectation licensed nurses received orientation related to facility policies regarding CPR, and Advance Directives, and RN #1 should have received the training. Review of the A[NAME] revealed the facility implemented the following: 1. An investigation related to Resident #1 and the incident which occurred on [DATE], was initiated on [DATE] and completed by [DATE], by the Director of Nursing (DON) and

Based on interview, record review, review of the facility's policies, review of the Kentucky Board of Nursing (KBN) Advisory Opinion Statements (AOS), and review of the American Heart Association Journal, Ethical Issues Around Out of Hospital Resuscitation, Withholding CPR at the Start versus Withdrawing CPR at the End, it was determined the facility failed to have an effective system in place to ensure services provided met professional standards of quality for one (1) of ten (10) sampled residents (Resident #1). The facility admitted Resident #1 on [DATE]. The resident had an Advance Directive/Informed Consent Form, which stated, Full Code. However, per staff interview and record review, on [DATE] at approximately 5:45 PM, Registered Nurse (RN) #1 observed Resident #1 to be unresponsive, with absence of respirations and heart rate, and the nurse failed to check the resident's code status and initiate Cardiopulmonary Resuscitation (CPR) immediately. RN #1 had been employed at the facility for two (2) months, but was unaware of facility protocol of what to do when finding a resident unresponsive and had not been oriented on initiating a code at the facility. At approximately 6:07 PM, RN #1 called the Director of Nursing (DON) who directed her to check the resident's chart for code status. When RN #1 identified the resident was a Full Code, the DON instructed the nurse to hang up the phone, call 911, grab the crash cart, and code the resident. RN #1 initiated CPR on [DATE] at approximately 6:08 PM which was approximately twenty-three (23) minutes after finding the resident unresponsive with no respirations and heartbeat. However, RN #1 performed three (3) to five (5) chest compressions, and then stopped. Review of the Emergency Medical Response Report revealed Emergency Medical Services received a call on [DATE] at 6:08 PM and arrived on scene at 6:14 PM to find Resident #1 in [MEDICAL CONDITION] with no efforts at CPR or oxygenation. EMS transported Resident #1 to the Hospital where the resident was pronounced dead on [DATE] at 6:53 PM. (Refer to F-678) The facility's failure to have an effective system to ensure services provided met professional standards of quality has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) was identified on [DATE], and determined to exist on [DATE]. The facility provided an acceptable credible Allegation of Compliance (AoC) on [DATE], with the facility alleging removal of the Immediate Jeopardy on [DATE]. However, the State Survey Agency (SSA) determined the Immediate Jeopardy was not removed on [DATE] as alleged. Through record review, the SSA identified discrepancies regarding code status related to Advance Directives, physician's orders [REDACTED]. The facility made corrections and conducted another audit on [DATE]. Therefore, the SSA determined the Immediate Jeopardy was not removed until [DATE]. Non-compliance remains at a Scope and Severity of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's Cardiopulmonary Resuscitation Policy, undated, revealed CPR would be attempted for any resident who was found to have no palpable pulse and/or no discernible respirations, unless there was a written physician's orders [REDACTED]. Continued review revealed if a resident was found unresponsive and without respirations, a licensed staff member who was certified in CPR would promptly initiate CPR for residents who had requested CPR in their Advance Directive. Further review revealed CPR would be continued by the facility staff until EMS arrived to assume responsibility for providing CPR. Interview with the Administrator on [DATE] at 3:33 PM, revealed the facility did not use a specific professional standards of clinical practice, but used KBN Guidelines in providing care to the residents. Review of KBN, AOS #14, revised (MONTH) (YEAR), Roles of Nurses in the implementation of Patient Care Orders, revealed in accordance with Kentucky Revised Statutes (KRS) 314.021 (2), nurses were responsible and accountable for making decisions that are based upon the individual's educational preparation and current clinical competence in nursing and requires licensees to practice nursing with reasonable skill and safety. Further review revealed licensed nurses should administer medication and treatment as prescribed by the Physician, Physician Assistant, Dentist, or Advanced Practice Registered Nurse (ARNP). Review of the KBN's Advisory Opinion Statement (AOS) #36, Resuscitation, approved (MONTH) 2008, revealed nurse's were required to honor the Advanced Directives of patients who had the Advanced Directive documented in the medical record, unless a Physician or healthcare facility refused to comply and the patient and surrogate were informed of the refusal. Review of the American Heart Association Journal, Ethical Issues Around Out of Hospital Resuscitation, Withholding CPR at the Start versus Withdrawing CPR at the End, dated [DATE], revealed Basic Life Support (BLS) Training urges the average citizen responding first to a [MEDICAL CONDITION] to perform CPR. Healthcare professionals are expected to provide BLS and Advanced Cardiac Life Support (ACLS) as part of their professional duty to respond. The exceptions included: when a person lies dead, with no obvious clinical signs of irreversible death; when attempts to perform CPR would place the rescuer at risk of physical injury; and when the patient or surrogate has indicated that resuscitation is not desired. Review of Resident #1's medical record revealed the facility admitted the resident on [DATE]. Review of Resident #1's Advance Directive/Informed Consent Form, signed by the resident's son on [DATE], revealed Full Code, indicating in the event the resident experienced a cardiopulmonary arrest, the resident wanted CPR performed. Review of the resident's physician's orders [REDACTED]. Review of Resident #1's Progress Note, dated [DATE] at 6:28 PM, written by RN #1, revealed RN #1 entered the resident's room to pick up the dinner tray, and the resident was noted to be unconscious and didn't respond to word or touch. The Note further revealed Resident #1's skin was cold and his/her eyes were open. Additional review of the Note, revealed RN #1 placed the resident in a lying position and started CPR; and LPN #1 quickly replaced RN #1 in order for RN #1 to call 911 and the family. Continued review of the Note, revealed CPR continued and EMS arrived and took over life resuscitation attempts. Review of the facility's Investigation Report, completed by the Administrator, dated [DATE], revealed RN #1 gave Resident #1 his/her dinner tray at approximately 5:15 PM on [DATE]. Subsequently RN #1 returned to the resident's room at approximately 5:45 PM and found Resident #1 cold, with his/her eyes open, unresponsive, and CPR was initiated. EMS was called and the resident was transported to the hospital where he/she later expired. Continued review of the Investigation Report, revealed an interview was conducted with RN #1 who stated she initiated CPR to Resident #1 after speaking with the DON by phone, after being instructed to do so. Additional review revealed RN #1 stated she initiated CPR, but became confused and called the resident's son to inform him of the resident's condition. Per the Report, while RN #1 was on the phone talking with the resident's son, EMS arrived and took over CPR and transported the resident to the hospital. The investigation had no timeline of events. Review of Resident #1's Emergency Medical Response Report, dated [DATE], revealed EMS received a call on [DATE] at 6:08 PM; and arrived on the scene at 6:14 PM to find Resident #1 in [MEDICAL CONDITION]. Per the Report, the resident was in arrest for an unknown amount of time with no efforts at CPR or oxygenation; and the resident was unresponsive, warm to touch, and no lividity was noted. Additional review of the Report, revealed on EMS arrival, the nurse was at the nurse's station with no efforts being made for CPR, no one was with the resident, and the resident appeared to have been dressed and posed. The Report further revealed a right [MEDICAL CONDITION] tracheal tube and intraosseous line was placed, [MEDICATION NAME] (medication used as a heart stimulant), [MEDICATION NAME] (medication to relax muscles), and [MEDICATION NAME] (opioid antagonist) was given enroute as well as the Lucas Device was used for compressions, and EMS departed the scene at 6:34 PM and CPR was discontinued at 6:55 PM. Interview on [DATE] at 6:20 PM with RN #1, revealed she was assigned to Resident #1 on [DATE], and at approximately 5:45 PM she noticed his/her eyes were slightly open and he/she was cold to the touch. Per interview, she did not have her stethoscope with her, so she put her head on the resident's chest to see if he/she was breathing and he/she was not breathing. She stated she checked his/her mouth for food and did not find anything in the resident's mouth, and then checked the resident's pulse and noted there was no pulse. RN #1 stated she went to the door and yelled down the hall for LPN #1, who came to the room. RN #1 stated she told LPN #1 she thought the resident had passed away and asked LPN #1 what she should do and LPN #1 told her she needed to call the DON. Per interview, neither RN #1 or LPN #1 knew the facility's protocol for finding a resident unresponsive. Interview on [DATE] at 12:15 PM, with LPN #1, revealed RN #1 informed her a resident had died and she wanted her to check the resident. LPN #1 revealed she entered Resident #1's room and observed the resident sitting up in the bed with eyes slightly open, and chest not moving. LPN #1 stated she touched the resident's hand which was cold, but neither she (LPN) #1 or RN #1 checked to see if Resident #1 had a pulse or respirations. LPN #1 revealed she and RN #1 left the room to go to the nurse's station to call the DON and she verified no one was performing CPR on the resident at this time. Further interview with RN #1, on [DATE] at 6:20 PM, revealed she went to the nurses' station and called Unit A and Unit D to find out what the protocol was for finding a resident unresponsive and no one answered the phone so she overhead paged for a nurse from Unit A or Unit D to call the Unit B Hall immediately. RN #1 further stated LPN #2 returned the call and asked RN #1 about the resident's code status, and she checked the resident's chart and saw a sticker that said Full Code, and informed LPN #2 the resident was a Full Code. RN #1 stated LPN #2 told her, you are supposed to code {him/her}. Interview on [DATE] at 3:05 PM, with LPN #2, revealed she heard an overhead page for an RN or LPN to call B Wing immediately. LPN #2 revealed she responded to the page, and RN #1 answered the phone. LPN #2 further revealed RN #1 asked her of it took two (2) nurses to pronounce a resident dead. Additional interview revealed she told RN #1 she did not know, but she would check with another nurse. LPN #2 stated RN #1 told her no that's ok and then hung up the phone. Per interview, RN #1 did not say anything to her about Resident #1's code status. Continued interview with RN #1, revealed she then called the DON and was told to go do a code at which time RN #1 informed the DON, the resident was already dead. RN #1 stated the DON told her I don't care, call 911 and go do CPR. Per interview, RN #1 called 911, hung up the phone, and grabbed the code cart, but left it outside the resident's room. RN #1 stated she entered the resident's room, put on gloves, and pushed on the resident's chest about three (3) or four (4) times and stopped. RN #1 stated the resident was cold and she felt like it was wrong to continue with CPR because it had been about twenty (20) minutes since she initially found the resident unresponsive. Per interview, RN #1 stopped CPR, went to the nurse's station. RN #1 confirmed after she left the resident's room, nobody was performing CPR on the resident. Interview on [DATE] at 3:03 PM, with the DON, revealed she received a call from RN #1 on [DATE] at 6:07 PM, who stated Resident #1 had passed away. The DON revealed she directed RN #1 to check the resident's code status and when RN #1 identified the resident's code status was Full Code, she informed RN #1 she had to perform CPR. The DON revealed RN #1 told her it's too late, and she (DON) instructed RN #1 to perform CPR because Resident #1 was a Full Code and to call EMS. Per interview, RN #1 called back at 6:21 PM and informed her EMS had arrived and the resident was on the way to the Hospital emergency room . Additional interview with the DON, on [DATE] at 3:03 PM, revealed approximately one (1) hour later, LPN #1 called her and told her RN #1 had lied and reported LPN #1 performed CPR while RN #1 was making phone calls. The DON stated LPN #1 informed her she never touched the resident. Further interview revealed RN #1 should have checked the resident's code status, then immediately initiated CPR and continued CPR until EMS arrived and transported the resident to the hospital. Additional interview with LPN #1, on [DATE] at 12:15 PM, revealed at about 7:30 PM she overheard RN #1 talking to the triage center on the phone and overheard RN #1 state that LPN #1 was performing CPR to the resident while she (RN#1) was calling 911. However, LPN #1 stated that was not the truth, and she never layed hands on the resident. Continued interview revealed RN #1 should have checked Resident #1's chart for code status, and should have called a code blue when the resident was observed to be unresponsive with no respirations and heartbeat as per professional standards. Continued interview with RN #1, on [DATE] at 6:20 PM, revealed after she found the resident unresponsive with no respirations or heart rate, she should have checked the resident's code status, and immediately initiated CPR, and continued CPR until EMS arrived as per professional standards. However, she stated although she had worked codes in the hospital setting, she had only been working at the facility for two (2) months before the incident where she found Resident #1 unresponsive. She revealed she had not been oriented on how to initiate a code; how to use the crash cart; or how to complete code documentation after a code during orientation at the facility. RN #1 further stated she had asked both the Administrator who was a nurse, and the DON for the facility's protocol for conducting a code after hire. However, RN #1 stated she was informed by the DON, the SDC would get RN #1 the information whenever she had time. Review of RN #1's training submitted by the facility revealed there was no documented evidence the facility trained RN #1 on facility policies and procedure related to codes. Interview on [DATE] at 9:45 AM, with Staff Development Coordinator (SDC) #2, who no longer worked at the facility, revealed she had been employed by the facility for six (6) months and two (2) of those months she worked in the role of SDC. She revealed during her time at the facility as SDC, she was given a notebook by SDC #1 and told to go through the notebook with new hires. Per interview, she was not given any training on what her role or duties were as the SDC. Further interview revealed she was not given any orientation on hire on how to call a code, conduct a code, or how to use the crash cart and complete the code paperwork after a code. She stated the only thing related to codes she received in her three (3) day orientation, was a sheet of paper located in the orientation packet that went over the steps for CPR. She further stated nobody conducted mock code drills with new hires during orientation. Additional interview with SDC #2, revealed she oriented RN #1 and at that time, the orientation included information about the company, company policies, skills check offs including vital signs, weights, medication administration, how to care for gastrostomy-tubes and tracheotomies, and other nurse related tasks. However, SDC #2 revealed she did not recall covering information with new hires related to how to conduct a code or covering code status. SDC #2 stated the DON and Administrator just assumed if you were a nurse you knew how to conduct a code and perform CPR. SDC #2 stated if a resident was a Full Code she would expect any staff member who was CPR certified to perform CPR until EMS arrived and assumed care of the resident as per professional standards. Further interview with the DON, on [DATE] at 3:03 PM, revealed it was her expectation for all new licensed staff to receive training on the facility code policies and procedures, and RN #1 should have received this training during orientation. Continued interview with the DON, revealed she expected staff to follow the facility's CPR and Advance Directives Policy in order to ensure professional standards of care were met. Interview, on [DATE] at 11:40 AM, with Resident #1's Attending Physician (AP), revealed the facility did not inform him there was a delay in initiating CPR or that CPR had been initiated and stopped after only three (3) to four (4) chest compressions. Per interview, in the event a nurse found a resident unresponsive, he expected the nurse to follow the protocols outlined by the facility's policies, and per the American Heart Association's (AHA) recommendations, and initiate CPR. Additional interview revealed he expected CPR to be initiated in timely manner because the longer the delay, the less likely CPR would be successful. The AP revealed he expected the resident's choices to be honored in regards to Advance Directives and code status and expected the facility to follow professional standards of care. Interview on [DATE] at 3:33 PM, with the Administrator, revealed she was notified on [DATE] by the DON, Resident #1 had passed and there may have been a delay in initiation of CPR. She stated RN #1 failed to immediately verify the resident's code status by looking in Resident #1's chart and failed to initiate CPR in a timely manner. Also, she stated RN #1 failed to continue CPR until EMS arrived at the facility to assume care of the resident. Per interview, it was her expectation that staff follow facility's policy related to Advance Directives and CPR. Continued interview revealed it was her expectation licensed nurses receive orientation related to facility policies regarding CPR, and Advance Directives, and RN #1 should have received the training. The Administrator further stated Resident #1 had an Advance Directive for Full Code on admission, and professional standards of care should have been followed related to CPR and Advance Directives. Review of the A[NAME] revealed the facility implemented the following: 1. An investigation related to Resident #1 and the incident which occurred on [DATE], was initiated on [DATE] and completed by [DATE], by the Director of Nursing (DON) and the Administrator. During the investigation a review of Resident #1's medical record, code blue process, and cardiopulmonary resuscitation process, staff interviews, and resident interviews was completed. It was determined by the facility there was a failure in following policies and procedures including the Cardiopulmonary Resuscitation Policy and Care Plan Policy. 2. Beginning on [DATE] and concluding on [DATE], the DON, Assistant Director of Nursing (ADON), Unit Managers, Staff Development Coordinator (SDC), Minimum Data Set (MDS) Coordinator, Restorative Nurse Manager and Nursing Supervisor received Mock Code training by the Registered Nurse Consultant (RNC). 3. Beginning on [DATE] and concluding on [DATE], all Registered Nurses (RN) and Licensed Practical Nurses (LPN) received Mock Code training by the SDC. RNs and LPNs received a post test and had to obtain a score of one hundred percent (100%). RNs and LPNs who had not completed the required training by [DATE] would be notified by certified letter, that they would not be allowed to work until the Mock Code training had been completed. As of [DATE], a total of twenty-two (22) out of twenty-seven (27) nurses completed training. Five (5) PRN (as needed) nurses the facility was unable to contact were sent certified letters stating they would not be scheduled to work until training was completed and that training was mandatory. The education related to the policies and procedures was added to the training agenda for New Employee Orientation. The facility does not utilize agency staff. 4. Education related to Advance Directive Policy and Procedure, where Advance Directives were located in the clinical record, Admission/Physician order [REDACTED]. Certified letters were sent to the thirteen (13) staff members to notify them of the mandatory education prior to returning to duty. Education was provided by the Staff Development Coordinator, Unit Mangers Nursing Supervisors or RNC. All licensed staff received a post test and were required to attain a passing score of one hundred percent (100%). The education related to the policies and procedures was added to the training agenda for New Employee Orientation. The facility does not utilize agency staff. 5. On [DATE], all Department Managers were educated by the RNC on the Advance Directive Policy and Procedure, Admission/physician's orders [REDACTED]. Department Managers could not return to work until education had been completed. 6. Beginning on [DATE] and concluding on [DATE], the Social Service Director, DON, Unit Managers, and Nursing Supervisors assessed all residents to ensure all quality of care needs were being met. Residents with a Brief Interview of Mental Status (BIMS) score of eight (8) or greater were interviewed and residents with a BIMS less than eight (8) were physically assessed for any signs and symptoms of possible quality of life or resident rights violations. 7. Beginning on [DATE] and concluding on [DATE], compliance audits of the admission process were completed on all admissions within the previous thirty (30) days. The audits were performed by the DON, Unit Managers or RNC of all resident's medical records to ensure compliance with the admission process to include reviewing admitting orders including Advance Directives/code status, and care plans. 8. On [DATE], an audit was conducted of all licensed nurse personnel files for CPR certification and licensure by the Staff Development Coordinator (SDC). 9. Beginning on [DATE] and concluding on [DATE], audits of all residents who expired within the previous sixty (60) days were performed by the RNC to ensure: Advance Directives were signed and witnessed to designate code status; Code Status was designated by Advance Directive; physician's orders [REDACTED]. 10. By [DATE], an audit was conducted by the RNC on all Emergency Code Documentation sheets for the previous thirty (30) days for compliance with CPR Policy. 11. By [DATE], an audit was conducted by the RNC of all Accidents and Incidents for the previous thirty (30) days to ensure all code blue processes were followed and within compliance with the CPR Policy. 12. The DON, Unit Managers, SDC, MDS Coordinator, Restorative Nurse Manager, or Nursing Supervisor will conduct an audit/review of care plans daily to ensure accuracy with code status along with implementation and individualization of the care plan and the SRNA care plan. The findings will be reviewed by the DON daily during the morning clinical white board meeting and discussed with the QAPI team during monthly QAPI meeting. 13. The DON, Unit Managers, SDC, MDS Coordinator, Restorative Nurse Manager, or Nursing Supervisor will conduct an audit/review Nurse's Notes, Social Service Notes, Accidents and Incidents, and the Twenty-Four (24) Hour Report daily to ensure any change in condition noted had appropriate interventions implemented and updated on the care plan. The findings will be reviewed by the DON daily during the morning clinical white board meeting and discussed with the QAPI team during monthly QAPI meeting. 14. The DON, Unit Managers, SDC, MDS Coordinator, Restorative Nurse Manager, or Nursing Supervisor will conduct an audit/review of all emergency code documentation sheets daily to ensure completeness, accuracy, and compliance with CPR Policy and Procedure along with the process. The findings will be reviewed by the DON daily during the morning clinical white board meeting and discussed with the QAPI team during monthly QAPI meeting. 15. By [DATE], the Unit Managers, Nursing Supervisors, and the DON conducted an audit of all in house residents' charts regarding Advance Directives to ensure they were signed, witnessed, current, complete and matched code status; Code Status to ensure current, complete, displayed in chart and matched physician's orders [REDACTED]. 16. On [DATE], a Quality Assurance Performance Improvement (QAPI) Meeting was held to review the Immediate Jeopardy (IJ) incident, initiation of the investigation, and current plan for the Medical Directors input, recommendations, and approval. Additional QAPI meetings were held on [DATE] and [DATE] to review the on-going plan, compliance, validation, and for any needed recommended changes to the plan. Findings of the daily audits will be reviewed by the DON daily during clinical white board meetings and discussed with QAPI team during monthly QAPI. QAPI meetings will be conducted monthly for three (3) months to review the effectiveness of the plan with progression through the plan. The State Survey Agency validated the implementation of the facility's A[NAME] on [DATE] as follows: 1. Review of the facility's investigation of the incident involving Resident #1 on [DATE], revealed an audit of Resident #1's medical record was completed on [DATE] with areas of concern noted. Interview with the DON, on [DATE] at 3:03 PM, revealed she audited Resident #1's medical record and assisted with the investigation related to Resident #1, and identified areas of concern with CPR Policy and Procedure, Advance Directive Policy and Procedure, Professional Standards, and the Care Plan Policy not followed. Per interview, there was immediate implementation of education to licensed nursing staff. 2. Review of the (MONTH) (YEAR) calendar documentation of Mock codes, revealed all nursing administration staff had received Mock Code training by the RNC by [DATE]. Continued review revealed all licensed nursing staff had received Mock code training by [DATE] by the SDC. Interview on [DATE] at 3:03 PM with the DON; [DATE] at 6:00 PM with the D Wing Unit Manager; [DATE] at 12:10 PM with the SDC; [DATE] at 12:39 PM with the Reflections Unit Manager; [DATE] at 12:48 PM with the B Wing Unit Manager; and [DATE] at 2:38 PM with the A Wing Unit Manager; revealed they had received Mock code training in (MONTH) (YEAR) by the RNC. Interview on [DATE] at 12:54 PM with the RNC, revealed she had conducted Mock code training with all nursing administration staff. 3. Review of the (MONTH) calendar utilized to conduct mock code training for licensed nursing staff on 7:00 AM shift and 7:00 PM shifts, for two (2) weeks starting [DATE], revealed training had been conducted and reviewed by the DON for compliance weekly. Interview on [DATE] at 3:03 PM, with the DON, revealed mock code training for licensed staff on 7:00 AM shift and 7:00 PM shifts had been conducted for two (2) weeks starting [DATE] and reviewed by her for compliance weekly. Continued interview revealed the DON presented the audit findings to the monthly QAPI team meetings. Interviews on [DATE] at 6:00 PM with the D Wing Unit Manager; [DATE] at 12:10 PM with the SDC; [DATE] at 12:39 PM with the B Wing Unit Manager; [DATE] at 12:48 PM with the Reflections Unit Manager; [DATE] at 12:55 PM with the Restorative Nurse Manager; [DATE] at 1:18 PM with the MDS Coordinator; and [DATE] at 2:38 PM with the A Wing Unit Manager; revealed they had conducted mock code training for licensed staff on 7:00 AM shift and 7:00 PM shifts for two (2) weeks starting on [DATE]. Interview on [DATE] at 12:30 PM with LPN #1; [DATE] at 2:23 PM with LPN #8; [DATE] and at 3:05 PM with LPN #2; [DATE] at 12:55 PM with RN #4; [DATE] at 2:36 PM with RN #6; [DATE] at 4:25 PM with LPN #7; and [DATE] at 4:37 PM with LPN; revealed they had received Mock code training in (MONTH) (YEAR) by the SDC. 4. Review of the education provided to all licensed staff related to Advance Directive Policy and Procedure, Admission/Physician order [REDACTED]. Review of the POS [REDACTED]. Review of the New Hire Orientation Packet revealed the education related to the policies and procedures had been added to the training agenda for New Employee Orientation. Interview on [DATE] at 12:30 PM, with LPN #1; [DATE] at 2:23 PM with LPN #8; and [DATE] at 3:05 PM with LPN #2; revealed they had received education related to Advance Directive Policy and Procedure, Admission/Physician order [REDACTED]. Interview on [DATE] at 12:55 PM with RN #4; [DATE] at 2:36 PM with RN #6; [DATE] at at 4:25 PM with LPN #7; and [DATE] at 4:37 PM with LPN #8; revealed they had received education related to Advance Directive Policy and Procedure, Admission/Physician order [REDACTED]. 5. Review of the education provided to all Department Managers related to Advance Directive Policy and Procedure, Admission/Physician order [REDACTED]. Review of the POS [REDACTED]. Interview on [DATE] at 3:03 PM with the DON; [DATE] at 6:00 PM with the D Wing Unit Manager; [DATE] at 12:10 PM wi (TRUNCATED)

Based on interview, record review, and review of facility's policy, it was determined the facility failed to ensure the Baseline Care Plan was implemented to provide effective and person-centered care for one (1) of ten (10) sampled residents (Resident #1). Resident #1's Baseline Care Plan, dated [DATE], revealed the resident and family had chosen a code status of Full Code, meaning in the event the resident experienced a cardiopulmonary arrest, Cardiopulmonary Resuscitation (CPR) was to be performed. However, on [DATE], per staff interview, at approximately 5:45 PM, when Registered Nurse (RN) #1 observed Resident #1 to be unresponsive and cold to the touch with absence of respirations and heartbeat, she failed to immediately check the medical record for code status, and initiate CPR as she did not know the facility's protocol when a resident was found unresponsive. RN #1 consulted with Licensed Practical Nurse (LPN) #1 on facility protocol, and then overhead paged for a nurse from other units to call Unit B Hall immediately. Subsequently RN #1 called the DON who instructed her to to check the resident's code status, call 911, get the crash cart, and code the resident. RN #1 called 911, and initiated CPR at approximately 6:08 PM, which was approximately twenty-three (23) minutes after the resident was found with absence of respirations and heartbeat. However, RN #1 only performed three (3) to five (5) chest compressions before stopping CPR and staff interviews revealed no other staff continued with the CPR. Record review revealed staff were not performing CPR when Emergency Medical Services (EMS) arrived. EMS transported the resident to the Hospital emergency room and Resident #1 was pronounced dead on [DATE] at 6:53 PM. (Refer to F-678) The facility's failure to have an effective system in place to ensure staff implement the Baseline Care Plan to provide effective and person-centered care has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) was identified on [DATE] and determined to exist on [DATE]. The facility provided an acceptable credible Allegation of Compliance (AoC) on [DATE], with the facility alleging removal of the Immediate Jeopardy on [DATE]. However, the State Survey Agency (SSA) determined the Immediate Jeopardy was not removed on [DATE] as alleged. Through record review, the SSA identified discrepancies regarding code status related to Advance Directives, physician's orders [REDACTED]. The facility made corrections and conducted another audit on [DATE]. Therefore, the SSA determined the Immediate Jeopardy was not removed until [DATE]. Non-compliance remains at a Scope and Severity of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's Baseline Care Plan Policy, undated, revealed a Baseline Plan of Care shall be developed for each resident within forty-eight (48) hours of admission. Continued review revealed the Baseline Care Plan would include the minimum healthcare information necessary to properly care for a resident including, but not limited to: initial goals based on admission orders [REDACTED]. Review of Resident #1's clinical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Advance Directive/Informed Consent Form, signed by the resident's son on [DATE], revealed Full Code, which indicated in the event the resident experienced a cardiopulmonary arrest, Cardiopulmonary Resuscitation (CPR) was to be performed. Review of Resident #1's (MONTH) (YEAR) physician's orders [REDACTED].>Review of Resident #1's Baseline Care Plan, dated [DATE], revealed the resident and family had elected Full Code. Review of the Progress Note, dated [DATE] at 6:28 PM, signed by RN #1, revealed RN #1 entered Resident #1's room to pick up the dinner tray, and the resident was noted to be unconscious and did not respond to word or touch. Per the Note, Resident #1's skin was cold and his/her eyes were open. Further review of the Note, revealed RN #1 placed the resident in a lying position and started CPR; and LPN #1 quickly replaced RN #1 in order for RN #1 to call 911 and the family. Per the Note, CPR continued and EMS arrived and took over life resuscitation attempts. However, review of the facility's Investigation Report, completed by the Administrator, dated [DATE], revealed RN #1 initiated CPR to Resident #1 after speaking with the DON by phone and after being instructed to do so. Per the Report, RN #1 stated she initiated CPR, but became confused and called the resident's son to inform him of the resident's condition. The Report further stated, while RN #1 was on the phone with the resident's son, EMS arrived and took over CPR and transported the resident to the hospital. Review of Resident #1's Emergency Medical Response Report, dated [DATE], revealed EMS received a call on [DATE] at 6:08 PM; and arrived on scene at 6:14 PM to find Resident #1 in [MEDICAL CONDITION]. Further review of the Report, revealed on EMS arrival, the nurse was at the nurse's station with no efforts being made for CPR, no one was with the resident, and the resident appeared to have been dressed and posed. EMS left the scene at 6:34 PM and CPR was discontinued at 6:55 PM. Interview on [DATE] at 6:20 PM with RN #1, revealed when she found the resident not breathing and cold to the touch, she thought the resident had passed away and asked LPN #1 what she should do. Per interview, LPN #1 told her she needed to call the DON, and she and LPN #1 then went to the nurse's desk because neither one of them knew the protocol of what to did if they found a resident unresponsive. Interview on [DATE] at 12:15 PM, with LPN #1, revealed on [DATE] at approximately 5:30 PM, RN #1 called out to her and told her a resident had died and she wanted her to check to ensure the resident was deceased . LPN #1 stated upon entering Resident #1's room she observed the resident sitting up in the bed with eyes slightly open, and chest not moving and she touched the resident's hand which was cold. She further stated neither she or RN #1 checked to see if Resident #1 had a pulse or respirations, but left the room to go to the nurse's station to call the DON. Continued interview revealed she and RN #1 should have checked Resident #1's chart for code status, and should have called a code blue when they found the resident unresponsive. She stated Resident #1's Baseline Care Plan should have been followed related to code status. Further interview with RN #1, on [DATE] at 6:20 PM, revealed she was in a panic mode and called the DON and was told to go do a code. Per interview, RN #1 went to the resident's room to initiate CPR. She stated she pushed on the resident's chest about three (3) or four (4) times and stopped because the resident was cold and she felt like it was wrong to continue with CPR due to it had been about twenty (20) minutes since she initially found the resident unresponsive. Further interview revealed after she left the resident's room, nobody was performing CPR on the resident. Per interview, she should have initiated CPR immediately and once she initiated CPR, she should have continued CPR until EMS arrived. Further interview revealed the resident's Baseline Care Plan stated the resident/s code status was Full Code, and the Care Plan should have been followed. Interview on [DATE] at 3:03 PM, with the DON, revealed RN #1 called her on [DATE] at 6:07 PM, stating Resident #1 had passed away. The DON stated the resident had not been at the facility long and she thought the resident was a Full Code, but told RN #1 to check the code status. Per interview, when RN #1 informed her the resident was a Full Code she instructed RN #1 to perform CPR. The DON stated RN #1 told her it's too late, and she (DON) instructed RN #1 to perform CPR because Resident #1 was a Full Code and to call EMS. She further stated RN #1 called back at 6:21 PM and informed her EMS had arrived and the resident was on the way to the Hospital emergency room . Further interview revealed RN #1 should have checked the resident's code status when she found the resident unresponsive with absence of respirations and heartbeat and immediately initiated CPR, and continued CPR until EMS arrived and transported the resident to the hospital. The DON further stated she expected staff to follow the Baseline Care Plan related to code status. Interview on [DATE] at 11:40 AM, with Resident #1's Attending Physician (AP), revealed he was informed on [DATE], that Resident #1 had expired. He stated he was aware the resident had been admitted to the facility on [DATE] with a Full Code status, but was unaware there was a delay in initiating CPR and was unaware staff had stopped CPR. Further interview revealed in the event a nurse found a resident unresponsive, he expected the nurse to follow the resident's Care Plan related to code status because it guided the resident's care. Interview on [DATE] at 3:33 PM, with the Administrator, revealed she was notified on [DATE] by the DON, Resident #1 had passed. She stated RN #1 failed to immediately verify the resident's code status by looking in Resident #1's chart and failed to initiate CPR in a timely manner. Also, she stated RN #1 failed to continue CPR until EMS arrived at the facility to assume care of the resident. The Administrator stated it was her expectation that staff follow the Baseline Care Plan related to code status in order to honor the resident's wishes. Review of the A[NAME] revealed the facility implemented the following: 1. An investigation related to Resident #1 and the incident which occurred on [DATE], was initiated on [DATE] and completed by [DATE], by the Director of Nursing (DON) and the Administrator. During the investigation a review of Resident #1's medical record, code blue process, and cardiopulmonary resuscitation process, staff interviews, and resident interviews was completed. It was determined by the facility there was a failure in following policies and procedures including the Cardiopulmonary Resuscitation Policy and Care Plan Policy. 2. Beginning on [DATE] and concluding on [DATE], the DON, Assistant Director of Nursing (ADON), Unit Managers, Staff Development Coordinator (SDC), Minimum Data Set (MDS) Coordinator, Restorative Nurse Manager and Nursing Supervisor received Mock Code training by the Registered Nurse Consultant (RNC). 3. Beginning on [DATE] and concluding on [DATE], all Registered Nurses (RN) and Licensed Practical Nurses (LPN) received Mock Code training by the SDC. RNs and LPNs received a post test and had to obtain a score of one hundred percent (100%). RNs and LPNs who had not completed the required training by [DATE] would be notified by certified letter, that they would not be allowed to work until the Mock Code training had been completed. As of [DATE], a total of twenty-two (22) out of twenty-seven (27) nurses completed training. Five (5) PRN (as needed) nurses the facility was unable to contact were sent certified letters stating they would not be scheduled to work until training was completed and that training was mandatory. The education related to the policies and procedures was added to the training agenda for New Employee Orientation. The facility does not utilize agency staff. 4. Education related to Advance Directive Policy and Procedure, where Advance Directives were located in the clinical record, Admission/Physician order [REDACTED]. Certified letters were sent to the thirteen (13) staff members to notify them of the mandatory education prior to returning to duty. Education was provided by the Staff Development Coordinator, Unit Mangers Nursing Supervisors or RNC. All licensed staff received a post test and were required to attain a passing score of one hundred percent (100%). The education related to the policies and procedures was added to the training agenda for New Employee Orientation. The facility does not utilize agency staff. 5. On [DATE], all Department Managers were educated by the RNC on the Advance Directive Policy and Procedure, Admission/physician's orders [REDACTED]. Department Managers could not return to work until education had been completed. 6. Beginning on [DATE] and concluding on [DATE], the Social Service Director, DON, Unit Managers, and Nursing Supervisors assessed all residents to ensure all quality of care needs were being met. Residents with a Brief Interview of Mental Status (BIMS) score of eight (8) or greater were interviewed and residents with a BIMS less than eight (8) were physically assessed for any signs and symptoms of possible quality of life or resident rights violations. 7. Beginning on [DATE] and concluding on [DATE], compliance audits of the admission process were completed on all admissions within the previous thirty (30) days. The audits were performed by the DON, Unit Managers or RNC of all resident's medical records to ensure compliance with the admission process to include reviewing admitting orders including Advance Directives/code status, and care plans. 8. On [DATE], an audit was conducted of all licensed nurse personnel files for CPR certification and licensure by the Staff Development Coordinator (SDC). 9. Beginning on [DATE] and concluding on [DATE], audits of all residents who expired within the previous sixty (60) days were performed by the RNC to ensure: Advance Directives were signed and witnessed to designate code status; Code Status was designated by Advance Directive; physician's orders [REDACTED]. 10. By [DATE], an audit was conducted by the RNC on all Emergency Code Documentation sheets for the previous thirty (30) days for compliance with CPR Policy. 11. By [DATE], an audit was conducted by the RNC of all Accidents and Incidents for the previous thirty (30) days to ensure all code blue processes were followed and within compliance with the CPR Policy. 12. The DON, Unit Managers, SDC, MDS Coordinator, Restorative Nurse Manager, or Nursing Supervisor will conduct an audit/review of care plans daily to ensure accuracy with code status along with implementation and individualization of the care plan and the SRNA care plan. The findings will be reviewed by the DON daily during the morning clinical white board meeting and discussed with the QAPI team during monthly QAPI meeting. 13. The DON, Unit Managers, SDC, MDS Coordinator, Restorative Nurse Manager, or Nursing Supervisor will conduct an audit/review Nurse's Notes, Social Service Notes, Accidents and Incidents, and the Twenty-Four (24) Hour Report daily to ensure any change in condition noted had appropriate interventions implemented and updated on the care plan. The findings will be reviewed by the DON daily during the morning clinical white board meeting and discussed with the QAPI team during monthly QAPI meeting. 14. The DON, Unit Managers, SDC, MDS Coordinator, Restorative Nurse Manager, or Nursing Supervisor will conduct an audit/review of all emergency code documentation sheets daily to ensure completeness, accuracy, and compliance with CPR Policy and Procedure along with the process. The findings will be reviewed by the DON daily during the morning clinical white board meeting and discussed with the QAPI team during monthly QAPI meeting. 15. By [DATE], the Unit Managers, Nursing Supervisors, and the DON conducted an audit of all in house residents' charts regarding Advance Directives to ensure they were signed, witnessed, current, complete and matched code status; Code Status to ensure current, complete, displayed in chart and matched physician's orders [REDACTED]. 16. On [DATE], a Quality Assurance Performance Improvement (QAPI) Meeting was held to review the Immediate Jeopardy (IJ) incident, initiation of the investigation, and current plan for the Medical Directors input, recommendations, and approval. Additional QAPI meetings were held on [DATE] and [DATE] to review the on-going plan, compliance, validation, and for any needed recommended changes to the plan. Findings of the daily audits will be reviewed by the DON daily during clinical white board meetings and discussed with QAPI team during monthly QAPI. QAPI meetings will be conducted monthly for three (3) months to review the effectiveness of the plan with progression through the plan. The State Survey Agency validated the implementation of the facility's A[NAME] on [DATE] as follows: 1. Review of the facility's investigation of the incident involving Resident #1 on [DATE], revealed an audit of Resident #1's medical record was completed on [DATE] with areas of concern noted. Interview with the DON, on [DATE] at 3:03 PM, revealed she audited Resident #1's medical record and assisted with the investigation related to Resident #1, and identified areas of concern with CPR Policy and Procedure, Advance Directive Policy and Procedure, Professional Standards, and the Care Plan Policy not followed. Per interview, there was immediate implementation of education to licensed nursing staff. 2. Review of the (MONTH) (YEAR) calendar documentation of Mock codes, revealed all nursing administration staff had received Mock Code training by the RNC by [DATE]. Continued review revealed all licensed nursing staff had received Mock code training by [DATE] by the SDC. Interview on [DATE] at 3:03 PM with the DON; [DATE] at 6:00 PM with the D Wing Unit Manager; [DATE] at 12:10 PM with the SDC; [DATE] at 12:39 PM with the Reflections Unit Manager; [DATE] at 12:48 PM with the B Wing Unit Manager; and [DATE] at 2:38 PM with the A Wing Unit Manager; revealed they had received Mock code training in (MONTH) (YEAR) by the RNC. Interview on [DATE] at 12:54 PM with the RNC, revealed she had conducted Mock code training with all nursing administration staff. 3. Review of the (MONTH) calendar utilized to conduct mock code training for licensed nursing staff on 7:00 AM shift and 7:00 PM shifts, for two (2) weeks starting [DATE], revealed training had been conducted and reviewed by the DON for compliance weekly. Interview on [DATE] at 3:03 PM, with the DON, revealed mock code training for licensed staff on 7:00 AM shift and 7:00 PM shifts had been conducted for two (2) weeks starting [DATE] and reviewed by her for compliance weekly. Continued interview revealed the DON presented the audit findings to the monthly QAPI team meetings. Interviews on [DATE] at 6:00 PM with the D Wing Unit Manager; [DATE] at 12:10 PM with the SDC; [DATE] at 12:39 PM with the B Wing Unit Manager; [DATE] at 12:48 PM with the Reflections Unit Manager; [DATE] at 12:55 PM with the Restorative Nurse Manager; [DATE] at 1:18 PM with the MDS Coordinator; and [DATE] at 2:38 PM with the A Wing Unit Manager; revealed they had conducted mock code training for licensed staff on 7:00 AM shift and 7:00 PM shifts for two (2) weeks starting on [DATE]. Interview on [DATE] at 12:30 PM with LPN #1; [DATE] at 2:23 PM with LPN #8; [DATE] and at 3:05 PM with LPN #2; [DATE] at 12:55 PM with RN #4; [DATE] at 2:36 PM with RN #6; [DATE] at 4:25 PM with LPN #7; and [DATE] at 4:37 PM with LPN; revealed they had received Mock code training in (MONTH) (YEAR) by the SDC. 4. Review of the education provided to all licensed staff related to Advance Directive Policy and Procedure, Admission/Physician order [REDACTED]. Review of the POS [REDACTED]. Review of the New Hire Orientation Packet revealed the education related to the policies and procedures had been added to the training agenda for New Employee Orientation. Interview on [DATE] at 12:30 PM, with LPN #1; [DATE] at 2:23 PM with LPN #8; and [DATE] at 3:05 PM with LPN #2; revealed they had received education related to Advance Directive Policy and Procedure, Admission/Physician order [REDACTED]. Interview on [DATE] at 12:55 PM with RN #4; [DATE] at 2:36 PM with RN #6; [DATE] at at 4:25 PM with LPN #7; and [DATE] at 4:37 PM with LPN #8; revealed they had received education related to Advance Directive Policy and Procedure, Admission/Physician order [REDACTED]. 5. Review of the education provided to all Department Managers related to Advance Directive Policy and Procedure, Admission/Physician order [REDACTED]. Review of the POS [REDACTED]. Interview on [DATE] at 3:03 PM with the DON; [DATE] at 6:00 PM with the D Wing Unit Manager; [DATE] at 12:10 PM with the SDC; [DATE] at 12:39 PM with the Reflections Unit Manager; [DATE] at 12:48 PM with the B Wing Unit Manager; and [DATE] at 2:38 PM with the A Wing Unit Manager; revealed they had received education from the RNC on Advance Directive Policy and Procedure, Admission/Physician order [REDACTED]. Interview on [DATE] at 12:54 PM, with the RNC, revealed she had conducted re-education with all nursing administration staff related to Advance Directive Policy and Procedure, Admission/Physician order [REDACTED]. 6. Review of the facility's audit tool utilized to interview and assess all residents for possible resident rights violations, revealed the Social Services Director (SSD) interviewed all residents with a Brief Interview for Mental Status (BIMS) score of eight (8) or greater; and a physical assessment was completed by Nursing Administration staff for residents whose BIMS was less than eight (8). The audit was completed on [DATE]. Interview on [DATE] at 3:03 PM, with the DON, revealed the SSD and nursing management staff interviewed or assessed each resident for any signs or symptoms of resident rights violations and quality of care issues. 7. Review of the audit tool utilized to audit the previous thirty (30) days of facility new admissions, revealed new admissions had been audited for compliance with admission process, Advance Directive/Code status, Care Plans, and review of New Admission physician's orders [REDACTED]. Interviews on [DATE] at 3:03 PM with the DON; [DATE] at 6:00 PM with the D Wing Unit Manager; [DATE] at 12:39 PM with the Reflections Unit Manager; [DATE] at 12:48 PM with the B Wing Unit Manager; [DATE] at 2:38 PM with the A Wing Unit Manager; and [DATE] at 2:54 PM, with the RNC, revealed they had participated with other management staff to audit all resident's records who were admitted to the facility in the previous thirty (30) days to verify accuracy of each resident's Advance Directive, Care Plan, and physician's orders [REDACTED]. 8. Review of the audit tool utilized to audit all licensed nurse personnel files for CPR certification and licensure, revealed the audit was completed on [DATE]. Interview on [DATE] at 12:10 PM, with the SDC, revealed she had conducted an audit of all licensed nurse personnel files to ensure compliance with CPR certification and licensure on [DATE]. 9. Review of the audit tool utilized to audit all residents who expired within the previous sixty (60) days to ensure Advance Directives were signed and witnessed to designate code status, code status was designated by Advance Directive, physician's orders [REDACTED]. Interview on [DATE] at 12:54 PM, with the RNC, revealed she had conducted an audit of all residents who expired within the previous sixty (60) days to ensure Advance Directives were signed and witnessed to designate code status, code status was designated by Advance Directive, Physician orders [REDACTED]. 10. Review of the audit tool utilized to audit all Emergency Code Documentation Sheets for the previous thirty (30) days to ensure completeness, accuracy, and compliance with CPR policy and procedure, revealed the audit was completed on [DATE]. Interview on [DATE] at 12:54 PM, with the RNC, revealed she had conducted and audit of all Emergency Code Documentation sheets for the previous thirty (30) days to ensure completeness, accuracy, and compliance with CPR Policy and Procedure on [DATE]. 11. Review of the audit tool utilized to audit all Accidents and Incidents for the previous thirty (30) days to ensure all codes blue processes were followed and within compliance with the CPR Policy and Procedure, revealed the audit was completed on [DATE]. Interview on [DATE] at 2:54 PM, with the RNC, revealed she had conducted an audit of all Accidents and Incidents to ensure code blue processes were followed and within compliance with the CPR Policy and Procedure on [DATE]. 12. Review of the audit tool utilized to conduct daily audit/review of care plans to ensure accuracy with code status along with implementation and individualization of the care plan and the SRNA care plan revealed audits were being completed daily by the nursing administration staff. Per review, the findings were presented by the DON in the morning white board meetings. Interview on [DATE] at 3:03 PM with the DON; [DATE] at 6:00 PM with the D Wing Unit Manager; [DATE] at 12:10 PM with the SDC; [DATE] at 12:39 PM with the Reflections Unit Manager; [DATE] at 12:48 PM with the B Wing Unit Manager; [DATE] at 12:55 PM with the Restorative Nurse Manager; [DATE] at 1:18 PM with the MDS Coordinator; and [DATE] at 2:38 PM with the A Wing Unit Manager, revealed they had participated in daily audit/review of care plans to ensure accuracy with code status along with implementation and individualization of the care plan and the SRNA care plan and the audits were completed daily. Continued interview revealed the DON presented the audit findings to the monthly QAPI team meetings. 13. Review of the audit tool utilized to conduct audit/review of Nurse's Notes, Social Service Notes, Accidents and Incidents, and the Twenty-Four (24) Hour Report daily to ensure any change in condition noted had appropriate interventions implemented and updated on the care plan, revealed audits were being completed daily by the nursing administration staff. Interview on [DATE] at 3:03 PM, with the DON, revealed she had participated in daily audit/review of Nurse's Notes, Social Service Notes, Accident and Incidents, and the Twenty-Four (24) Hour Report daily to ensure any change in condition noted had appropriate interventions implemented and updated on the care plan. Continued interview revealed the DON presented the audit findings to the monthly QAPI team meeting. Interviews on [DATE] at 6:00 PM with the D Wing Unit Manager; [DATE] at 12:10 PM with the SDC; [DATE] at 12:39 PM with the Reflections Unit Manager; [DATE] at 12:48 PM with the B Wing Unit Manager; [DATE] at 12:55 PM with the Restorative Nurse Manager; [DATE] at 1:18 PM with the MDS Coordinator; and [DATE] at 2:38 PM with the A Wing Unit Manager; revealed she they had conducted daily audit/review of Nurse's Notes, Social Service Notes, Accidents and Incidents, and the Twenty-Four (24) Hour Report to ensure any change in condition noted had appropriate interventions implemented and updated on the care plan. 14. Review of the audit tool utilized to conduct audit/review of all emergency code documentation sheets daily to ensure completeness, accuracy, and compliance with CPR Policy and Procedure, along with the process revealed the audits were being conducted daily by the nursing administration staff. Interview on [DATE] at 3:03 PM, with the DON, revealed she had participated in daily audit/review of all emergency code documentation sheets to ensure completeness, accuracy, and compliance with CPR Policy and Procedure. Per interview, the audits were being conducted daily by the nursing administration staff. Continued interview revealed the DON presented the audit findings to the monthly QAPI team meetings. Interviews on [DATE] at 6:00 PM with the D Wing Unit Manager; [DATE] at 12:10 PM with the SDC; [DATE] at 12:39 PM with the Reflections Unit Manager; [DATE] at 12:48 PM with the B Wing Unit Manager; [DATE] at 12:55 PM with the Restorative Nurse Manager; [DATE] at 1:18 PM with the MDS Coordinator; and [DATE] at 2:38 PM with the A Wing Unit Manager; revealed they had conducted daily audit/review of all emergency code documentation sheets daily to ensure completeness, accuracy, and compliance with CPR Policy and Procedure along with the process revealed the audits were being conducted daily. 15. Review of the Audits, revealed a one hundred percent (100%) audit was conducted by the facility of all i (TRUNCATED)

Based on interview, record review and review of the facility's policy, it was determined the facility failed to have an effective system to ensure the Advance Directives for one (1) of twelve (12) sampled residents (Resident #1) were honored. On [DATE], Resident #1's Responsible Party (RP) signed Advance Directives requesting the resident have a Full Code status (Full Code indicated life-saving measures were to be implemented in the event of cardiac or [MEDICAL CONDITION]), to include Cardiopulmonary Resuscitation (CPR). However, on [DATE] at approximately 7:15 AM, when State Registered Nursing Assistant (SRNA) #1 entered Resident #1's room, found him/her unresponsive and notified Licensed Practical Nurse (LPN) #1 and #2, the LPN's failed to honor the resident's Advance Directives regarding his/her Full Code status. LPN #1 entered Resident #1's room, checked Resident #1 for a pulse, could not obtain a pulse and failed to initiate CPR as per the resident's Advance Directives. LPN #2 entered Resident #1's room, observed LPN #1 checking the resident for a pulse, went to the nurse's station, checked the resident's chart for his/her code status and called Registered Nurse (RN) #1. LPN #2 also failed to initiate CPR as per the resident's Advance Directives. RN #1, who was on another unit, arrived to Resident #1's room, assessed the resident to have no heart rate and no respirations and pronounced the resident deceased at 7:23 AM. Per interview, RN #1 determined Resident #1 was a Full Code, but she did not initiate CPR according to the resident's Advance Directives. The facility's failure to ensure resident's Advance Directives regarding their requested Full Code status was honored has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on [DATE], and was determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable credible Allegation of Compliance (AOC) was received on [DATE] which alleged removal of the Immediate Jeopardy on [DATE]. The Immediate Jeopardy was verified to be removed on [DATE] as alleged, prior to exit on [DATE], with remaining non-compliance in the area of 42 CFR 483.10, Resident Rights, F-155 at a Scope and Severity of a D while the facility develops and implements a Plan of Correction (POC) and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's policy titled Advance Directives - Kentucky, effective ,[DATE], revealed it was the policy of the facility to recognize and support the use of Advance Directives through family, staff and community education, and to encourage the resident's rights to self-determination through recognition and assistance with executing such directives. Continued review revealed, as long as the resident was competent to make decisions, his/her wishes would be followed to the maximum extent possible as dictated by state law and sound medical judgment. If a resident became incompetent, but had provided evidence of a properly executed Advance Directive, the facility would implement the resident's choices as outlined in the document or expressed to the appointed agent to the same extent that the competent resident's wishes would be followed. Further review revealed, all residents would receive full resuscitative measures unless a Do Not Resuscitate (DNR) directive was written in the resident's medical record and was identified in the resident's Advance Directive. Review of the facility's policy titled, Cardiopulmonary Resuscitation, undated, revealed CPR would be attempted for any resident who was found to have no pulse and or no discernible respirations, unless there was a written physician order [REDACTED]. Review of the facility's policy titled Resident Rights, reviewed [DATE], revealed residents had the right to choose a physician, treatment, participation in decisions, and care planning. Further review revealed, residents were entitled to exercise their rights and privileges to the fullest extent possible. Per the policy, employees had a duty to read and learn the residents' rights. Review of Resident #1's medical record, revealed the facility admitted him/her on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #1's Nursing Admission Information, dated [DATE], revealed the resident was alert and oriented to person with independent mobility. Review of the Advance Directives/Informed Consent, dated [DATE], revealed it was signed by the resident's Responsible Party on [DATE]. Continued review of the form revealed the resident wished to be a Full Code. Review of the physician's orders [REDACTED].#1 had an order for [REDACTED].>However, review of the Nurse's Note, dated [DATE], not timed, signed by LPN #1, revealed the nurse found Resident #1 sitting on the floor next to the bed with blood noted to be on the pillow and ear with no pulse found. Continued review revealed no documented evidence LPN #1 immediately initiated CPR according to Resident #1's Advance Directive. Interview with LPN #1, on [DATE] at 6:12 PM, revealed when he found Resident #1 on [DATE] around 7:15 AM, he did not initiate CPR. Continued interview revealed he did not know if Resident #1 was a Full Code status and felt the resident required further assessment, and stated the RN was more qualified. Per interview, LPN #1 was unfamiliar with the facility's policy; however, he stated he did not know why he didn't initiate CPR. Review of the Nurse's Note, dated [DATE] at 7:23 AM, signed by LPN #2, revealed LPN #2 found Resident #1 sitting beside the bed with his/her back to the bed and leaning to his/her left side with fresh wet blood from the left ear on the pillow. Continued review revealed no documented evidence LPN #2 initiated CPR according to Resident #1's Advance Directive. Further review of the Nurse's Note revealed LPN #2 immediately called the RN and the on-call Physician. Continued review of the Note revealed, LPN #2 received an order from the on call Physician to with hold CPR related to no signs of life, no pulse, no respiration and no blood pressure. Interview with the on-call Physician, on [DATE] at 8:13 AM, revealed the facility did notify him of the resident's death. However, per interview, he was not aware Resident #1 was a Full Code status and he would not give an order to withhold CPR. Interview with LPN #2, on [DATE] at 4:31 PM, revealed she had entered Resident #1's room behind LPN #1 and found the resident with no pulse; however, she did not initiate CPR. LPN #2 stated she went to the nurse's station to check the resident's code status and call the RN. Further interview revealed, she identified the resident to be a Full Code status and informed LPN #1 and RN #1 of the resident's Advance Directive; even though she did not initiate CPR. LPN #2 reported the resident was just too far gone. Per interview, LPN #2 stated she reported to the on-call Physician the resident had expired and the RN had decided the resident was too far gone to perform CPR. Review of the Nurse's Note, dated [DATE] at 7:30 AM, signed by RN #1, revealed she found the resident sitting on the floor with his/her back to the bed and leaning to the left side with blood from the left ear with no heart rate and no respirations. Further review of the Note, revealed Resident #1 was pronounced deceased by RN #1 at 7:23 AM. Interview with RN #1, on [DATE] at 5:50 PM, revealed she responded to a call on [DATE] around 7:10 AM or 7:15 AM, from LPN #2 requesting a nurse to pronounce a resident deceased . Per interview, RN #1 was not aware Resident #1 was a Full Code status until she went to the nurse's station to document her assessment; however, she did not initiate CPR because in my nursing opinion, she had been passed for a while. Further interview revealed, it was the facility's policy to initiate CPR when a resident was found in [MEDICAL CONDITION] or unresponsive and was a Full Code status. RN #1 stated she did not follow the facility's policy. Interview with the Director of Nursing (DON), on [DATE] at 3:09 PM, revealed if a resident was found unresponsive, staff should confirm the resident's Advance Directive, and CPR should be immediately initiated for any resident with a Full Code status Advance Directive. Continued interview revealed staff did not follow the facility's policy for Resident #1. Interview with the Administrator, on [DATE] at 4:50 PM, revealed Resident #1 had the right to an Advance Directive and the resident's wishes should have been honored by the facility and the staff. Continued interview revealed, staff did not follow the facility's policy related to the initiation of CPR. The facility provided an acceptable credible Allegation of Compliance (AOC) on [DATE], which alleged removal of the IJ effective [DATE]. Review of the AOC revealed the facility implemented the following: 1. On [DATE], the Director of Nursing (DON) reviewed Resident #1's medical record and care plan with the following areas of concern identified: a. The date and time were missing regarding the Physician notification on the Nursing Admission Assessment b. the Advance Directive of Full Code status was not care planned on the Interim Care Plan. c. CPR was not immediately initiated per Resident #1's/Power of Attorney's (POA's) request as indicated on the Advance Directive. 2. Beginning [DATE] and concluding on [DATE], the DON, Unit Managers, Nursing Supervisors or Medical Records staff audited all resident Advance Directive/Code Status/physician's orders [REDACTED]. 3. Beginning [DATE] and concluding on [DATE], the DON, Assistant Director of Nursing (ADON), Unit Managers and Nursing Supervisors assessed all residents for any possible resident rights violations. Residents with a Brief Interview of Mental Status (BIMS) score of eight (8) or greater were interviewed and residents with a BIMS of less than eight (8) were physically assessed for any signs and symptoms of possible quality of life or resident rights violations. 4. Compliance audits of the admission process were completed by [DATE] of all admissions within the previous thirty (30) days. The audits were performed by the DON, ADON, Unit Managers or Nursing Supervisors of all resident's medical records to include notification of the Attending Physician, review of the Physician Admitting Orders with the Attending Physician and ensuring professional standards were followed. 5. The DON, Unit Managers, Nursing Supervisors or Medical Records staff completed audits of all resident charts by [DATE]. The Audit included; resident's Advance Directive, physician's orders [REDACTED]. 6. On [DATE], all management staff was educated by the Regional Nurse Consultant. Education included: Advance Directive Policy and Procedure, Admission/physician's orders [REDACTED]. 7. Education for all nursing staff was initiated on [DATE] and completed by [DATE], with the exception of four (4) full-time status staff on leave and twenty-one (21) part-time staff. Certified letters were sent to the twenty-one (21) part-time staff to notify each of the mandatory education prior to returning to duty. Education was provided by the Staff Development Coordinator, Unit Mangers and Nursing Supervisors. Education included Advance Directive Policy and Procedure, Admission/Physician order [REDACTED]. The education related to the policies and procedures was added to the training agenda for New Employee Orientation. 8. Beginning [DATE] and concluding on [DATE], the Staff Development Coordinator, Unit Managers and Nursing Supervisors conducted education for all licensed staff (with the exception of the part-time staff who were notified by certified letter they could not work until receiving the required education) on the admission policy and procedure, to include: clarification of the process for Physician notification of new admissions, obtaining admission orders [REDACTED]. The above education was incorporated into the facility's New Employee Orientation. 9. On [DATE], all Physicians with privileges at the facility were educated by the DON in regards to the admission process and expectations with compliance to include: Discharge Summaries or Orders from a discharging facility would be faxed to the Physician's office and the Physician would be called for approval of the Orders with a Telephone Order written stating the Physician's review and approval of the Orders. 10. Human Resources and/or Staff Development performed audits of all personnel files for CPR certifications. Audits were completed by [DATE] and given to the Regional Nurse Consultant to review for non-compliance with CPR regulations. Seventeen (17) licensed nurses were noted to have on-line only CPR certifications. 11. Sixteen (16) of the seventeen (17) staff identified to have on-line CPR certifications received CPR instruction with hands on component by [DATE], provided by the DON, a certified American Heart CPR Instructor. One (1) employee would not be allowed to work until CPR certification with hands on component was obtained. 12. Beginning [DATE], the DON, ADON, Unit Manager, Nursing Supervisor or Medical Records staff will review all new admissions daily during the morning clinical meeting to ensure compliance with Physician notification, Physician Orders, Interim Care Plan, Advance Directive, and Resident Rights. Findings of the review will be reported in the Quality Assurance (QA) committee meeting. The committee consists of the Medical Director, Administrator, DON, Social Services Director and at least two (2) other department managers, different line staff as appropriate, and outside consultants as appropriate. The committee will meet weekly for four (4) weeks then monthly to determine the need for continued education or revision of the plan. Based on evaluation, the QA committee will determine at what frequency the ongoing review of new admissions will need to continue. Concerns identified will be corrected immediately by the DON, ADON, Unit Managers or Nursing Supervisor and reported to the Administrator to ensure any needed investigation initiated and reported guidelines were met. 13. The DON, ADON, Unit Managers, or Nursing Supervisor will monitor care delivery as outlined per the care plan on five (5) residents per unit per day until immediacy is removed, beginning [DATE], then five (5) residents daily for four (4) weeks, to ensure compliance with care delivery as outlined by the Care Plan along with compliance of Professional Standards requirements. Findings will be reported in the QA committee weekly to determine the further need of continued education or the revision of the plan. 14. Mock codes will be conducted by the DON, ADON, Unit Managers, Staff Development Coordinator or Nursing Supervisor twice weekly, on rotating shifts, for four (4) weeks beginning [DATE], to ensure understanding and compliance with Code Blue Policy and Procedure. The first two (2) mock codes were conducted by Clinical Managers for education on how to conduct a code; the Mock codes will be conducted by the nurses. Findings will be reported to the QA committee weekly to determine compliance and any further need of continued education or revision of the plan. 15. The DON, Staff Development Coordinator or Human Resources will track all licensed nurses CPR certification monthly beginning [DATE], to ensure compliance with CPR policy, procedure and governing regulations. Findings and compliance will be reported monthly to the QA committee to determine any need for education or revision of the process. 16. A Regional Nurse or corporate office staff was on site since [DATE] and will remain on site daily until immediacy is removed, then will be on site three (3) times weekly for four (4) weeks. Regional/Corporate staff will review compliance with the plan and will review compliance with policy and procedure of any code blue that occurs and review compliance with new or re-admissions. During weekly follow-up, guidance and recommendations will be provided with compliance validated. 17. Administrative oversight of the facility will be completed by the Vice President of Operations, Nurse Consultant, or Special Projects Administrator daily until removal of the immediacy beginning [DATE], then weekly for four (4) weeks, then monthly. 18. A Quality Assurance meeting will be held weekly until immediacy is removed beginning on [DATE], the for four (4) weeks, then monthly for recommendations and further follow up regarding the stated plan. Based on evaluation, the QA committee will determine at what frequency any ongoing audits will need to continue. The Administrator has the oversight to ensure an effective plan is in place to meet resident well-being and ensure resident rights as well as an effective plan to identify facility concerns and implement a plan of correction to involve all staff of the facility. Corporate Administrative oversight of the Quality Assurance meeting will be completed by the Special projects Administrator, the Regional Vice President of Operations, or a member of regional staff three (3) times a week until immediacy is removed beginning [DATE], then weekly for four (4) weeks, then monthly. The State Survey Agency validated the implementation of the facility's AOC as follows: 1. Review of the facility's investigation of the incident revealed an audit of Resident #1's medical record with areas concern noted. Interview with the DON, on [DATE] at 5:20 PM, revealed she audited Resident #1's medical record and identified areas of concern with immediate implementation of education provided to staff. 2. Review of the facility's audit of all resident's Advance Directive, Care Plans and physician's orders [REDACTED]. Interview with the DON, on [DATE] at 5:20 PM, revealed she had participated with other management staff to audit all resident records to verify accuracy of the resident's Advance Directive, Care Plans and Physician's code status order. 3. Review of the audit tool utilized to interview and assess all residents for possible resident rights violations revealed management staff interviewed all resident's with a Brief Interview for Mental Status (BIMS) score of eight (8) or greater and a physical assessment was completed for resident's whose BIMS was less than eight (8). Interview with the DON, on [DATE] at 5:20 PM, revealed management staff interviewed or assessed each of the facility's residents for any signs or symptoms of resident rights violations. Interview with interviewable residents revealed staff did talk with them regarding their resident rights. 4. The audit tool, dated [DATE], utilized to audit previous thirty (30) days facility new admissions was reviewed. New admissions were audited for compliance with admission process including: Physician notification, review of New Admission physician's orders [REDACTED]. Areas of concern identified with the audit were documentation in relation to missing dates and times on the Nursing Admission Assessment on four (4) residents. Review of the education provided to staff revealed policy and procedures related to accuracy of the admission process and documentation was provided. Review of the staff sign in sheets revealed instruction was provided beginning [DATE] with review of policy and procedure. On [DATE], a more comprehensive education was provided to staff related to the policy and procedure. Interview with the DON, on [DATE] at 5:20 PM, revealed she initiated education to the nursing staff immediately on [DATE]. Per the DON, the Regional Nurse provided comprehensive education to the management staff on [DATE]. Further interview revealed, after receiving the comprehensive education, the management staff were responsible for providing the comprehensive education to the facility's nursing staff. 5. Review of the audit of each resident's medical record to include: Advance Directive, physician's orders [REDACTED]. Interview with the DON, on [DATE] at 5:20 PM, revealed she and other management staff audited each resident's medical record to ensure compliance with quality of care delivery. 6. Review of education provided by the Regional Nurse to all management staff with the sign in sheet dated [DATE] and signed by the Regional Nurse revealed the education provided included: Cardiopulmonary Resuscitation, Advance Directives, Physician Visits and Medical Orders, Admission Criteria, Care Planning - Interdisciplinary Team, Resident Rights, Quality of Care, Professional Standards, and QA. Interview with the Regional Nurse Consultant, on [DATE] at 5:20 PM, revealed he provided comprehensive education to management staff related to the facility's policies and procedures stated above. Continued interview revealed the facility revised the CPR policy to include mandatory hands on skills certification for staff. 7. Review of education provided to all nursing staff to include: Cardiopulmonary Resuscitation, Advance Directives, Physician Visits and Medical Orders, Admission Criteria, Care Planning - Interdisciplinary Team, Resident Rights, Quality of Care, Professional Standards, and QA. Review of sign in sheets revealed the education was initiated on [DATE] and concluded on [DATE]. Review of certified letters sent to twenty-one (21) part-time clinical staff related to mandatory education prior to working. Continued review of sign-in sheets revealed education for part-time clinical staff, non-licensed staff and non-nursing staff continued per AOC. Review of New Orientation Agenda for clinical staff, revealed education would be provided with orientation process. Review of audit tool utilized for validation of CPR certification with hands on skills component revealed staff had obtained education with hands on skill component. Interview, on [DATE] at 10:20 AM with SRNA #8; at 10:30 AM with SRNA #7; at 10:40 AM with SRNA #4; at 10:50 AM with SRNA #2; and, at 11:00 AM with SRNA #6 revealed they had all been provided education related to Cardiopulmonary Resuscitation, Resident Rights, Quality of Care and Professional Standards between [DATE] and [DATE] in a verbal lecture setting allowing for question and answers. Interview, on [DATE] at 5:50 PM with RN #1 and at 6:12 PM with LPN #1; on [DATE] at 11:15 AM with LPN #12; at 11:25 AM with LPN #3; at 4:16 PM with LPN #11; at 4:30 PM with LPN #2; at 4:45 PM with RN #4; at 5:00 PM with RN #2; at 5:17 PM with RN #3; and, Unit Manager #1 at 4:29 PM, revealed they had all been provided education related to Cardiopulmonary Resuscitation, Advance Directives, Physician Visits and Medical Orders, Admission Criteria, Care Planning, Resident Rights, Professional Standards, and Quality of Care in a verbal lecture setting allowing for question and answers. 8. Review of the education provided to all licensed staff related to the admission policy and procedure revealed the education was initiated on [DATE] and completed on [DATE] after additional education was provided by the Regional Nurse Consultant. Interview with the DON, on [DATE] at 5:20 PM, revealed she had initiated staff education on [DATE]. After receiving comprehensive education provided by the Regional Nurse Consultant on [DATE], the management team re-educated staff with the completion date for full-time clinical staff to be [DATE]. 9. Review of the education provided to all Physicians with privileges to included; clarification of the process for notifying the Physician of new admits and obtaining orders, and the Interim Care Plan and Professional Standards. Further review, revealed there was follow up letters sent to each Physician related to the educations provided. 10. Review of the Audit of personnel files for CPR certification revealed the Audit was completed on [DATE] with the Regional Nurse Consultant review on [DATE]. Data from the audit revealed seventeen (17) staff without the hands on skill component for CPR certification. 11. Review of the Audit of personnel files for CPR certifications revealed sixteen (16) of the seventeen (17) identified staff without hands on skill component CPR certifications had obtained certifications with the hands on skills component. Interview with the DON, on [DATE] at 5:20 PM, revealed she was a Certified American Heart CPR Instructor. Further interview revealed, she had conducted four (4) CPR classes for staff that included the hands on skills component. Per interview, one staff still remained out of compliance with the CPR certification hands on component and would not be allowed to work until appropriate certification was obtained. 12. Review of the Daily New Admission Log, revealed new admissions were reviewed daily for compliance with Physician Notification, Physician Orders, Interim Care Plan, Advance Directive, and Resident Rights beginning [DATE]. Interview with the DON on [DATE] at 5:20 PM, revealed areas of concern were identified when the audits were initiated on [DATE]; however, after staff received education, data collected had improved. Further interview revealed any issues identified would be immediately corrected with data reviewed with the QA committee weekly for four (4) weeks, then monthly with the results of the collected data to determine the need for additional education or the revision of the plan. 13. Review of documentation monitoring care delivery as outlined per the resident's care plan, revealed five (5) resident care plans per day per unit were reviewed by management staff beginning [DATE]. Interview with the DON, on [DATE] at 5:20 PM, revealed management staff had audited resident care plans daily. Further interview revealed five (5) care plans were audited on each unit daily since [DATE]. 14. Review of documentation of the Mock codes revealed they were conducted twice weekly on rotating shifts beginning [DATE]. Interview, on [DATE] at 5:50 PM with RN #1 and at 6:12 PM with LPN #1; on [DATE] at 11:15 AM with LPN #12; at 11:25 AM with LPN #3; at 4:16 PM with LPN #11; at 4:30 PM with LPN #2; at 4:45 PM with RN #4; at 5:00 PM with RN #2; at 5:17 PM with RN #3; and, Unit Manager #1 at 4:29 PM, revealed they had all been provided education related to Cardiopulmonary Resuscitation and Advance Directives with Mock Codes conducted on different shifts. 15. Review of documentation of CPR certification tracking revealed the date the certification was obtained and verification the certification contained a hands on skills component. Interview with the DON, on [DATE] at 5:20 PM, revealed the facility had previously been tracking CPR expiration dates; however, the facility added verification of a hands on skills component to their tracking data to ensure compliance. 16. Review of the documentation of a calendar, signed by the Regional Nurse and Regional Vice President of Operations revealed the Regional Vice President of Operations was on site [DATE] and [DATE]. Further review revealed, the Regional Nurse was on site daily from [DATE] to [DATE] with the exception of [DATE]. Interview with the Regional Nurse, on [DATE] at 5:20 PM, revealed he had been in the facility each day with the exception of [DATE]. Interview with the Administrator on [DATE] at 5:20 PM, revealed the Regional Nurse had been on site daily since [DATE] with the exception of [DATE]. Interview with Unit Manager #1, on [DATE] at 4:29 PM, revealed the Regional Nurse had been on site seemed like daily for over two (2) weeks. 17. Review of documentation of a calendar, signed by the Regional Nurse and Regional Vice President of Operations revealed on site Administrative oversight was performed by the Regional Vice President of Operations on [DATE] and [DATE]. Further review revealed, on site Administrative oversight was performed by the Regional Nurse on each day from [DATE] to [DATE], with the exception of [DATE]. Interview with the Regional Nurse, on [DATE] at 5:20 PM, revealed he had been on site at the facility daily since [DATE] with the exception of [DATE]. Interview with the Administrator on [DATE] at 5:20 PM, revealed the Regional Nurse had been on site daily since [DATE] with the exception of [DATE]. Interview with Unit Manager #1, on [DATE] at 4:29 PM, revealed the Regional Nurse had been on site seemed like daily for over two (2) weeks. 18. Review of the QA sign in sheets revealed, meetings were conducted on [DATE], [DATE], and [DATE] with the areas of concern discussed. The Medical Director was in attendance on [DATE]. Interview with the Administrator, on [DATE] at 11:15 AM, revealed the data obtained from the audits performed, revealed areas of concern related to the Mock codes which were initially performed. Continued interview revealed, the data was analyzed and it was determined additional education was needed. Further interview revealed the additional education was provided with positive data resulting from ongoing Mock codes and audits.

Based on interview, record review and review of the facility's policy, it was determined the facility failed to have an effective system to ensure a Physician provided written recommendation for admittance to the facility, and failed to ensure each resident was supervised by a physician, for one (1) of twelve (12) sampled residents (Resident #1). Resident #1 was admitted by the facility on [DATE]; however, there was no documented evidence the Physician was aware of the resident's admission. Additionally, on [DATE], Resident #1 was found to be unresponsive, and without a pulse or respirations. Staff notified the on-call Physician of Resident #1's death; however, staff failed to inform the Physician the resident was a Full Code status and CPR was not performed. The facility's failure to notify the Attending Physician of a resident's admission, and failure to provide relative information when the Physician was notified, has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE], and was determined to exist on [DATE]. The facility was notified of the Immediate jeopardy on [DATE]. The facility provided an acceptable credible Allegation of Compliance (AOC) on [DATE] with the facility alleging removal of the Immediate Jeopardy on [DATE]. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on [DATE], prior to exit on [DATE], with remaining non-compliance in the area of 42 CFR 483.40 Physician Services, F-385 at a Scope and Severity of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's policy titled Physician Visits and Medical Orders, effective ,[DATE], revealed all residents admitted to the facility would be under the direct supervision of a member of the active medical staff who had delineated clinical privileges to admit residents to the facility. Continued review revealed the Attending Physician would directly supervise the activities related to treatment of [REDACTED]. Review of the facility's policy titled Admission Criteria, undated, revealed prior to or at the time of admission, the resident's Attending Physician would provide the facility with information needed for the care of the resident, to include at least: diet, medication orders, Advance Directive, allergies [REDACTED]. Review of the facility's policy titled Telephone Orders, undated, revealed each entry should contain the instructions from the Physician, and should include the date, time, and signature and title of the person transcribing the information. Review of the medical record revealed the facility admitted Resident #1 from the hospital on [DATE], with [DIAGNOSES REDACTED]. Review of the Nursing Admission Information form, dated [DATE], revealed Resident #1 was admitted to the facility under the care of Attending Physician (AP) #1, on [DATE] at 6:40 PM; however, there was no documented evidence the AP was notified of the resident's admission. Interview with Registered Nurse (RN) #2, on [DATE] at 3:21 PM, revealed she did assess residents for admission to the facility. Continued interview revealed the facility's practice included notification of the Attending Physician upon the resident's arrival. RN #2 explained when residents were transferred to the facility from an acute care facility (hospital), they arrived with a Discharge Summary from the acute care facility. RN #2 stated this summary was to be faxed to the Attending Physician's office as notification of the resident's arrival. RN #2 further stated staff should follow-up with the Physician via telephone to verify the orders on the Discharge Summary were to be continued at the facility. Interview with AP #1, on [DATE] at 10:37 AM, revealed he was on-call on [DATE] but did not receive notification Resident #1 was admitted to the facility. Further interview revealed Resident #1 was not a previous patient of his and he was not familiar with the resident's medical history. Continued interview revealed AP #1 was not informed of Resident #1's admission until [DATE], after the resident had expired. AP #1 stated it was his expectation for staff to notify him when a resident arrived at the facility in order to verify the admitting orders with staff. AP #1 further stated notification was essential to enable him to have oversight of the resident's care. Continued review of Resident #1's medical record revealed an Advance Directives/Informed Consent, signed and dated [DATE] by Resident #1's Responsible Party (RP). According to the consent form, the RP requested and consented to the use of cardiac compressions or artificial ventilation (Full Code) to resuscitate the resident in the event of death. Review of the physician's orders [REDACTED].#2, revealed a telephone order was received from Resident #1's on-call Physician to withhold CPR (cardiopulmonary resuscitation). Continued review revealed the order was given related to resident already deceased when found, no heart rate, no respirations, and cool to touch. Interview with LPN #2, on [DATE] at 4:31 PM, revealed she contacted the on-call Physician to notify him of Resident #1's death. Continued interview revealed she informed the Physician the RN had decided the resident was too far gone for CPR. She stated she thought she had advised him the resident was a Full Code status. Continued interview revealed the Physician responded, Oh, no .OK, but did not say to withhold CPR. Interview with the on-call Physician, on [DATE] at 12:07 PM, revealed he was notified by the facility on [DATE] around 7:30 AM of Resident #1's death. Continued interview revealed staff did not inform him Resident #1 was a Full Code, and he did not give an order to withhold CPR. Further interview revealed his expectation was for staff to initiate CPR for a resident with a Full Code status, notify Emergency Medical Services (EMS)for transfer to a hospital, and then call to notify him (the Physician) of the resident's change in condition. Interview with the Director of Nursing (DON), on [DATE] at 3:09 PM, revealed she was not aware Resident #1's AP was not notified by staff of the resident's admission on [DATE]. She stated the facility's process for new admissions was for the nurse to notify the AP when the resident arrived at the facility and verify the admission orders [REDACTED]. Per interview, staff should completely inform the Physician of a resident's status and document exactly what the physician orders. Interview with the Administrator, on [DATE] at 4:50 PM, revealed her expectation was for staff to notify the Attending Physician to verify orders when the resident arrived to the facility. Continued interview revealed should a resident be transferred from another facility, the Discharge Summary could be utilized as admission orders [REDACTED]. Further interview revealed the Administrator's expectation for staff to fully inform the Physician when making notification of a change in status, and to write orders as stated by the Physician. The facility provided an acceptable credible Allegation of Compliance (AOC) on [DATE], which alleged removal of the IJ effective [DATE]. Review of the AOC revealed the facility implemented the following: 1. On [DATE], the Director of Nursing (DON) reviewed Resident #1's medical record and care plan with the following areas of concern identified: a. The date and time were missing regarding the Physician notification on the Nursing Admission Assessment b. the Advance Directive of Full Code status was not care planned on the Interim Care Plan. c. CPR was not immediately initiated per Resident #1's/Power of Attorney's (POA's) request as indicated on the Advance Directive. 2. Beginning [DATE] and concluding on [DATE], the DON, Unit Managers, Nursing Supervisors or Medical Records staff audited all resident Advance Directive/Code Status/physician's orders [REDACTED]. 3. Beginning [DATE] and concluding on [DATE], the DON, Assistant Director of Nursing (ADON), Unit Managers and Nursing Supervisors assessed all residents for any possible resident rights violations. Residents with a Brief Interview of Mental Status (BIMS) score of eight (8) or greater were interviewed and residents with a BIMS of less than eight (8) were physically assessed for any signs and symptoms of possible quality of life or resident rights violations. 4. Compliance audits of the admission process were completed by [DATE] of all admissions within the previous thirty (30) days. The audits were performed by the DON, ADON, Unit Managers or Nursing Supervisors of all resident's medical records to include notification of the Attending Physician, review of the Physician Admitting Orders with the Attending Physician and ensuring professional standards were followed. 5. The DON, Unit Managers, Nursing Supervisors or Medical Records staff completed audits of all resident charts by [DATE]. The Audit included; resident's Advance Directive, physician's orders [REDACTED]. 6. On [DATE], all management staff was educated by the Regional Nurse Consultant. Education included: Advance Directive Policy and Procedure, Admission/physician's orders [REDACTED]. 7. Education for all nursing staff was initiated on [DATE] and completed by [DATE], with the exception of four (4) full-time status staff on leave and twenty-one (21) part-time staff. Certified letters were sent to the twenty-one (21) part-time staff to notify each of the mandatory education prior to returning to duty. Education was provided by the Staff Development Coordinator, Unit Mangers and Nursing Supervisors. Education included Advance Directive Policy and Procedure, Admission/Physician order [REDACTED]. The education related to the policies and procedures was added to the training agenda for New Employee Orientation. 8. Beginning [DATE] and concluding on [DATE], the Staff Development Coordinator, Unit Managers and Nursing Supervisors conducted education for all licensed staff (with the exception of the part-time staff who were notified by certified letter they could not work until receiving the required education) on the admission policy and procedure, to include: clarification of the process for Physician notification of new admissions, obtaining admission orders [REDACTED]. The above education was incorporated into the facility's New Employee Orientation. 9. On [DATE], all Physicians with privileges at the facility were educated by the DON in regards to the admission process and expectations with compliance to include: Discharge Summaries or Orders from a discharging facility would be faxed to the Physician's office and the Physician would be called for approval of the Orders with a Telephone Order written stating the Physician's review and approval of the Orders. 10. Human Resources and/or Staff Development performed audits of all personnel files for CPR certifications. Audits were completed by [DATE] and given to the Regional Nurse Consultant to review for non-compliance with CPR regulations. Seventeen (17) licensed nurses were noted to have on-line only CPR certifications. 11. Sixteen (16) of the seventeen (17) staff identified to have on-line CPR certifications received CPR instruction with hands on component by [DATE], provided by the DON, a certified American Heart CPR Instructor. One (1) employee would not be allowed to work until CPR certification with hands on component was obtained. 12. Beginning [DATE], the DON, ADON, Unit Manager, Nursing Supervisor or Medical Records staff will review all new admissions daily during the morning clinical meeting to ensure compliance with Physician notification, Physician Orders, Interim Care Plan, Advance Directive, and Resident Rights. Findings of the review will be reported in the Quality Assurance (QA) committee meeting. The committee consists of the Medical Director, Administrator, DON, Social Services Director and at least two (2) other department managers, different line staff as appropriate, and outside consultants as appropriate. The committee will meet weekly for four (4) weeks then monthly to determine the need for continued education or revision of the plan. Based on evaluation, the QA committee will determine at what frequency the ongoing review of new admissions will need to continue. Concerns identified will be corrected immediately by the DON, ADON, Unit Managers or Nursing Supervisor and reported to the Administrator to ensure any needed investigation initiated and reported guidelines were met. 13. The DON, ADON, Unit Managers, or Nursing Supervisor will monitor care delivery as outlined per the care plan on five (5) residents per unit per day until immediacy is removed, beginning [DATE], then five (5) residents daily for four (4) weeks, to ensure compliance with care delivery as outlined by the Care Plan along with compliance of Professional Standards requirements. Findings will be reported in the QA committee weekly to determine the further need of continued education or the revision of the plan. 14. Mock codes will be conducted by the DON, ADON, Unit Managers, Staff Development Coordinator or Nursing Supervisor twice weekly, on rotating shifts, for four (4) weeks beginning [DATE], to ensure understanding and compliance with Code Blue Policy and Procedure. The first two (2) mock codes were conducted by Clinical Managers for education on how to conduct a code; the Mock codes will be conducted by the nurses. Findings will be reported to the QA committee weekly to determine compliance and any further need of continued education or revision of the plan. 15. The DON, Staff Development Coordinator or Human Resources will track all licensed nurses CPR certification monthly beginning [DATE], to ensure compliance with CPR policy, procedure and governing regulations. Findings and compliance will be reported monthly to the QA committee to determine any need for education or revision of the process. 16. A Regional Nurse or corporate office staff was on site since [DATE] and will remain on site daily until immediacy is removed, then will be on site three (3) times weekly for four (4) weeks. Regional/Corporate staff will review compliance with the plan and will review compliance with policy and procedure of any code blue that occurs and review compliance with new or re-admissions. During weekly follow-up, guidance and recommendations will be provided with compliance validated. 17. Administrative oversight of the facility will be completed by the Vice President of Operations, Nurse Consultant, or Special Projects Administrator daily until removal of the immediacy beginning [DATE], then weekly for four (4) weeks, then monthly. 18. A Quality Assurance meeting will be held weekly until immediacy is removed beginning on [DATE], the for four (4) weeks, then monthly for recommendations and further follow up regarding the stated plan. Based on evaluation, the QA committee will determine at what frequency any ongoing audits will need to continue. The Administrator has the oversight to ensure an effective plan is in place to meet resident well-being and ensure resident rights as well as an effective plan to identify facility concerns and implement a plan of correction to involve all staff of the facility. Corporate Administrative oversight of the Quality Assurance meeting will be completed by the Special projects Administrator, the Regional Vice President of Operations, or a member of regional staff three (3) times a week until immediacy is removed beginning [DATE], then weekly for four (4) weeks, then monthly. The State Survey Agency validated the implementation of the facility's AOC as follows: 1. Review of the facility's investigation of the incident revealed an audit of Resident #1's medical record with areas concern noted. Interview with the DON, on [DATE] at 5:20 PM, revealed she audited Resident #1's medical record and identified areas of concern with immediate implementation of education provided to staff. 2. Review of the facility's audit of all resident's Advance Directive, Care Plans and physician's orders [REDACTED]. Interview with the DON, on [DATE] at 5:20 PM, revealed she had participated with other management staff to audit all resident records to verify accuracy of the resident's Advance Directive, Care Plans and Physician's code status order. 3. Review of the audit tool utilized to interview and assess all residents for possible resident rights violations revealed management staff interviewed all resident's with a Brief Interview for Mental Status (BIMS) score of eight (8) or greater and a physical assessment was completed for resident's whose BIMS was less than eight (8). Interview with the DON, on [DATE] at 5:20 PM, revealed management staff interviewed or assessed each of the facility's residents for any signs or symptoms of resident rights violations. Interview with interviewable residents revealed staff did talk with them regarding their resident rights. 4. The audit tool, dated [DATE], utilized to audit previous thirty (30) days facility new admissions was reviewed. New admissions were audited for compliance with admission process including: Physician notification, review of New Admission physician's orders [REDACTED]. Areas of concern identified with the audit were documentation in relation to missing dates and times on the Nursing Admission Assessment on four (4) residents. Review of the education provided to staff revealed policy and procedures related to accuracy of the admission process and documentation was provided. Review of the staff sign in sheets revealed instruction was provided beginning [DATE] with review of policy and procedure. On [DATE], a more comprehensive education was provided to staff related to the policy and procedure. Interview with the DON, on [DATE] at 5:20 PM, revealed she initiated education to the nursing staff immediately on [DATE]. Per the DON, the Regional Nurse provided comprehensive education to the management staff on [DATE]. Further interview revealed, after receiving the comprehensive education, the management staff were responsible for providing the comprehensive education to the facility's nursing staff. 5. Review of the audit of each resident's medical record to include: Advance Directive, physician's orders [REDACTED]. Interview with the DON, on [DATE] at 5:20 PM, revealed she and other management staff audited each resident's medical record to ensure compliance with quality of care delivery. 6. Review of education provided by the Regional Nurse to all management staff with the sign in sheet dated [DATE] and signed by the Regional Nurse revealed the education provided included: Cardiopulmonary Resuscitation, Advance Directives, Physician Visits and Medical Orders, Admission Criteria, Care Planning - Interdisciplinary Team, Resident Rights, Quality of Care, Professional Standards, and QA. Interview with the Regional Nurse Consultant, on [DATE] at 5:20 PM, revealed he provided comprehensive education to management staff related to the facility's policies and procedures stated above. Continued interview revealed the facility revised the CPR policy to include mandatory hands on skills certification for staff. 7. Review of education provided to all nursing staff to include: Cardiopulmonary Resuscitation, Advance Directives, Physician Visits and Medical Orders, Admission Criteria, Care Planning - Interdisciplinary Team, Resident Rights, Quality of Care, Professional Standards, and QA. Review of sign in sheets revealed the education was initiated on [DATE] and concluded on [DATE]. Review of certified letters sent to twenty-one (21) part-time clinical staff related to mandatory education prior to working. Continued review of sign-in sheets revealed education for part-time clinical staff, non-licensed staff and non-nursing staff continued per AOC. Review of New Orientation Agenda for clinical staff, revealed education would be provided with orientation process. Review of audit tool utilized for validation of CPR certification with hands on skills component revealed staff had obtained education with hands on skill component. Interview, on [DATE] at 10:20 AM with SRNA #8; at 10:30 AM with SRNA #7; at 10:40 AM with SRNA #4; at 10:50 AM with SRNA #2; and, at 11:00 AM with SRNA #6 revealed they had all been provided education related to Cardiopulmonary Resuscitation, Resident Rights, Quality of Care and Professional Standards between [DATE] and [DATE] in a verbal lecture setting allowing for question and answers. Interview, on [DATE] at 5:50 PM with RN #1 and at 6:12 PM with LPN #1; on [DATE] at 11:15 AM with LPN #12; at 11:25 AM with LPN #3; at 4:16 PM with LPN #11; at 4:30 PM with LPN #2; at 4:45 PM with RN #4; at 5:00 PM with RN #2; at 5:17 PM with RN #3; and, Unit Manager #1 at 4:29 PM, revealed they had all been provided education related to Cardiopulmonary Resuscitation, Advance Directives, Physician Visits and Medical Orders, Admission Criteria, Care Planning, Resident Rights, Professional Standards, and Quality of Care in a verbal lecture setting allowing for question and answers. 8. Review of the education provided to all licensed staff related to the admission policy and procedure revealed the education was initiated on [DATE] and completed on [DATE] after additional education was provided by the Regional Nurse Consultant. Interview with the DON, on [DATE] at 5:20 PM, revealed she had initiated staff education on [DATE]. After receiving comprehensive education provided by the Regional Nurse Consultant on [DATE], the management team re-educated staff with the completion date for full-time clinical staff to be [DATE]. 9. Review of the education provided to all Physicians with privileges to included; clarification of the process for notifying the Physician of new admits and obtaining orders, and the Interim Care Plan and Professional Standards. Further review, revealed there was follow up letters sent to each Physician related to the educations provided. 10. Review of the Audit of personnel files for CPR certification revealed the Audit was completed on [DATE] with the Regional Nurse Consultant review on [DATE]. Data from the audit revealed seventeen (17) staff without the hands on skill component for CPR certification. 11. Review of the Audit of personnel files for CPR certifications revealed sixteen (16) of the seventeen (17) identified staff without hands on skill component CPR certifications had obtained certifications with the hands on skills component. Interview with the DON, on [DATE] at 5:20 PM, revealed she was a Certified American Heart CPR Instructor. Further interview revealed, she had conducted four (4) CPR classes for staff that included the hands on skills component. Per interview, one staff still remained out of compliance with the CPR certification hands on component and would not be allowed to work until appropriate certification was obtained. 12. Review of the Daily New Admission Log, revealed new admissions were reviewed daily for compliance with Physician Notification, Physician Orders, Interim Care Plan, Advance Directive, and Resident Rights beginning [DATE]. Interview with the DON on [DATE] at 5:20 PM, revealed areas of concern were identified when the audits were initiated on [DATE]; however, after staff received education, data collected had improved. Further interview revealed any issues identified would be immediately corrected with data reviewed with the QA committee weekly for four (4) weeks, then monthly with the results of the collected data to determine the need for additional education or the revision of the plan. 13. Review of documentation monitoring care delivery as outlined per the resident's care plan, revealed five (5) resident care plans per day per unit were reviewed by management staff beginning [DATE]. Interview with the DON, on [DATE] at 5:20 PM, revealed management staff had audited resident care plans daily. Further interview revealed five (5) care plans were audited on each unit daily since [DATE]. 14. Review of documentation of the Mock codes revealed they were conducted twice weekly on rotating shifts beginning [DATE]. Interview, on [DATE] at 5:50 PM with RN #1 and at 6:12 PM with LPN #1; on [DATE] at 11:15 AM with LPN #12; at 11:25 AM with LPN #3; at 4:16 PM with LPN #11; at 4:30 PM with LPN #2; at 4:45 PM with RN #4; at 5:00 PM with RN #2; at 5:17 PM with RN #3; and, Unit Manager #1 at 4:29 PM, revealed they had all been provided education related to Cardiopulmonary Resuscitation and Advance Directives with Mock Codes conducted on different shifts. 15. Review of documentation of CPR certification tracking revealed the date the certification was obtained and verification the certification contained a hands on skills component. Interview with the DON, on [DATE] at 5:20 PM, revealed the facility had previously been tracking CPR expiration dates; however, the facility added verification of a hands on skills component to their tracking data to ensure compliance. 16. Review of the documentation of a calendar, signed by the Regional Nurse and Regional Vice President of Operations revealed the Regional Vice President of Operations was on site [DATE] and [DATE]. Further review revealed, the Regional Nurse was on site daily from [DATE] to [DATE] with the exception of [DATE]. Interview with the Regional Nurse, on [DATE] at 5:20 PM, revealed he had been in the facility each day with the exception of [DATE]. Interview with the Administrator on [DATE] at 5:20 PM, revealed the Regional Nurse had been on site daily since [DATE] with the exception of [DATE]. Interview with Unit Manager #1, on [DATE] at 4:29 PM, revealed the Regional Nurse had been on site seemed like daily for over two (2) weeks. 17. Review of documentation of a calendar, signed by the Regional Nurse and Regional Vice President of Operations revealed on site Administrative oversight was performed by the Regional Vice President of Operations on [DATE] and [DATE]. Further review revealed, on site Administrative oversight was performed by the Regional Nurse on each day from [DATE] to [DATE], with the exception of [DATE]. Interview with the Regional Nurse, on [DATE] at 5:20 PM, revealed he had been on site at the facility daily since [DATE] with the exception of [DATE]. Interview with the Administrator on [DATE] at 5:20 PM, revealed the Regional Nurse had been on site daily since [DATE] with the exception of [DATE]. Interview with Unit Manager #1, on [DATE] at 4:29 PM, revealed the Regional Nurse had been on site seemed like daily for over two (2) weeks. 18. Review of the QA sign in sheets revealed, meetings were conducted on [DATE], [DATE], and [DATE] with the areas of concern discussed. The Medical Director was in attendance on [DATE]. Interview with the Administrator, on [DATE] at 11:15 AM, revealed the data obtained from the audits performed, revealed areas of concern related to the Mock codes which were initially performed. Continued interview revealed, the data was analyzed and it was determined additional education was needed. Further interview revealed the additional education was provided with positive data resulting from ongoing Mock codes and audits.

Based interview, record review and review of facility policy, it was determined the facility failed to have an effective system to ensure clinical records were maintained in accordance with accepted professional standards and practices which were complete and accurately documented, for one (1) of twelve (12) sampled residents (Resident #1). On [DATE], Resident #1 was found to be unresponsive, and without a pulse or respirations. Staff notified the on-call Physician of Resident #1's death; however, staff failed to inform the Physician the resident was a Full Code status and CPR was not performed. In addition a Telephone Order dated [DATE] was documented to withhold CPR (cardiopulmonary resuscitation) related to resident already deceased when found, no heart rate, no respirations, and cool to touch as received by the on-call Physician. However, interview with Licensed Practical Nurse (LPN) #2 who wrote the order, and interview with the on-call Physician revealed there was no order instructing staff to withhold CPR. Also, the Nurse's Note dated [DATE] written by LPN #1 was not complete and accurately documented as there was no time noted for the entry. The facility's failure to maintain clinical records which were complete and accurately documented has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE], and was determined to exist on [DATE]. The facility was notified of the Immediate jeopardy on [DATE]. The facility provided an acceptable credible Allegation of Compliance (AOC) on [DATE] with the facility alleging removal of the Immediate Jeopardy on [DATE]. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on [DATE], prior to exit on [DATE], with remaining non-compliance in the area of 42 CFR 483.75 Administration, F-514 Clinical Records at a Scope and Severity of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's policy titled Telephone Orders, undated, revealed each entry should contain the instructions from the Physician, and should include the date, time, and signature and title of the person transcribing the information. Review of Resident #1's clinical record, revealed the facility admitted the resident on [DATE], with [DIAGNOSES REDACTED]. Review of the Nursing Admission Information form, dated [DATE], revealed the facility admitted Resident #1 under the care of the Attending Physician, on [DATE] at 6:40 PM. Review of the Advance Directives/Informed Consent, signed by Resident #1's Responsible Party (RP) on [DATE], revealed the RP had requested/consented in the event of death for staff to use cardiac compressions or artificial ventilation to resuscitate Resident #1. Review of the physician's orders [REDACTED].>Review of the Nurse's Note, dated [DATE], not timed, completed by LPN #1, revealed LPN #1 found the resident sitting on the floor next to the bed with blood on the pillow and ear, with no pulse found. However, there was no documented evidence LPN #1 immediately initiated CPR for Resident #1's as per physician's orders [REDACTED]. Review of the physician's orders [REDACTED].#2, revealed a Telephone Order was received from Resident #1's on-call Physician to withhold CPR (cardiopulmonary resuscitation). Continued review revealed the order was given related to resident already deceased when found, no heart rate, no respirations, and cool to touch. Interview with LPN #2, on [DATE] at 4:31 PM, revealed she contacted the on-call Physician to notify him of Resident #1's death. Continued interview revealed she informed the Physician the Registered Nurse (RN) had decided the resident was too far gone for CPR. She stated she thought she had advised him the resident was a Full Code status. Continued interview revealed the Physician responded, Oh, no .OK, but did not say to withhold CPR. Interview with the on-call Physician, on [DATE] at 12:07 PM, revealed he was notified on [DATE] around 7:30 AM by the facility of Resident #1's death. Continued interview revealed staff did not inform him Resident #1 was a Full Code, and he did not give an order to withhold CPR. Interview with the Director of Nursing (DON), on [DATE] at 3:09 PM, revealed staff should completely inform the Physician of a resident's status and document exactly what the physician orders, and all documentation should be dated and timed. Interview with the Administrator, on [DATE] at 4:50 PM, revealed staff should write orders as stated by the Physician as well as ensure documentation was complete and accurate. The facility provided an acceptable credible Allegation of Compliance (AOC) on [DATE], which alleged removal of the IJ effective [DATE]. Review of the AOC revealed the facility implemented the following: 1. On [DATE], the Director of Nursing (DON) reviewed Resident #1's medical record and care plan with the following areas of concern identified: a. The date and time were missing regarding the Physician notification on the Nursing Admission Assessment b. the Advance Directive of Full Code status was not care planned on the Interim Care Plan. c. CPR was not immediately initiated per Resident #1's/Power of Attorney's (POA's) request as indicated on the Advance Directive. 2. Beginning [DATE] and concluding on [DATE], the DON, Unit Managers, Nursing Supervisors or Medical Records staff audited all resident Advance Directive/Code Status/physician's orders [REDACTED]. 3. Beginning [DATE] and concluding on [DATE], the DON, Assistant Director of Nursing (ADON), Unit Managers and Nursing Supervisors assessed all residents for any possible resident rights violations. Residents with a Brief Interview of Mental Status (BIMS) score of eight (8) or greater were interviewed and residents with a BIMS of less than eight (8) were physically assessed for any signs and symptoms of possible quality of life or resident rights violations. 4. Compliance audits of the admission process were completed by [DATE] of all admissions within the previous thirty (30) days. The audits were performed by the DON, ADON, Unit Managers or Nursing Supervisors of all resident's medical records to include notification of the Attending Physician, review of the Physician Admitting Orders with the Attending Physician and ensuring professional standards were followed. 5. The DON, Unit Managers, Nursing Supervisors or Medical Records staff completed audits of all resident charts by [DATE]. The Audit included; resident's Advance Directive, physician's orders [REDACTED]. 6. On [DATE], all management staff was educated by the Regional Nurse Consultant. Education included: Advance Directive Policy and Procedure, Admission/physician's orders [REDACTED]. 7. Education for all nursing staff was initiated on [DATE] and completed by [DATE], with the exception of four (4) full-time status staff on leave and twenty-one (21) part-time staff. Certified letters were sent to the twenty-one (21) part-time staff to notify each of the mandatory education prior to returning to duty. Education was provided by the Staff Development Coordinator, Unit Mangers and Nursing Supervisors. Education included Advance Directive Policy and Procedure, Admission/Physician order [REDACTED]. The education related to the policies and procedures was added to the training agenda for New Employee Orientation. 8. Beginning [DATE] and concluding on [DATE], the Staff Development Coordinator, Unit Managers and Nursing Supervisors conducted education for all licensed staff (with the exception of the part-time staff who were notified by certified letter they could not work until receiving the required education) on the admission policy and procedure, to include: clarification of the process for Physician notification of new admissions, obtaining admission orders [REDACTED]. The above education was incorporated into the facility's New Employee Orientation. 9. On [DATE], all Physicians with privileges at the facility were educated by the DON in regards to the admission process and expectations with compliance to include: Discharge Summaries or Orders from a discharging facility would be faxed to the Physician's office and the Physician would be called for approval of the Orders with a Telephone Order written stating the Physician's review and approval of the Orders. 10. Human Resources and/or Staff Development performed audits of all personnel files for CPR certifications. Audits were completed by [DATE] and given to the Regional Nurse Consultant to review for non-compliance with CPR regulations. Seventeen (17) licensed nurses were noted to have on-line only CPR certifications. 11. Sixteen (16) of the seventeen (17) staff identified to have on-line CPR certifications received CPR instruction with hands on component by [DATE], provided by the DON, a certified American Heart CPR Instructor. One (1) employee would not be allowed to work until CPR certification with hands on component was obtained. 12. Beginning [DATE], the DON, ADON, Unit Manager, Nursing Supervisor or Medical Records staff will review all new admissions daily during the morning clinical meeting to ensure compliance with Physician notification, Physician Orders, Interim Care Plan, Advance Directive, and Resident Rights. Findings of the review will be reported in the Quality Assurance (QA) committee meeting. The committee consists of the Medical Director, Administrator, DON, Social Services Director and at least two (2) other department managers, different line staff as appropriate, and outside consultants as appropriate. The committee will meet weekly for four (4) weeks then monthly to determine the need for continued education or revision of the plan. Based on evaluation, the QA committee will determine at what frequency the ongoing review of new admissions will need to continue. Concerns identified will be corrected immediately by the DON, ADON, Unit Managers or Nursing Supervisor and reported to the Administrator to ensure any needed investigation initiated and reported guidelines were met. 13. The DON, ADON, Unit Managers, or Nursing Supervisor will monitor care delivery as outlined per the care plan on five (5) residents per unit per day until immediacy is removed, beginning [DATE], then five (5) residents daily for four (4) weeks, to ensure compliance with care delivery as outlined by the Care Plan along with compliance of Professional Standards requirements. Findings will be reported in the QA committee weekly to determine the further need of continued education or the revision of the plan. 14. Mock codes will be conducted by the DON, ADON, Unit Managers, Staff Development Coordinator or Nursing Supervisor twice weekly, on rotating shifts, for four (4) weeks beginning [DATE], to ensure understanding and compliance with Code Blue Policy and Procedure. The first two (2) mock codes were conducted by Clinical Managers for education on how to conduct a code; the Mock codes will be conducted by the nurses. Findings will be reported to the QA committee weekly to determine compliance and any further need of continued education or revision of the plan. 15. The DON, Staff Development Coordinator or Human Resources will track all licensed nurses CPR certification monthly beginning [DATE], to ensure compliance with CPR policy, procedure and governing regulations. Findings and compliance will be reported monthly to the QA committee to determine any need for education or revision of the process. 16. A Regional Nurse or corporate office staff was on site since [DATE] and will remain on site daily until immediacy is removed, then will be on site three (3) times weekly for four (4) weeks. Regional/Corporate staff will review compliance with the plan and will review compliance with policy and procedure of any code blue that occurs and review compliance with new or re-admissions. During weekly follow-up, guidance and recommendations will be provided with compliance validated. 17. Administrative oversight of the facility will be completed by the Vice President of Operations, Nurse Consultant, or Special Projects Administrator daily until removal of the immediacy beginning [DATE], then weekly for four (4) weeks, then monthly. 18. A Quality Assurance meeting will be held weekly until immediacy is removed beginning on [DATE], the for four (4) weeks, then monthly for recommendations and further follow up regarding the stated plan. Based on evaluation, the QA committee will determine at what frequency any ongoing audits will need to continue. The Administrator has the oversight to ensure an effective plan is in place to meet resident well-being and ensure resident rights as well as an effective plan to identify facility concerns and implement a plan of correction to involve all staff of the facility. Corporate Administrative oversight of the Quality Assurance meeting will be completed by the Special projects Administrator, the Regional Vice President of Operations, or a member of regional staff three (3) times a week until immediacy is removed beginning [DATE], then weekly for four (4) weeks, then monthly. The State Survey Agency validated the implementation of the facility's AOC as follows: 1. Review of the facility's investigation of the incident revealed an audit of Resident #1's medical record with areas concern noted. Interview with the DON, on [DATE] at 5:20 PM, revealed she audited Resident #1's medical record and identified areas of concern with immediate implementation of education provided to staff. 2. Review of the facility's audit of all resident's Advance Directive, Care Plans and physician's orders [REDACTED]. Interview with the DON, on [DATE] at 5:20 PM, revealed she had participated with other management staff to audit all resident records to verify accuracy of the resident's Advance Directive, Care Plans and Physician's code status order. 3. Review of the audit tool utilized to interview and assess all residents for possible resident rights violations revealed management staff interviewed all resident's with a Brief Interview for Mental Status (BIMS) score of eight (8) or greater and a physical assessment was completed for resident's whose BIMS was less than eight (8). Interview with the DON, on [DATE] at 5:20 PM, revealed management staff interviewed or assessed each of the facility's residents for any signs or symptoms of resident rights violations. Interview with interviewable residents revealed staff did talk with them regarding their resident rights. 4. The audit tool, dated [DATE], utilized to audit previous thirty (30) days facility new admissions was reviewed. New admissions were audited for compliance with admission process including: Physician notification, review of New Admission physician's orders [REDACTED]. Areas of concern identified with the audit were documentation in relation to missing dates and times on the Nursing Admission Assessment on four (4) residents. Review of the education provided to staff revealed policy and procedures related to accuracy of the admission process and documentation was provided. Review of the staff sign in sheets revealed instruction was provided beginning [DATE] with review of policy and procedure. On [DATE], a more comprehensive education was provided to staff related to the policy and procedure. Interview with the DON, on [DATE] at 5:20 PM, revealed she initiated education to the nursing staff immediately on [DATE]. Per the DON, the Regional Nurse provided comprehensive education to the management staff on [DATE]. Further interview revealed, after receiving the comprehensive education, the management staff were responsible for providing the comprehensive education to the facility's nursing staff. 5. Review of the audit of each resident's medical record to include: Advance Directive, physician's orders [REDACTED]. Interview with the DON, on [DATE] at 5:20 PM, revealed she and other management staff audited each resident's medical record to ensure compliance with quality of care delivery. 6. Review of education provided by the Regional Nurse to all management staff with the sign in sheet dated [DATE] and signed by the Regional Nurse revealed the education provided included: Cardiopulmonary Resuscitation, Advance Directives, Physician Visits and Medical Orders, Admission Criteria, Care Planning - Interdisciplinary Team, Resident Rights, Quality of Care, Professional Standards, and QA. Interview with the Regional Nurse Consultant, on [DATE] at 5:20 PM, revealed he provided comprehensive education to management staff related to the facility's policies and procedures stated above. Continued interview revealed the facility revised the CPR policy to include mandatory hands on skills certification for staff. 7. Review of education provided to all nursing staff to include: Cardiopulmonary Resuscitation, Advance Directives, Physician Visits and Medical Orders, Admission Criteria, Care Planning - Interdisciplinary Team, Resident Rights, Quality of Care, Professional Standards, and QA. Review of sign in sheets revealed the education was initiated on [DATE] and concluded on [DATE]. Review of certified letters sent to twenty-one (21) part-time clinical staff related to mandatory education prior to working. Continued review of sign-in sheets revealed education for part-time clinical staff, non-licensed staff and non-nursing staff continued per AOC. Review of New Orientation Agenda for clinical staff, revealed education would be provided with orientation process. Review of audit tool utilized for validation of CPR certification with hands on skills component revealed staff had obtained education with hands on skill component. Interview, on [DATE] at 10:20 AM with SRNA #8; at 10:30 AM with SRNA #7; at 10:40 AM with SRNA #4; at 10:50 AM with SRNA #2; and, at 11:00 AM with SRNA #6 revealed they had all been provided education related to Cardiopulmonary Resuscitation, Resident Rights, Quality of Care and Professional Standards between [DATE] and [DATE] in a verbal lecture setting allowing for question and answers. Interview, on [DATE] at 5:50 PM with RN #1 and at 6:12 PM with LPN #1; on [DATE] at 11:15 AM with LPN #12; at 11:25 AM with LPN #3; at 4:16 PM with LPN #11; at 4:30 PM with LPN #2; at 4:45 PM with RN #4; at 5:00 PM with RN #2; at 5:17 PM with RN #3; and, Unit Manager #1 at 4:29 PM, revealed they had all been provided education related to Cardiopulmonary Resuscitation, Advance Directives, Physician Visits and Medical Orders, Admission Criteria, Care Planning, Resident Rights, Professional Standards, and Quality of Care in a verbal lecture setting allowing for question and answers. 8. Review of the education provided to all licensed staff related to the admission policy and procedure revealed the education was initiated on [DATE] and completed on [DATE] after additional education was provided by the Regional Nurse Consultant. Interview with the DON, on [DATE] at 5:20 PM, revealed she had initiated staff education on [DATE]. After receiving comprehensive education provided by the Regional Nurse Consultant on [DATE], the management team re-educated staff with the completion date for full-time clinical staff to be [DATE]. 9. Review of the education provided to all Physicians with privileges to included; clarification of the process for notifying the Physician of new admits and obtaining orders, and the Interim Care Plan and Professional Standards. Further review, revealed there was follow up letters sent to each Physician related to the educations provided. 10. Review of the Audit of personnel files for CPR certification revealed the Audit was completed on [DATE] with the Regional Nurse Consultant review on [DATE]. Data from the audit revealed seventeen (17) staff without the hands on skill component for CPR certification. 11. Review of the Audit of personnel files for CPR certifications revealed sixteen (16) of the seventeen (17) identified staff without hands on skill component CPR certifications had obtained certifications with the hands on skills component. Interview with the DON, on [DATE] at 5:20 PM, revealed she was a Certified American Heart CPR Instructor. Further interview revealed, she had conducted four (4) CPR classes for staff that included the hands on skills component. Per interview, one staff still remained out of compliance with the CPR certification hands on component and would not be allowed to work until appropriate certification was obtained. 12. Review of the Daily New Admission Log, revealed new admissions were reviewed daily for compliance with Physician Notification, Physician Orders, Interim Care Plan, Advance Directive, and Resident Rights beginning [DATE]. Interview with the DON on [DATE] at 5:20 PM, revealed areas of concern were identified when the audits were initiated on [DATE]; however, after staff received education, data collected had improved. Further interview revealed any issues identified would be immediately corrected with data reviewed with the QA committee weekly for four (4) weeks, then monthly with the results of the collected data to determine the need for additional education or the revision of the plan. 13. Review of documentation monitoring care delivery as outlined per the resident's care plan, revealed five (5) resident care plans per day per unit were reviewed by management staff beginning [DATE]. Interview with the DON, on [DATE] at 5:20 PM, revealed management staff had audited resident care plans daily. Further interview revealed five (5) care plans were audited on each unit daily since [DATE]. 14. Review of documentation of the Mock codes revealed they were conducted twice weekly on rotating shifts beginning [DATE]. Interview, on [DATE] at 5:50 PM with RN #1 and at 6:12 PM with LPN #1; on [DATE] at 11:15 AM with LPN #12; at 11:25 AM with LPN #3; at 4:16 PM with LPN #11; at 4:30 PM with LPN #2; at 4:45 PM with RN #4; at 5:00 PM with RN #2; at 5:17 PM with RN #3; and, Unit Manager #1 at 4:29 PM, revealed they had all been provided education related to Cardiopulmonary Resuscitation and Advance Directives with Mock Codes conducted on different shifts. 15. Review of documentation of CPR certification tracking revealed the date the certification was obtained and verification the certification contained a hands on skills component. Interview with the DON, on [DATE] at 5:20 PM, revealed the facility had previously been tracking CPR expiration dates; however, the facility added verification of a hands on skills component to their tracking data to ensure compliance. 16. Review of the documentation of a calendar, signed by the Regional Nurse and Regional Vice President of Operations revealed the Regional Vice President of Operations was on site [DATE] and [DATE]. Further review revealed, the Regional Nurse was on site daily from [DATE] to [DATE] with the exception of [DATE]. Interview with the Regional Nurse, on [DATE] at 5:20 PM, revealed he had been in the facility each day with the exception of [DATE]. Interview with the Administrator on [DATE] at 5:20 PM, revealed the Regional Nurse had been on site daily since [DATE] with the exception of [DATE]. Interview with Unit Manager #1, on [DATE] at 4:29 PM, revealed the Regional Nurse had been on site seemed like daily for over two (2) weeks. 17. Review of documentation of a calendar, signed by the Regional Nurse and Regional Vice President of Operations revealed on site Administrative oversight was performed by the Regional Vice President of Operations on [DATE] and [DATE]. Further review revealed, on site Administrative oversight was performed by the Regional Nurse on each day from [DATE] to [DATE], with the exception of [DATE]. Interview with the Regional Nurse, on [DATE] at 5:20 PM, revealed he had been on site at the facility daily since [DATE] with the exception of [DATE]. Interview with the Administrator on [DATE] at 5:20 PM, revealed the Regional Nurse had been on site daily since [DATE] with the exception of [DATE]. Interview with Unit Manager #1, on [DATE] at 4:29 PM, revealed the Regional Nurse had been on site seemed like daily for over two (2) weeks. 18. Review of the QA sign in sheets revealed, meetings were conducted on [DATE], [DATE], and [DATE] with the areas of concern discussed. The Medical Director was in attendance on [DATE]. Interview with the Administrator, on [DATE] at 11:15 AM, revealed the data obtained from the audits performed, revealed areas of concern related to the Mock codes which were initially performed. Continued interview revealed, the data was analyzed and it was determined additional education was needed. Further interview revealed the additional education was provided with positive data resulting from ongoing Mock codes and audits.

Based on interview, record review, review of the Job Description for the Administrator, and review of the facility's policy, it was determined the facility's Administration failed to have an effective system to evaluate its policies and staffing requirements, to ensure each resident's Advance Directives and personal choices were honored. Interview and record review revealed the facility failed to ensure all staff trained in CPR received training with a hands-on skills component. Review of the facility's policies revealed they were not specific regarding the requirement related to a mandatory hands-on skill component as part of the CPR training. (Refer to F-155, F-281 and F-309) On [DATE], Resident #1's Responsible Party signed Advance Directives requesting Full Code status for the resident, with life-saving measures to include Cardiopulmonary Resuscitation (CPR), in the event the resident's heart or lungs failed to function. On [DATE] at approximately 7:15 AM, Licensed Practical Nurse (LPN) #1 found Resident #1 to be unresponsive; however, the nurse failed to honor the resident's Advanced Directives related to his/her Full Code status when he did not initiate CPR. LPN #2 entered Resident #1 room behind LPN #1 and found Resident #1 to be unresponsive; however, this nurse also failed to honor the resident's Advanced Directives related to his/her Full Code status when she did not initiate CPR. RN #1 was called to Resident #1's room by LPN #2, and found Resident #1 to be unresponsive; again, this nurse also failed to honor the resident's Advance Directives related to his/her Full Code status when she did not initiate CPR, but pronounced the resident to be deceased . The facility's failure to have an effective Administration with oversight of planned interventions to ensure residents' wishes were honored at end-of-life has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on [DATE], and was determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. The facility provided an acceptable credible Allegation of Compliance (AOC) on [DATE] with the facility alleging removal of the Immediate Jeopardy on [DATE]. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on [DATE], prior to exit on [DATE], with remaining non-compliance at 42 CFR 483.75 Administration, F-490 at a Scope and Severity of a D while the facility develops and implements a Plan of Corrections and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the Administrator's Job Description, updated [DATE], revealed the Administrator was responsible for leading and directing the overall operations of the facility in accordance with residents' needs, government regulations and company policies. Continued review revealed the Administrator's management duties included, but were not limited to, hiring, training, developing, coaching, counseling and terminating facility staff as deemed necessary. In addition, the Job Description revealed the Administrator's duties included monitoring the delivery of nursing care and ensuring residents' needs were addressed. per the Job Description, the Administrator was responsible for the facility's Quality Assurance (QA) program, and was expected to maintain a working knowledge of, and compliance with, all governmental regulations. Review of the facility's policy, titled Advance Directives - Kentucky, effective ,[DATE], revealed it was the policy of the facility to recognize and support the use of Advance Directives through family, staff and community education and to encourage the resident's rights to self-determination through recognition and assistance with executing such directives. Continued review revealed, as long as the resident was competent to make decisions, his/her wishes would be followed to the maximum extent possible as dictated by state law and sound medical judgment. If a resident became incompetent, but had provided evidence of a properly executed Advance Directive, the facility would implement the resident's choices as outlined in the document or expressed to the appointed agent to the same extent that the competent resident's wishes would be followed. Further review revealed all residents would receive full resuscitative measures unless a Do Not Resuscitate (DNR) directive was written in the resident's medical record and was identified in the resident's Advance Directive. Review of the facility's policy titled Resident Rights, reviewed [DATE], revealed residents had the right to choose a physician, receive treatment, and participate in decision-making and care planning. Continued review revealed residents were entitled to exercise their rights and privileges to the fullest extent possible. Per the policy, employees had a duty to read and learn the residents' rights. Review of the facility's policy titled Cardiopulmonary Resuscitation, undated, revealed CPR would be attempted for any resident who was found to have no palpable pulse and/or no discernible respirations, unless there was a written physician order [REDACTED]. Continued review revealed, should a resident be found unresponsive and without respirations, a licensed staff member who was certified in CPR would promptly initiate CPR in the following circumstances: for residents who have requested CPR in their Advance Directive; for residents who have not formulated an Advance Directive; and for residents who do not have a valid DNR order; and in the event the initiation of CPR would pose a danger to self or others. On [DATE], Resident #1 was found to be unresponsive, with no pulse and no respiratory effort, by LPN #1, LPN #2 and RN #1. Review of the Advance Directives, signed by the Responsible Party on [DATE], and review of the physician's orders [REDACTED].#1, LPN #2 and RN #1 did not initiate CPR in accordance with the resident's wishes. Review of the CPR training records and staffing schedules revealed the facility failed to have an effective system to ensure all staff received CPR training which included the mandatory hands-on skill component, as required by regulation. Review of the facility's CPR certification tracking, revealed seventeen (17) staff had not received the hands-on skill component. Interview with the Administrator, on [DATE] at 4:50 PM, revealed residents had a right to execute an Advance Directive which should be honored by the staff. Continued interview revealed LPN #1, LPN #2 and RN #1 should have initiated CPR for Resident #1, who was a Full Code, when they found the resident non-responsive. Further interview revealed licensed nursing staff were required to be CPR certified; however, the Administrator was not aware CPR training could not be obtained solely on-line. Per interview, the Administrator was not aware staff requiring re-certification were required to have a hands-on skills component included in their CPR training, to ensure competency in the provision of CPR when indicated, per the regulation. The facility provided an acceptable credible Allegation of Compliance (AOC) on [DATE], which alleged removal of the IJ effective [DATE]. Review of the AOC revealed the facility implemented the following: 1. On [DATE], the Director of Nursing (DON) reviewed Resident #1's medical record and care plan with the following areas of concern identified: a. The date and time were missing regarding the Physician notification on the Nursing Admission Assessment b. the Advance Directive of Full Code status was not care planned on the Interim Care Plan. c. CPR was not immediately initiated per Resident #1's/Power of Attorney's (POA's) request as indicated on the Advance Directive. 2. Beginning [DATE] and concluding on [DATE], the DON, Unit Managers, Nursing Supervisors or Medical Records staff audited all resident Advance Directive/Code Status/physician's orders [REDACTED]. 3. Beginning [DATE] and concluding on [DATE], the DON, Assistant Director of Nursing (ADON), Unit Managers and Nursing Supervisors assessed all residents for any possible resident rights violations. Residents with a Brief Interview of Mental Status (BIMS) score of eight (8) or greater were interviewed and residents with a BIMS of less than eight (8) were physically assessed for any signs and symptoms of possible quality of life or resident rights violations. 4. Compliance audits of the admission process were completed by [DATE] of all admissions within the previous thirty (30) days. The audits were performed by the DON, ADON, Unit Managers or Nursing Supervisors of all resident's medical records to include notification of the Attending Physician, review of the Physician Admitting Orders with the Attending Physician and ensuring professional standards were followed. 5. The DON, Unit Managers, Nursing Supervisors or Medical Records staff completed audits of all resident charts by [DATE]. The Audit included; resident's Advance Directive, physician's orders [REDACTED]. 6. On [DATE], all management staff was educated by the Regional Nurse Consultant. Education included: Advance Directive Policy and Procedure, Admission/physician's orders [REDACTED]. 7. Education for all nursing staff was initiated on [DATE] and completed by [DATE], with the exception of four (4) full-time status staff on leave and twenty-one (21) part-time staff. Certified letters were sent to the twenty-one (21) part-time staff to notify each of the mandatory education prior to returning to duty. Education was provided by the Staff Development Coordinator, Unit Mangers and Nursing Supervisors. Education included Advance Directive Policy and Procedure, Admission/Physician order [REDACTED]. The education related to the policies and procedures was added to the training agenda for New Employee Orientation. 8. Beginning [DATE] and concluding on [DATE], the Staff Development Coordinator, Unit Managers and Nursing Supervisors conducted education for all licensed staff (with the exception of the part-time staff who were notified by certified letter they could not work until receiving the required education) on the admission policy and procedure, to include: clarification of the process for Physician notification of new admissions, obtaining admission orders [REDACTED]. The above education was incorporated into the facility's New Employee Orientation. 9. On [DATE], all Physicians with privileges at the facility were educated by the DON in regards to the admission process and expectations with compliance to include: Discharge Summaries or Orders from a discharging facility would be faxed to the Physician's office and the Physician would be called for approval of the Orders with a Telephone Order written stating the Physician's review and approval of the Orders. 10. Human Resources and/or Staff Development performed audits of all personnel files for CPR certifications. Audits were completed by [DATE] and given to the Regional Nurse Consultant to review for non-compliance with CPR regulations. Seventeen (17) licensed nurses were noted to have on-line only CPR certifications. 11. Sixteen (16) of the seventeen (17) staff identified to have on-line CPR certifications received CPR instruction with hands on component by [DATE], provided by the DON, a certified American Heart CPR Instructor. One (1) employee would not be allowed to work until CPR certification with hands on component was obtained. 12. Beginning [DATE], the DON, ADON, Unit Manager, Nursing Supervisor or Medical Records staff will review all new admissions daily during the morning clinical meeting to ensure compliance with Physician notification, Physician Orders, Interim Care Plan, Advance Directive, and Resident Rights. Findings of the review will be reported in the Quality Assurance (QA) committee meeting. The committee consists of the Medical Director, Administrator, DON, Social Services Director and at least two (2) other department managers, different line staff as appropriate, and outside consultants as appropriate. The committee will meet weekly for four (4) weeks then monthly to determine the need for continued education or revision of the plan. Based on evaluation, the QA committee will determine at what frequency the ongoing review of new admissions will need to continue. Concerns identified will be corrected immediately by the DON, ADON, Unit Managers or Nursing Supervisor and reported to the Administrator to ensure any needed investigation initiated and reported guidelines were met. 13. The DON, ADON, Unit Managers, or Nursing Supervisor will monitor care delivery as outlined per the care plan on five (5) residents per unit per day until immediacy is removed, beginning [DATE], then five (5) residents daily for four (4) weeks, to ensure compliance with care delivery as outlined by the Care Plan along with compliance of Professional Standards requirements. Findings will be reported in the QA committee weekly to determine the further need of continued education or the revision of the plan. 14. Mock codes will be conducted by the DON, ADON, Unit Managers, Staff Development Coordinator or Nursing Supervisor twice weekly, on rotating shifts, for four (4) weeks beginning [DATE], to ensure understanding and compliance with Code Blue Policy and Procedure. The first two (2) mock codes were conducted by Clinical Managers for education on how to conduct a code; the Mock codes will be conducted by the nurses. Findings will be reported to the QA committee weekly to determine compliance and any further need of continued education or revision of the plan. 15. The DON, Staff Development Coordinator or Human Resources will track all licensed nurses CPR certification monthly beginning [DATE], to ensure compliance with CPR policy, procedure and governing regulations. Findings and compliance will be reported monthly to the QA committee to determine any need for education or revision of the process. 16. A Regional Nurse or corporate office staff was on site since [DATE] and will remain on site daily until immediacy is removed, then will be on site three (3) times weekly for four (4) weeks. Regional/Corporate staff will review compliance with the plan and will review compliance with policy and procedure of any code blue that occurs and review compliance with new or re-admissions. During weekly follow-up, guidance and recommendations will be provided with compliance validated. 17. Administrative oversight of the facility will be completed by the Vice President of Operations, Nurse Consultant, or Special Projects Administrator daily until removal of the immediacy beginning [DATE], then weekly for four (4) weeks, then monthly. 18. A Quality Assurance meeting will be held weekly until immediacy is removed beginning on [DATE], the for four (4) weeks, then monthly for recommendations and further follow up regarding the stated plan. Based on evaluation, the QA committee will determine at what frequency any ongoing audits will need to continue. The Administrator has the oversight to ensure an effective plan is in place to meet resident well-being and ensure resident rights as well as an effective plan to identify facility concerns and implement a plan of correction to involve all staff of the facility. Corporate Administrative oversight of the Quality Assurance meeting will be completed by the Special projects Administrator, the Regional Vice President of Operations, or a member of regional staff three (3) times a week until immediacy is removed beginning [DATE], then weekly for four (4) weeks, then monthly. The State Survey Agency validated the implementation of the facility's AOC as follows: 1. Review of the facility's investigation of the incident revealed an audit of Resident #1's medical record with areas concern noted. Interview with the DON, on [DATE] at 5:20 PM, revealed she audited Resident #1's medical record and identified areas of concern with immediate implementation of education provided to staff. 2. Review of the facility's audit of all resident's Advance Directive, Care Plans and physician's orders [REDACTED]. Interview with the DON, on [DATE] at 5:20 PM, revealed she had participated with other management staff to audit all resident records to verify accuracy of the resident's Advance Directive, Care Plans and Physician's code status order. 3. Review of the audit tool utilized to interview and assess all residents for possible resident rights violations revealed management staff interviewed all resident's with a Brief Interview for Mental Status (BIMS) score of eight (8) or greater and a physical assessment was completed for resident's whose BIMS was less than eight (8). Interview with the DON, on [DATE] at 5:20 PM, revealed management staff interviewed or assessed each of the facility's residents for any signs or symptoms of resident rights violations. Interview with interviewable residents revealed staff did talk with them regarding their resident rights. 4. The audit tool, dated [DATE], utilized to audit previous thirty (30) days facility new admissions was reviewed. New admissions were audited for compliance with admission process including: Physician notification, review of New Admission physician's orders [REDACTED]. Areas of concern identified with the audit were documentation in relation to missing dates and times on the Nursing Admission Assessment on four (4) residents. Review of the education provided to staff revealed policy and procedures related to accuracy of the admission process and documentation was provided. Review of the staff sign in sheets revealed instruction was provided beginning [DATE] with review of policy and procedure. On [DATE], a more comprehensive education was provided to staff related to the policy and procedure. Interview with the DON, on [DATE] at 5:20 PM, revealed she initiated education to the nursing staff immediately on [DATE]. Per the DON, the Regional Nurse provided comprehensive education to the management staff on [DATE]. Further interview revealed, after receiving the comprehensive education, the management staff were responsible for providing the comprehensive education to the facility's nursing staff. 5. Review of the audit of each resident's medical record to include: Advance Directive, physician's orders [REDACTED]. Interview with the DON, on [DATE] at 5:20 PM, revealed she and other management staff audited each resident's medical record to ensure compliance with quality of care delivery. 6. Review of education provided by the Regional Nurse to all management staff with the sign in sheet dated [DATE] and signed by the Regional Nurse revealed the education provided included: Cardiopulmonary Resuscitation, Advance Directives, Physician Visits and Medical Orders, Admission Criteria, Care Planning - Interdisciplinary Team, Resident Rights, Quality of Care, Professional Standards, and QA. Interview with the Regional Nurse Consultant, on [DATE] at 5:20 PM, revealed he provided comprehensive education to management staff related to the facility's policies and procedures stated above. Continued interview revealed the facility revised the CPR policy to include mandatory hands on skills certification for staff. 7. Review of education provided to all nursing staff to include: Cardiopulmonary Resuscitation, Advance Directives, Physician Visits and Medical Orders, Admission Criteria, Care Planning - Interdisciplinary Team, Resident Rights, Quality of Care, Professional Standards, and QA. Review of sign in sheets revealed the education was initiated on [DATE] and concluded on [DATE]. Review of certified letters sent to twenty-one (21) part-time clinical staff related to mandatory education prior to working. Continued review of sign-in sheets revealed education for part-time clinical staff, non-licensed staff and non-nursing staff continued per AOC. Review of New Orientation Agenda for clinical staff, revealed education would be provided with orientation process. Review of audit tool utilized for validation of CPR certification with hands on skills component revealed staff had obtained education with hands on skill component. Interview, on [DATE] at 10:20 AM with SRNA #8; at 10:30 AM with SRNA #7; at 10:40 AM with SRNA #4; at 10:50 AM with SRNA #2; and, at 11:00 AM with SRNA #6 revealed they had all been provided education related to Cardiopulmonary Resuscitation, Resident Rights, Quality of Care and Professional Standards between [DATE] and [DATE] in a verbal lecture setting allowing for question and answers. Interview, on [DATE] at 5:50 PM with RN #1 and at 6:12 PM with LPN #1; on [DATE] at 11:15 AM with LPN #12; at 11:25 AM with LPN #3; at 4:16 PM with LPN #11; at 4:30 PM with LPN #2; at 4:45 PM with RN #4; at 5:00 PM with RN #2; at 5:17 PM with RN #3; and, Unit Manager #1 at 4:29 PM, revealed they had all been provided education related to Cardiopulmonary Resuscitation, Advance Directives, Physician Visits and Medical Orders, Admission Criteria, Care Planning, Resident Rights, Professional Standards, and Quality of Care in a verbal lecture setting allowing for question and answers. 8. Review of the education provided to all licensed staff related to the admission policy and procedure revealed the education was initiated on [DATE] and completed on [DATE] after additional education was provided by the Regional Nurse Consultant. Interview with the DON, on [DATE] at 5:20 PM, revealed she had initiated staff education on [DATE]. After receiving comprehensive education provided by the Regional Nurse Consultant on [DATE], the management team re-educated staff with the completion date for full-time clinical staff to be [DATE]. 9. Review of the education provided to all Physicians with privileges to included; clarification of the process for notifying the Physician of new admits and obtaining orders, and the Interim Care Plan and Professional Standards. Further review, revealed there was follow up letters sent to each Physician related to the educations provided. 10. Review of the Audit of personnel files for CPR certification revealed the Audit was completed on [DATE] with the Regional Nurse Consultant review on [DATE]. Data from the audit revealed seventeen (17) staff without the hands on skill component for CPR certification. 11. Review of the Audit of personnel files for CPR certifications revealed sixteen (16) of the seventeen (17) identified staff without hands on skill component CPR certifications had obtained certifications with the hands on skills component. Interview with the DON, on [DATE] at 5:20 PM, revealed she was a Certified American Heart CPR Instructor. Further interview revealed, she had conducted four (4) CPR classes for staff that included the hands on skills component. Per interview, one staff still remained out of compliance with the CPR certification hands on component and would not be allowed to work until appropriate certification was obtained. 12. Review of the Daily New Admission Log, revealed new admissions were reviewed daily for compliance with Physician Notification, Physician Orders, Interim Care Plan, Advance Directive, and Resident Rights beginning [DATE]. Interview with the DON on [DATE] at 5:20 PM, revealed areas of concern were identified when the audits were initiated on [DATE]; however, after staff received education, data collected had improved. Further interview revealed any issues identified would be immediately corrected with data reviewed with the QA committee weekly for four (4) weeks, then monthly with the results of the collected data to determine the need for additional education or the revision of the plan. 13. Review of documentation monitoring care delivery as outlined per the resident's care plan, revealed five (5) resident care plans per day per unit were reviewed by management staff beginning [DATE]. Interview with the DON, on [DATE] at 5:20 PM, revealed management staff had audited resident care plans daily. Further interview revealed five (5) care plans were audited on each unit daily since [DATE]. 14. Review of documentation of the Mock codes revealed they were conducted twice weekly on rotating shifts beginning [DATE]. Interview, on [DATE] at 5:50 PM with RN #1 and at 6:12 PM with LPN #1; on [DATE] at 11:15 AM with LPN #12; at 11:25 AM with LPN #3; at 4:16 PM with LPN #11; at 4:30 PM with LPN #2; at 4:45 PM with RN #4; at 5:00 PM with RN #2; at 5:17 PM with RN #3; and, Unit Manager #1 at 4:29 PM, revealed they had all been provided education related to Cardiopulmonary Resuscitation and Advance Directives with Mock Codes conducted on different shifts. 15. Review of documentation of CPR certification tracking revealed the date the certification was obtained and verification the certification contained a hands on skills component. Interview with the DON, on [DATE] at 5:20 PM, revealed the facility had previously been tracking CPR expiration dates; however, the facility added verification of a hands on skills component to their tracking data to ensure compliance. 16. Review of the documentation of a calendar, signed by the Regional Nurse and Regional Vice President of Operations revealed the Regional Vice President of Operations was on site [DATE] and [DATE]. Further review revealed, the Regional Nurse was on site daily from [DATE] to [DATE] with the exception of [DATE]. Interview with the Regional Nurse, on [DATE] at 5:20 PM, revealed he had been in the facility each day with the exception of [DATE]. Interview with the Administrator on [DATE] at 5:20 PM, revealed the Regional Nurse had been on site daily since [DATE] with the exception of [DATE]. Interview with Unit Manager #1, on [DATE] at 4:29 PM, revealed the Regional Nurse had been on site seemed like daily for over two (2) weeks. 17. Review of documentation of a calendar, signed by the Regional Nurse and Regional Vice President of Operations revealed on site Administrative oversight was performed by the Regional Vice President of Operations on [DATE] and [DATE]. Further review revealed, on site Administrative oversight was performed by the Regional Nurse on each day from [DATE] to [DATE], with the exception of [DATE]. Interview with the Regional Nurse, on [DATE] at 5:20 PM, revealed he had been on site at the facility daily since [DATE] with the exception of [DATE]. Interview with the Administrator on [DATE] at 5:20 PM, revealed the Regional Nurse had been on site daily since [DATE] with the exception of [DATE]. Interview with Unit Manager #1, on [DATE] at 4:29 PM, revealed the Regional Nurse had been on site seemed like daily for over two (2) weeks. 18. Review of the QA sign in sheets revealed, meetings were conducted on [DATE], [DATE], and [DATE] with the areas of concern discussed. The Medical Director was in attendance on [DATE]. Interview with the Administrator, on [DATE] at 11:15 AM, revealed the data obtained from the audits performed, revealed areas of concern related to the Mock codes which were initially performed. Continued interview revealed, the data was analyzed and it was determined additional education was needed. Further interview revealed the additional education was provided with positive data resulting from ongoing Mock codes and audits.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to have an effective system in place to ensure each resident received Cardiopulmonary Resuscitation (CPR) according to established professional standards, the Advanced Directives, and requested code status, for one (1) of twelve (12) sampled residents (Resident #1). On [DATE], Resident #1's Responsible Party (RP) signed Advance Directives requesting the resident have a Full Code status (Full Code indicates life-saving measures were to be implemented in the event of cardiac or [MEDICAL CONDITION]), to include CPR. However, on [DATE] at approximately 7:15 AM, when State Registered Nursing Assistant (SRNA) #1 entered Resident #1's room and found the resident to be unresponsive, she notified Licensed Practical Nurses (LPNs) #1 and #2, who failed to honor the resident's Advance Directives for Full Code status. LPN #1 entered Resident #1's room, checked Resident #1 for a pulse without success and failed to initiate CPR according to the resident's Advance Directives. LPN #2 entered Resident #1's room, observed LPN #1 checking the resident for a pulse, went to the Nurse's Station and checked the resident's chart for code status and called Registered Nurse (RN) #1. LPN #2 also failed to initiate CPR according to the resident's Advance Directives. RN #1, who was on another unit, arrived to Resident #1's room, assessed the resident to have no heart rate and no respirations and pronounced the resident deceased at 7:23 AM. Per interview, RN #1 determined Resident #1 was Full Code status, but she did not initiate CPR according to the resident's Advance Directives. The facility's failure to provide the necessary care and services related to the resident's requested Full Code status and the provision of CPR, has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE], and was determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. The facility provided an acceptable credible Allegation of Compliance (AOC) on [DATE] with the facility alleging removal of the Immediate Jeopardy on [DATE]. The State Survey Agency validated removal of the Immediate Jeopardy as alleged, on [DATE], prior to exit on [DATE], with remaining non-compliance in the area of 42 CFR 483.25 Quality of Care, F-309 at a Scope and Severity of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's policy titled Advance Directives - Kentucky, effective ,[DATE], revealed it was the policy of the facility to recognize and support the use of Advance Directives through family, staff and community education, and to encourage the resident's rights to self-determination through recognition and assistance with executing such directives. Further review revealed, all residents would receive full resuscitative measures unless a Do Not Resuscitate (DNR) directive was written in the resident's medical record and was identified in the resident's Advance Directive. Review of the facility's policy, titled Cardiopulmonary Resuscitation, undated, revealed CPR would be attempted for any resident who was found to have no palpable pulse and/or no discernible respirations, unless there was a written physician's orders [REDACTED]. Continued review revealed, should a resident be found unresponsive and without respirations, a licensed staff member who was certified in CPR would promptly initiate CPR for residents who have requested CPR in their advance directive; who have not formulated an advance directive; and, who do not have a valid DNR order or unless it would pose a danger to self or others to initiate CPR. Review of Resident #1's clinical record revealed the facility admitted the resident on [DATE], with [DIAGNOSES REDACTED]. Review of the Advance Directives/Informed Consent, signed by Resident #1's RP on [DATE], revealed the RP had requested and consented in the event of death for staff to use cardiac compressions or artificial ventilation to resuscitate the resident. Review of the Nursing Admission Information dated [DATE], revealed Resident #1's Advance Directives had been completed. Review of the physician's orders [REDACTED].>Review of the Nurse's Note, dated [DATE], not timed, completed by LPN #1, revealed LPN #1 found the resident sitting on the floor next to the bed with blood on the pillow and ear, with no pulse found. However, there was no documented evidence LPN #1 immediately initiated CPR for Resident #1's as per physician's orders [REDACTED]. Review of LPN #1's Interviewer Statement, dated [DATE], documented by the Director of Nursing (DON), revealed LPN #1 found Resident #1 slumped in a sitting position against the low bed leaning toward his/her left side. According to the statement, LPN #1 immediately checked for a carotid pulse with no pulse found. Further review, revealed LPN #2 came into the room and LPN #1 continued assessing Resident #1 and found blood on his/her pillow and coming from the resident's left ear. Further review of the Statement, revealed LPN #1 called for an RN. According to the Statement, after RN #1 arrived, LPN #1 and RN #1 assessed the resident for any type of injury or trauma with no bruises, abrasions or knots noted. Per the Statement, LPN #2 obtained an order from the on-call Physician to withhold CPR related to the resident being deceased . Interview with LPN #1, on [DATE] at 6:12 PM, revealed he was the primary nurse for Resident #1 on the day shift of [DATE]. LPN #1 revealed he was certified to perform CPR; however, when he found Resident #1 on [DATE] around 7:15 AM, he did not initiate CPR. He further stated LPN #2 entered the resident's room behind him and did not initiate CPR, but left the room to call the RN for assistance. LPN #1 revealed, at the time of the incident, he did not know if Resident #1 had a Full Code status and felt the resident required further assessment stating the RN was more qualified to complete that assessment. LPN #1 further stated he was unfamiliar with the facility's policy; however, stated he did not know why he didn't initiate CPR. Review of the Nurse's Note dated [DATE], at 7:23 AM, completed by LPN #2, revealed the resident was found sitting beside the bed with his/her back to the bed, leaning to the left side with wet fresh blood, from the left ear on the pillow, with no pulse, no respirations, no blood pressure and no signs of life. However, there was no documented evidence LPN #2 immediately initiated CPR for Resident #1's as per the resident's physician's orders [REDACTED]. Review of LPN #2's Witness Statement, dated [DATE], revealed Resident #1 had been awake and walking up and down the hallway until 2:50 AM. According to the Statement, Resident #1 was seen during rounds at 5:00 AM lying in his/her bed, sleeping with a baby doll in his/her arms. Further review of the Statement revealed LPN #2 was called to Resident #1's room by a SRNA. LPN #2 found the resident deceased at 7:23 AM. Interview with LPN #2, on [DATE] at 4:31 PM, revealed she had entered Resident #1's room behind LPN #1 and found the resident with no pulse; and although she was certified in CPR, she did not initiate CPR. LPN #2 stated she left the resident's room to go to the nurse's station to check the resident's code status and call the RN. LPN #2 revealed, she identified the resident to be a Full Code status and even though she did not immediately initiate CPR, she did inform LPN #1 and RN #1 of the resident's Advance Directive. LPN #2 stated, the resident was just too far gone. Per interview LPN #2 notified the on-call Physician the resident had expired and the RN had decided the resident was too far gone to perform CPR. LPN #2 further stated she thought she informed the physician of the resident's Full Code status with the Physician's verbal response to be Oh no, OK. Continued interview revealed the Physician did not state to her to withhold CPR. LPN #2 revealed per the facility's policy, CPR should have been initiated for Resident #1. Interview with the on-call Physician, on [DATE] at 8:13 AM, revealed he was notified by the facility of Resident #1's death; however, he was not informed Resident #1 had a Full Code status and he did not give an order for [REDACTED]. Further review of the Nurse's Notes, revealed a Note dated [DATE], at 7:30 AM, completed by RN #1, which revealed Resident #1 was sitting on the floor with his/her back to the bed and leaning to the left side with blood from his/her left ear with no heart rate and no respirations. According to the Note, Resident #1 was pronounced deceased at 7:23 AM; however, there was no documented evidence RN #1 immediately initiated CPR as per Resident #1's physician's orders [REDACTED]. Review of RN #1's Witness Statement, dated [DATE], revealed the nurse was called to another unit at approximately 7:15 AM to pronounce the passing of a resident. Per the Statement, upon entering Resident #1's room, the resident was observed to be in a sitting position on the floor with his/her back against the bed. The Statement revealed Resident #1 was cold to touch with no respirations, no audible or palpable heart rate, color was pale and mottled with no obvious injuries. According to the Statement, RN #1 pronounced death at 7:23 AM. Interview with RN #1, on [DATE] at 5:50 PM, revealed she was working on another unit and responded to a call from LPN #2 on [DATE] around 7:10 AM or 7:15 AM, requesting a nurse to pronounce a resident deceased . Continued interview revealed with RN #1 revealed on arrival to Resident #1's room she assessed the resident and pronounced the resident deceased at 7:23 AM. RN #1 revealed she was not aware Resident #1 was a Full Code status until she went to the nurse's station to document her assessment; however, she did not initiate CPR because in my nursing opinion, (she/he) had been passed for a while. Continued interview revealed, it was the facility's policy to initiate CPR when a resident was found in [MEDICAL CONDITION] or unresponsive and was a Full Code status. However, RN #1 revealed she did not follow the facility's policy. Interview with the Director of Nursing (DON), on [DATE] at 3:09 PM, revealed the facility's policy related to resuscitation of a resident was to immediately initiate CPR for a resident found unresponsive without a pulse or respirations and to continue CPR until the Physician gave an order to stop, or Emergency Medical Services (EMS) arrived to transport the resident to the hospital. Continued interview revealed, staff should not with hold CPR while attempting to contact the resident's Physician. Per interview, staff did not follow the facility's policies and CPR should have been immediately initiated for Resident #1 when he/she was found unresponsive. Interview with the Administrator, on [DATE] at 4:50 PM, revealed staff did not follow the facility's policy related to the initiation of CPR. Per interview, her expectation was for staff to initiate CPR immediately for any Full Code status resident found to be unresponsive and without signs of life. The Administrator stated LPN #1, LPN #2 and RN #1 should have initiated CPR for Resident #1, who was a Full Code, when they found the resident non-responsive. The facility provided an acceptable credible Allegation of Compliance (AOC) on [DATE], which alleged removal of the IJ effective [DATE]. Review of the AOC revealed the facility implemented the following: 1. On [DATE], the Director of Nursing (DON) reviewed Resident #1's medical record and care plan with the following areas of concern identified: a. The date and time were missing regarding the Physician notification on the Nursing Admission Assessment b. the Advance Directive of Full Code status was not care planned on the Interim Care Plan. c. CPR was not immediately initiated per Resident #1's/Power of Attorney's (POA's) request as indicated on the Advance Directive. 2. Beginning [DATE] and concluding on [DATE], the DON, Unit Managers, Nursing Supervisors or Medical Records staff audited all resident Advance Directive/Code Status/physician's orders [REDACTED]. 3. Beginning [DATE] and concluding on [DATE], the DON, Assistant Director of Nursing (ADON), Unit Managers and Nursing Supervisors assessed all residents for any possible resident rights violations. Residents with a Brief Interview of Mental Status (BIMS) score of eight (8) or greater were interviewed and residents with a BIMS of less than eight (8) were physically assessed for any signs and symptoms of possible quality of life or resident rights violations. 4. Compliance audits of the admission process were completed by [DATE] of all admissions within the previous thirty (30) days. The audits were performed by the DON, ADON, Unit Managers or Nursing Supervisors of all resident's medical records to include notification of the Attending Physician, review of the Physician Admitting Orders with the Attending Physician and ensuring professional standards were followed. 5. The DON, Unit Managers, Nursing Supervisors or Medical Records staff completed audits of all resident charts by [DATE]. The Audit included; resident's Advance Directive, physician's orders [REDACTED]. 6. On [DATE], all management staff was educated by the Regional Nurse Consultant. Education included: Advance Directive Policy and Procedure, Admission/physician's orders [REDACTED]. 7. Education for all nursing staff was initiated on [DATE] and completed by [DATE], with the exception of four (4) full-time status staff on leave and twenty-one (21) part-time staff. Certified letters were sent to the twenty-one (21) part-time staff to notify each of the mandatory education prior to returning to duty. Education was provided by the Staff Development Coordinator, Unit Mangers and Nursing Supervisors. Education included Advance Directive Policy and Procedure, Admission/Physician order [REDACTED]. The education related to the policies and procedures was added to the training agenda for New Employee Orientation. 8. Beginning [DATE] and concluding on [DATE], the Staff Development Coordinator, Unit Managers and Nursing Supervisors conducted education for all licensed staff (with the exception of the part-time staff who were notified by certified letter they could not work until receiving the required education) on the admission policy and procedure, to include: clarification of the process for Physician notification of new admissions, obtaining admission orders [REDACTED]. The above education was incorporated into the facility's New Employee Orientation. 9. On [DATE], all Physicians with privileges at the facility were educated by the DON in regards to the admission process and expectations with compliance to include: Discharge Summaries or Orders from a discharging facility would be faxed to the Physician's office and the Physician would be called for approval of the Orders with a Telephone Order written stating the Physician's review and approval of the Orders. 10. Human Resources and/or Staff Development performed audits of all personnel files for CPR certifications. Audits were completed by [DATE] and given to the Regional Nurse Consultant to review for non-compliance with CPR regulations. Seventeen (17) licensed nurses were noted to have on-line only CPR certifications. 11. Sixteen (16) of the seventeen (17) staff identified to have on-line CPR certifications received CPR instruction with hands on component by [DATE], provided by the DON, a certified American Heart CPR Instructor. One (1) employee would not be allowed to work until CPR certification with hands on component was obtained. 12. Beginning [DATE], the DON, ADON, Unit Manager, Nursing Supervisor or Medical Records staff will review all new admissions daily during the morning clinical meeting to ensure compliance with Physician notification, Physician Orders, Interim Care Plan, Advance Directive, and Resident Rights. Findings of the review will be reported in the Quality Assurance (QA) committee meeting. The committee consists of the Medical Director, Administrator, DON, Social Services Director and at least two (2) other department managers, different line staff as appropriate, and outside consultants as appropriate. The committee will meet weekly for four (4) weeks then monthly to determine the need for continued education or revision of the plan. Based on evaluation, the QA committee will determine at what frequency the ongoing review of new admissions will need to continue. Concerns identified will be corrected immediately by the DON, ADON, Unit Managers or Nursing Supervisor and reported to the Administrator to ensure any needed investigation initiated and reported guidelines were met. 13. The DON, ADON, Unit Managers, or Nursing Supervisor will monitor care delivery as outlined per the care plan on five (5) residents per unit per day until immediacy is removed, beginning [DATE], then five (5) residents daily for four (4) weeks, to ensure compliance with care delivery as outlined by the Care Plan along with compliance of Professional Standards requirements. Findings will be reported in the QA committee weekly to determine the further need of continued education or the revision of the plan. 14. Mock codes will be conducted by the DON, ADON, Unit Managers, Staff Development Coordinator or Nursing Supervisor twice weekly, on rotating shifts, for four (4) weeks beginning [DATE], to ensure understanding and compliance with Code Blue Policy and Procedure. The first two (2) mock codes were conducted by Clinical Managers for education on how to conduct a code; the Mock codes will be conducted by the nurses. Findings will be reported to the QA committee weekly to determine compliance and any further need of continued education or revision of the plan. 15. The DON, Staff Development Coordinator or Human Resources will track all licensed nurses CPR certification monthly beginning [DATE], to ensure compliance with CPR policy, procedure and governing regulations. Findings and compliance will be reported monthly to the QA committee to determine any need for education or revision of the process. 16. A Regional Nurse or corporate office staff was on site since [DATE] and will remain on site daily until immediacy is removed, then will be on site three (3) times weekly for four (4) weeks. Regional/Corporate staff will review compliance with the plan and will review compliance with policy and procedure of any code blue that occurs and review compliance with new or re-admissions. During weekly follow-up, guidance and recommendations will be provided with compliance validated. 17. Administrative oversight of the facility will be completed by the Vice President of Operations, Nurse Consultant, or Special Projects Administrator daily until removal of the immediacy beginning [DATE], then weekly for four (4) weeks, then monthly. 18. A Quality Assurance meeting will be held weekly until immediacy is removed beginning on [DATE], the for four (4) weeks, then monthly for recommendations and further follow up regarding the stated plan. Based on evaluation, the QA committee will determine at what frequency any ongoing audits will need to continue. The Administrator has the oversight to ensure an effective plan is in place to meet resident well-being and ensure resident rights as well as an effective plan to identify facility concerns and implement a plan of correction to involve all staff of the facility. Corporate Administrative oversight of the Quality Assurance meeting will be completed by the Special projects Administrator, the Regional Vice President of Operations, or a member of regional staff three (3) times a week until immediacy is removed beginning [DATE], then weekly for four (4) weeks, then monthly. The State Survey Agency validated the implementation of the facility's AOC as follows: 1. Review of the facility's investigation of the incident revealed an audit of Resident #1's medical record with areas concern noted. Interview with the DON, on [DATE] at 5:20 PM, revealed she audited Resident #1's medical record and identified areas of concern with immediate implementation of education provided to staff. 2. Review of the facility's audit of all resident's Advance Directive, Care Plans and physician's orders [REDACTED]. Interview with the DON, on [DATE] at 5:20 PM, revealed she had participated with other management staff to audit all resident records to verify accuracy of the resident's Advance Directive, Care Plans and Physician's code status order. 3. Review of the audit tool utilized to interview and assess all residents for possible resident rights violations revealed management staff interviewed all resident's with a Brief Interview for Mental Status (BIMS) score of eight (8) or greater and a physical assessment was completed for resident's whose BIMS was less than eight (8). Interview with the DON, on [DATE] at 5:20 PM, revealed management staff interviewed or assessed each of the facility's residents for any signs or symptoms of resident rights violations. Interview with interviewable residents revealed staff did talk with them regarding their resident rights. 4. The audit tool, dated [DATE], utilized to audit previous thirty (30) days facility new admissions was reviewed. New admissions were audited for compliance with admission process including: Physician notification, review of New Admission physician's orders [REDACTED]. Areas of concern identified with the audit were documentation in relation to missing dates and times on the Nursing Admission Assessment on four (4) residents. Review of the education provided to staff revealed policy and procedures related to accuracy of the admission process and documentation was provided. Review of the staff sign in sheets revealed instruction was provided beginning [DATE] with review of policy and procedure. On [DATE], a more comprehensive education was provided to staff related to the policy and procedure. Interview with the DON, on [DATE] at 5:20 PM, revealed she initiated education to the nursing staff immediately on [DATE]. Per the DON, the Regional Nurse provided comprehensive education to the management staff on [DATE]. Further interview revealed, after receiving the comprehensive education, the management staff were responsible for providing the comprehensive education to the facility's nursing staff. 5. Review of the audit of each resident's medical record to include: Advance Directive, physician's orders [REDACTED]. Interview with the DON, on [DATE] at 5:20 PM, revealed she and other management staff audited each resident's medical record to ensure compliance with quality of care delivery. 6. Review of education provided by the Regional Nurse to all management staff with the sign in sheet dated [DATE] and signed by the Regional Nurse revealed the education provided included: Cardiopulmonary Resuscitation, Advance Directives, Physician Visits and Medical Orders, Admission Criteria, Care Planning - Interdisciplinary Team, Resident Rights, Quality of Care, Professional Standards, and QA. Interview with the Regional Nurse Consultant, on [DATE] at 5:20 PM, revealed he provided comprehensive education to management staff related to the facility's policies and procedures stated above. Continued interview revealed the facility revised the CPR policy to include mandatory hands on skills certification for staff. 7. Review of education provided to all nursing staff to include: Cardiopulmonary Resuscitation, Advance Directives, Physician Visits and Medical Orders, Admission Criteria, Care Planning - Interdisciplinary Team, Resident Rights, Quality of Care, Professional Standards, and QA. Review of sign in sheets revealed the education was initiated on [DATE] and concluded on [DATE]. Review of certified letters sent to twenty-one (21) part-time clinical staff related to mandatory education prior to working. Continued review of sign-in sheets revealed education for part-time clinical staff, non-licensed staff and non-nursing staff continued per AOC. Review of New Orientation Agenda for clinical staff, revealed education would be provided with orientation process. Review of audit tool utilized for validation of CPR certification with hands on skills component revealed staff had obtained education with hands on skill component. Interview, on [DATE] at 10:20 AM with SRNA #8; at 10:30 AM with SRNA #7; at 10:40 AM with SRNA #4; at 10:50 AM with SRNA #2; and, at 11:00 AM with SRNA #6 revealed they had all been provided education related to Cardiopulmonary Resuscitation, Resident Rights, Quality of Care and Professional Standards between [DATE] and [DATE] in a verbal lecture setting allowing for question and answers. Interview, on [DATE] at 5:50 PM with RN #1 and at 6:12 PM with LPN #1; on [DATE] at 11:15 AM with LPN #12; at 11:25 AM with LPN #3; at 4:16 PM with LPN #11; at 4:30 PM with LPN #2; at 4:45 PM with RN #4; at 5:00 PM with RN #2; at 5:17 PM with RN #3; and, Unit Manager #1 at 4:29 PM, revealed they had all been provided education related to Cardiopulmonary Resuscitation, Advance Directives, Physician Visits and Medical Orders, Admission Criteria, Care Planning, Resident Rights, Professional Standards, and Quality of Care in a verbal lecture setting allowing for question and answers. 8. Review of the education provided to all licensed staff related to the admission policy and procedure revealed the education was initiated on [DATE] and completed on [DATE] after additional education was provided by the Regional Nurse Consultant. Interview with the DON, on [DATE] at 5:20 PM, revealed she had initiated staff education on [DATE]. After receiving comprehensive education provided by the Regional Nurse Consultant on [DATE], the management team re-educated staff with the completion date for full-time clinical staff to be [DATE]. 9. Review of the education provided to all Physicians with privileges to included; clarification of the process for notifying the Physician of new admits and obtaining orders, and the Interim Care Plan and Professional Standards. Further review, revealed there was follow up letters sent to each Physician related to the educations provided. 10. Review of the Audit of personnel files for CPR certification revealed the Audit was completed on [DATE] with the Regional Nurse Consultant review on [DATE]. Data from the audit revealed seventeen (17) staff without the hands on skill component for CPR certification. 11. Review of the Audit of personnel files for CPR certifications revealed sixteen (16) of the seventeen (17) identified staff without hands on skill component CPR certifications had obtained certifications with the hands on skills component. Interview with the DON, on [DATE] at 5:20 PM, revealed she was a Certified American Heart CPR Instructor. Further interview revealed, she had conducted four (4) CPR classes for staff that included the hands on skills component. Per interview, one staff still remained out of compliance with the CPR certification hands on component and would not be allowed to work until appropriate certification was obtained. 12. Review of the Daily New Admission Log, revealed new admissions were reviewed daily for compliance with Physician Notification, Physician Orders, Interim Care Plan, Advance Directive, and Resident Rights beginning [DATE]. Interview with the DON on [DATE] at 5:20 PM, revealed areas of concern were identified when the audits were initiated on [DATE]; however, after staff received education, data collected had improved. Further interview revealed any issues identified would be immediately corrected with data reviewed with the QA committee weekly for four (4) weeks, then monthly with the results of the collected data to determine the need for additional education or the revision of the plan. 13. Review of documentation monitoring care delivery as outlined per the resident's care plan, revealed five (5) resident care plans per day per unit were reviewed by management staff beginning [DATE]. Interview with the DON, on [DATE] at 5:20 PM, revealed management staff had audited resident care plans daily. Further interview revealed five (5) care plans were audited on each unit daily since [DATE]. 14. Review of documentation of the Mock codes revealed they were conducted twice weekly on rotating shifts beginning [DATE]. Interview, on [DATE] at 5:50 PM with RN #1 and at 6:12 PM with LPN #1; on [DATE] at 11:15 AM with LPN #12; at 11:25 AM with LPN #3; at 4:16 PM with LPN #11; at 4:30 PM with LPN #2; at 4:45 PM with RN #4; at 5:00 PM with RN #2; at 5:17 PM with RN #3; and, Unit Manager #1 at 4:29 PM, revealed they had all been provided education related to Cardiopulmonary Resuscitation and Advance Directives with Mock Codes conducted on different shifts. 15. Review of documentation of CPR certification tracking revealed the date the certification was obtained and verification the certification contained a hands on skills component. Interview with the DON, on [DATE] at 5:20 PM, revealed the facility had previously been tracking CPR expiration dates; however, the facility added verification of a hands on skills component to their tracking data to ensure compliance. 16. Review of the documentation of a calendar, signed by the Regional Nurse and Regional Vice President of Operations revealed the Regional Vice President of Operations was on site [DATE] and [DATE]. Further review revealed, the Regional Nurse was on site daily from [DATE] to [DATE] with the exception of [DATE]. Interview with the Regional Nurse, on [DATE] at 5:20 PM, revealed he had been in the facility each day with the exception of [DATE]. Interview with the Administrator on [DATE] at 5:20 PM, revealed the Regional Nurse had been on site daily since [DATE] with the exception of [DATE]. Interview with Unit Manager #1, on [DATE] at 4:29 PM, revealed the Regional Nurse had been on site seemed like daily for over two (2) weeks. 17. Review of documentation of a calendar, signed by the Regional Nurse and Regional Vice President of Operations revealed on site Administrative oversight was performed by the Regional Vice President of Operations on [DATE] and [DATE]. Further review revealed, on site Administrative oversight was performed by the Regional Nurse on each day from [DATE] to [DATE], with the exception of [DATE]. Interview with the Regional Nurse, on [DATE] at 5:20 PM, revealed he had been on site at the facility daily since [DATE] with the exception of [DATE]. Interview with the Ad

Based on interview, record review, review of the facility's policy and review of the Kentucky Board of Nursing's (KBN's), Accountability & Responsibility of Nurses document and Advisory Opinion Statements (AOS), it was determined the facility failed to have an effective system to ensure services provided met professional standards of quality for one (1) of twelve (12) sampled residents (Resident #1) regarding ensuring nursing staff honored the resident's Advance Directives and ensuring care planning was sufficient to meet the needs of newly admitted residents related to code status. On [DATE], Resident #1's Responsible Party, signed Advance Directives requesting the resident have a Full Code status (Full Code specifies life saving measures would be implemented in the event of cardiac or [MEDICAL CONDITION]) with life-saving measures to include Cardiopulmonary Resuscitation (CPR). Resident #1 also had a physician's orders [REDACTED]. On [DATE] at approximately 7:15 AM, when State Registered Nursing Assistant (SRNA) #1 entered Resident #1's room, found the resident unresponsive, and notified Licensed Practical Nurse (LPN) #1 and #2, the LPN's failed to honor Resident #1's Advance Directives regarding Full Code status. LPN #1 entered Resident #1's room, checked the resident for a pulse, could not obtain a pulse, and failed to initiate CPR as per the resident's Advance Directives. LPN #2, then entered Resident #1's room, observed LPN #1 checking the resident for a pulse, went to the nurse's station, checked the resident's medical record for code status and called Registered Nurse (RN) #1. LPN #2 also failed to initiate CPR as per the resident's Advance Directives. RN #1, who was working on another unit, arrived to Resident #1's room, assessed the resident to have no heart rate and no respirations and pronounced the resident deceased at 7:23 AM, without prior approval or order obtained by the resident's physician. Per interview, RN #1 determined Resident #1 was a Full Code; however, she did not initiate CPR according to the resident's Advance Directives. The facility's failure to ensure services provided met professional standards of quality related to Advance Directives regarding residents' requested code status, and ensuring the Interim Care Plan was sufficient for newly admitted residents, caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE], and was determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. The facility provided an acceptable credible Allegation of Compliance (AOC) on [DATE] with the facility alleging removal of the Immediate Jeopardy on [DATE]. The State Survey Agency validated removal of the Immediate Jeopardy as alleged, on [DATE], prior to exit on [DATE], with remaining non-compliance in the area of 42 CFR 483.20 Resident Assessment, F-281 at a Scope and Severity of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's policy, titled Advance Directives - Kentucky effective ,[DATE], revealed it was the policy of the facility to recognize and support the use of Advance Directives through family, staff and community education and to encourage the resident's rights to self-determination through recognition and assistance with executing the directives. Further review revealed, as long as the resident was competent to make decisions, his/her wishes would be followed to the maximum extent possible as dictated by state law and sound medical judgment. If a resident became incompetent, but had provided evidence of a properly executed Advance Directive, the facility would implement the resident's choices as outlined in the document or expressed to the appointed agent to the same extent the competent resident's wishes would be followed. Continued review revealed, all residents would receive full resuscitative measures unless a Do Not Resuscitate (DNR) directive was written in the resident's medical record and was identified in the resident's Advance Directive. Review of the facility's policy, titled Resident Rights, reviewed [DATE], revealed residents had the right to choose a physician, treatment, and participate in decisions and care planning. Further review revealed, residents were entitled to exercise their rights and privileges to the fullest extent possible. According to the policy, employees had a duty to read and learn the residents' rights. Review of the facility's policy, titled Cardiopulmonary Resuscitation, undated, revealed CPR would be attempted for a resident who was found to have no palpable pulse and/or no discernible respirations, unless there was a written physician's orders [REDACTED]. Further review revealed, should a resident be found unresponsive and without respirations, a licensed staff member who was certified in CPR would promptly initiate CPR for residents who requested CPR in their advance directive; who had not formulated an advance directive; or who did not have a valid DNR order, unless it would pose a danger to self or others to initiate CPR. Review of the facility's policy, titled Death of Resident, Documenting, undated, revealed a resident may be declared dead by a Licensed Physician or Registered Nurse with Physician authorization in accordance with state law. Review of the KBN's, Accountability & Responsibility of Nurses document revealed KRS 314.021 (2) held nurses individually responsible and accountable for rendering safe, effective nursing care to clients and for judgements exercised and actions taken in the course of providing care. Review of the KBN's Advisory Opinion Statement (AOS) #36, Resuscitation, approved February 2008, revealed nurses were required to honor the Advance Directives of patients who had the Advance Directives documented in the medical record, unless a Physician or healthcare facility refused to comply, and the patient and surrogate were informed of the refusal. Review of the facility's policy, titled Care Planning - Interdisciplinary Team, undated, revealed the facility's Care Planning/Interdisciplinary Team was responsible for the development of an individualized comprehensive care plan for each resident, incorporating goals and objectives that lead to the residents' highest obtainable level of independence. Continued review revealed, the resident, the resident's family and/or the resident's legal representative/guardian or surrogate were encouraged to participate in the development of and revisions to the resident's care plan. Review of Resident #1's medical record revealed the facility admitted the resident on [DATE] from the hospital, with [DIAGNOSES REDACTED]. Review of the Advance Directives/Informed Consent, dated [DATE] signed by Resident #1's Responsible Party, revealed the Responsible Party had requested and consented in the event of death for staff to use cardiac compressions or artificial ventilation to resuscitate the resident. Review of the Nursing Admission Information document dated [DATE], revealed the resident's Advance Directives had been completed. Review of the physician's orders [REDACTED]. The State Survey Agency was unable to reach the resident's admitting nurse after multiple attempts. Review of the Nurse's Notes dated [DATE], not timed and documented by LPN #1, revealed LPN #1 found Resident #1 sitting on the floor next to the bed with blood on the pillow and ear with no pulse found. Further review of the Note, revealed no documented evidence LPN #1 immediately initiated CPR as per Resident #1's physician's orders [REDACTED]. Continued review of the Nurse's Notes, revealed a Note dated [DATE], at 7:23 AM, documented by LPN #2, which revealed Resident #1 was found sitting beside the bed with his/her back to the bed, leaning to the left side with wet fresh blood, from the left ear on the pillow with no pulse, no respirations, no blood pressure and no signs of life. However, there was no documented evidence LPN #2 immediately initiated CPR as per Resident #1's physician's orders [REDACTED]. Further review of the Nurse's Notes, revealed an entry dated [DATE], at 7:30 AM, documented by RN #1, which revealed Resident #1 was sitting on the floor with his/her back to the bed and leaning to the left side with blood from his/her left ear with no heart rate and no respirations. Per the note, Resident #1 was pronounced deceased at 7:23 AM; however, there was no documented evidence RN #1 immediately initiated CPR as per Resident #1's physician's orders [REDACTED]. Review of the Provisional Report of Death form revealed Resident #1's date and time of death was noted as being on [DATE] at 7:23 AM. Interview with LPN #1, on [DATE] at 6:12 PM, revealed on the day shift of [DATE], he was the primary nurse for Resident #1. LPN #1 revealed, he was certified to perform CPR; however, when he found Resident #1 on [DATE] around 7:15 AM, he did not initiate CPR. He further stated LPN #2 entered the resident's room behind him and did not initiate CPR; however, left the room to call the RN for assistance. Per interview, LPN #1 did not know if Resident #1 had a Full Code status and felt the resident required further assessment and the RN was more qualified to complete that assessment. LPN #1 further revealed, he was unfamiliar with the facility's policy; however, he stated he did not know why he didn't initiate CPR. Interview with LPN #2, on [DATE] at 4:31 PM, revealed she was certified in CPR and had entered Resident #1's room behind LPN #1 and found the resident with no pulse; however, she did not initiate CPR. LPN #2 stated she went to the nurse's station to check the resident's code status and call the RN. Further interview revealed, she identified the resident to be a Full Code status and even though she did not immediately initiate CPR, she did inform LPN #1 and RN #1 of the resident's Advance Directive. LPN #2 reported the resident was just too far gone. Continued interview revealed, she notified the on-call Physician of the resident's death. Per interview, LPN #2 stated she reported to the on-call Physician the resident had expired and the RN had decided the resident was too far gone to perform CPR. LPN #2 stated she thought she informed the physician of the resident's Full Code status with the Physician's verbal response to be Oh no, OK. LPN #2 further stated, per the facility's policy, CPR should have been initiated for Resident #1. Interview on [DATE] at 8:13 AM with the on-call Physician, revealed the facility did notify him of Resident #1's death; however, he was not informed Resident #1 had a Full Code status and he did not give an order for [REDACTED].>Interview with RN #1, on [DATE] at 5:50 PM, revealed she was certified in CPR and responded to a call from LPN #2 on [DATE] around 7:10 AM or 7:15 AM, requesting a nurse to pronounce a resident deceased . Continued interview revealed, upon arrival to Resident #1's room she assessed the resident and without obtaining an order from the resident's physician prior to pronouncing, RN #1, pronounced the resident deceased at 7:23 AM. Per interview, she was not aware Resident #1 was a Full Code status until she went to the nurse's station to document her assessment; however, she did not initiate CPR because in my nursing opinion, (she/he) had been passed for a while. Further interview revealed, it was the facility's policy to initiate CPR when a resident was found in [MEDICAL CONDITION] or unresponsive and had a Full Code status and she stated she should obtain an order from the physician prior to pronouncing a resident deceased . RN #1 reported she did not follow the facility's policy. Interview with the Director of Nursing (DON), on [DATE] at 3:09 PM, revealed should a resident be found unresponsive, staff should verify the resident's Advance Directive, and CPR should be immediately initiated for any resident with a Full Code status Advance Directive. The DON stated, per the facility's policy, prior to pronouncing a resident deceased , an order or approval from the resident's physician should be obtained by the RN. Continued interview at 4:02 PM, revealed a resident's code status should be documented on the resident's care plan to ensure appropriate care would be provided. She stated it would be the responsibility of the nurse who admits the resident to ensure the Interim Care Plan related to Advanced Directive was initiated. Further interview revealed her expectation was for staff to follow the facility's policy and staff did not follow the facility's policy. Interview on [DATE] at 4:50 PM, with the Administrator, revealed residents had a right to execute an Advance Directive and it should be honored by the staff. She stated a resident's care plan should include the resident's Advance Directive. Continued interview revealed, LPN #1, LPN #2 and RN #1 should have initiated CPR for Resident #1, who was a Full Code, when they found the resident non-responsive. Per interview, the facility's policy did allow for an RN to pronounce a resident deceased with the approval of the physician. The Administrator reported her expectation was for staff to follow the facility's policies to provide a professional standard of care to the residents. The facility provided an acceptable credible Allegation of Compliance (AOC) on [DATE], which alleged removal of the IJ effective [DATE]. Review of the AOC revealed the facility implemented the following: 1. On [DATE], the Director of Nursing (DON) reviewed Resident #1's medical record and care plan with the following areas of concern identified: a. The date and time were missing regarding the Physician notification on the Nursing Admission Assessment b. the Advance Directive of Full Code status was not care planned on the Interim Care Plan. c. CPR was not immediately initiated per Resident #1's/Power of Attorney's (POA's) request as indicated on the Advance Directive. 2. Beginning [DATE] and concluding on [DATE], the DON, Unit Managers, Nursing Supervisors or Medical Records staff audited all resident Advance Directive/Code Status/physician's orders [REDACTED]. 3. Beginning [DATE] and concluding on [DATE], the DON, Assistant Director of Nursing (ADON), Unit Managers and Nursing Supervisors assessed all residents for any possible resident rights violations. Residents with a Brief Interview of Mental Status (BIMS) score of eight (8) or greater were interviewed and residents with a BIMS of less than eight (8) were physically assessed for any signs and symptoms of possible quality of life or resident rights violations. 4. Compliance audits of the admission process were completed by [DATE] of all admissions within the previous thirty (30) days. The audits were performed by the DON, ADON, Unit Managers or Nursing Supervisors of all resident's medical records to include notification of the Attending Physician, review of the Physician Admitting Orders with the Attending Physician and ensuring professional standards were followed. 5. The DON, Unit Managers, Nursing Supervisors or Medical Records staff completed audits of all resident charts by [DATE]. The Audit included; resident's Advance Directive, physician's orders [REDACTED]. 6. On [DATE], all management staff was educated by the Regional Nurse Consultant. Education included: Advance Directive Policy and Procedure, Admission/physician's orders [REDACTED]. 7. Education for all nursing staff was initiated on [DATE] and completed by [DATE], with the exception of four (4) full-time status staff on leave and twenty-one (21) part-time staff. Certified letters were sent to the twenty-one (21) part-time staff to notify each of the mandatory education prior to returning to duty. Education was provided by the Staff Development Coordinator, Unit Mangers and Nursing Supervisors. Education included Advance Directive Policy and Procedure, Admission/Physician order [REDACTED]. The education related to the policies and procedures was added to the training agenda for New Employee Orientation. 8. Beginning [DATE] and concluding on [DATE], the Staff Development Coordinator, Unit Managers and Nursing Supervisors conducted education for all licensed staff (with the exception of the part-time staff who were notified by certified letter they could not work until receiving the required education) on the admission policy and procedure, to include: clarification of the process for Physician notification of new admissions, obtaining admission orders [REDACTED]. The above education was incorporated into the facility's New Employee Orientation. 9. On [DATE], all Physicians with privileges at the facility were educated by the DON in regards to the admission process and expectations with compliance to include: Discharge Summaries or Orders from a discharging facility would be faxed to the Physician's office and the Physician would be called for approval of the Orders with a Telephone Order written stating the Physician's review and approval of the Orders. 10. Human Resources and/or Staff Development performed audits of all personnel files for CPR certifications. Audits were completed by [DATE] and given to the Regional Nurse Consultant to review for non-compliance with CPR regulations. Seventeen (17) licensed nurses were noted to have on-line only CPR certifications. 11. Sixteen (16) of the seventeen (17) staff identified to have on-line CPR certifications received CPR instruction with hands on component by [DATE], provided by the DON, a certified American Heart CPR Instructor. One (1) employee would not be allowed to work until CPR certification with hands on component was obtained. 12. Beginning [DATE], the DON, ADON, Unit Manager, Nursing Supervisor or Medical Records staff will review all new admissions daily during the morning clinical meeting to ensure compliance with Physician notification, Physician Orders, Interim Care Plan, Advance Directive, and Resident Rights. Findings of the review will be reported in the Quality Assurance (QA) committee meeting. The committee consists of the Medical Director, Administrator, DON, Social Services Director and at least two (2) other department managers, different line staff as appropriate, and outside consultants as appropriate. The committee will meet weekly for four (4) weeks then monthly to determine the need for continued education or revision of the plan. Based on evaluation, the QA committee will determine at what frequency the ongoing review of new admissions will need to continue. Concerns identified will be corrected immediately by the DON, ADON, Unit Managers or Nursing Supervisor and reported to the Administrator to ensure any needed investigation initiated and reported guidelines were met. 13. The DON, ADON, Unit Managers, or Nursing Supervisor will monitor care delivery as outlined per the care plan on five (5) residents per unit per day until immediacy is removed, beginning [DATE], then five (5) residents daily for four (4) weeks, to ensure compliance with care delivery as outlined by the Care Plan along with compliance of Professional Standards requirements. Findings will be reported in the QA committee weekly to determine the further need of continued education or the revision of the plan. 14. Mock codes will be conducted by the DON, ADON, Unit Managers, Staff Development Coordinator or Nursing Supervisor twice weekly, on rotating shifts, for four (4) weeks beginning [DATE], to ensure understanding and compliance with Code Blue Policy and Procedure. The first two (2) mock codes were conducted by Clinical Managers for education on how to conduct a code; the Mock codes will be conducted by the nurses. Findings will be reported to the QA committee weekly to determine compliance and any further need of continued education or revision of the plan. 15. The DON, Staff Development Coordinator or Human Resources will track all licensed nurses CPR certification monthly beginning [DATE], to ensure compliance with CPR policy, procedure and governing regulations. Findings and compliance will be reported monthly to the QA committee to determine any need for education or revision of the process. 16. A Regional Nurse or corporate office staff was on site since [DATE] and will remain on site daily until immediacy is removed, then will be on site three (3) times weekly for four (4) weeks. Regional/Corporate staff will review compliance with the plan and will review compliance with policy and procedure of any code blue that occurs and review compliance with new or re-admissions. During weekly follow-up, guidance and recommendations will be provided with compliance validated. 17. Administrative oversight of the facility will be completed by the Vice President of Operations, Nurse Consultant, or Special Projects Administrator daily until removal of the immediacy beginning [DATE], then weekly for four (4) weeks, then monthly. 18. A Quality Assurance meeting will be held weekly until immediacy is removed beginning on [DATE], the for four (4) weeks, then monthly for recommendations and further follow up regarding the stated plan. Based on evaluation, the QA committee will determine at what frequency any ongoing audits will need to continue. The Administrator has the oversight to ensure an effective plan is in place to meet resident well-being and ensure resident rights as well as an effective plan to identify facility concerns and implement a plan of correction to involve all staff of the facility. Corporate Administrative oversight of the Quality Assurance meeting will be completed by the Special projects Administrator, the Regional Vice President of Operations, or a member of regional staff three (3) times a week until immediacy is removed beginning [DATE], then weekly for four (4) weeks, then monthly. The State Survey Agency validated the implementation of the facility's AOC as follows: 1. Review of the facility's investigation of the incident revealed an audit of Resident #1's medical record with areas concern noted. Interview with the DON, on [DATE] at 5:20 PM, revealed she audited Resident #1's medical record and identified areas of concern with immediate implementation of education provided to staff. 2. Review of the facility's audit of all resident's Advance Directive, Care Plans and physician's orders [REDACTED]. Interview with the DON, on [DATE] at 5:20 PM, revealed she had participated with other management staff to audit all resident records to verify accuracy of the resident's Advance Directive, Care Plans and Physician's code status order. 3. Review of the audit tool utilized to interview and assess all residents for possible resident rights violations revealed management staff interviewed all resident's with a Brief Interview for Mental Status (BIMS) score of eight (8) or greater and a physical assessment was completed for resident's whose BIMS was less than eight (8). Interview with the DON, on [DATE] at 5:20 PM, revealed management staff interviewed or assessed each of the facility's residents for any signs or symptoms of resident rights violations. Interview with interviewable residents revealed staff did talk with them regarding their resident rights. 4. The audit tool, dated [DATE], utilized to audit previous thirty (30) days facility new admissions was reviewed. New admissions were audited for compliance with admission process including: Physician notification, review of New Admission physician's orders [REDACTED]. Areas of concern identified with the audit were documentation in relation to missing dates and times on the Nursing Admission Assessment on four (4) residents. Review of the education provided to staff revealed policy and procedures related to accuracy of the admission process and documentation was provided. Review of the staff sign in sheets revealed instruction was provided beginning [DATE] with review of policy and procedure. On [DATE], a more comprehensive education was provided to staff related to the policy and procedure. Interview with the DON, on [DATE] at 5:20 PM, revealed she initiated education to the nursing staff immediately on [DATE]. Per the DON, the Regional Nurse provided comprehensive education to the management staff on [DATE]. Further interview revealed, after receiving the comprehensive education, the management staff were responsible for providing the comprehensive education to the facility's nursing staff. 5. Review of the audit of each resident's medical record to include: Advance Directive, physician's orders [REDACTED]. Interview with the DON, on [DATE] at 5:20 PM, revealed she and other management staff audited each resident's medical record to ensure compliance with quality of care delivery. 6. Review of education provided by the Regional Nurse to all management staff with the sign in sheet dated [DATE] and signed by the Regional Nurse revealed the education provided included: Cardiopulmonary Resuscitation, Advance Directives, Physician Visits and Medical Orders, Admission Criteria, Care Planning - Interdisciplinary Team, Resident Rights, Quality of Care, Professional Standards, and QA. Interview with the Regional Nurse Consultant, on [DATE] at 5:20 PM, revealed he provided comprehensive education to management staff related to the facility's policies and procedures stated above. Continued interview revealed the facility revised the CPR policy to include mandatory hands on skills certification for staff. 7. Review of education provided to all nursing staff to include: Cardiopulmonary Resuscitation, Advance Directives, Physician Visits and Medical Orders, Admission Criteria, Care Planning - Interdisciplinary Team, Resident Rights, Quality of Care, Professional Standards, and QA. Review of sign in sheets revealed the education was initiated on [DATE] and concluded on [DATE]. Review of certified letters sent to twenty-one (21) part-time clinical staff related to mandatory education prior to working. Continued review of sign-in sheets revealed education for part-time clinical staff, non-licensed staff and non-nursing staff continued per AOC. Review of New Orientation Agenda for clinical staff, revealed education would be provided with orientation process. Review of audit tool utilized for validation of CPR certification with hands on skills component revealed staff had obtained education with hands on skill component. Interview, on [DATE] at 10:20 AM with SRNA #8; at 10:30 AM with SRNA #7; at 10:40 AM with SRNA #4; at 10:50 AM with SRNA #2; and, at 11:00 AM with SRNA #6 revealed they had all been provided education related to Cardiopulmonary Resuscitation, Resident Rights, Quality of Care and Professional Standards between [DATE] and [DATE] in a verbal lecture setting allowing for question and answers. Interview, on [DATE] at 5:50 PM with RN #1 and at 6:12 PM with LPN #1; on [DATE] at 11:15 AM with LPN #12; at 11:25 AM with LPN #3; at 4:16 PM with LPN #11; at 4:30 PM with LPN #2; at 4:45 PM with RN #4; at 5:00 PM with RN #2; at 5:17 PM with RN #3; and, Unit Manager #1 at 4:29 PM, revealed they had all been provided education related to Cardiopulmonary Resuscitation, Advance Directives, Physician Visits and Medical Orders, Admission Criteria, Care Planning, Resident Rights, Professional Standards, and Quality of Care in a verbal lecture setting allowing for question and answers. 8. Review of the education provided to all licensed staff related to the admission policy and procedure revealed the education was initiated on [DATE] and completed on [DATE] after additional education was provided by the Regional Nurse Consultant. Interview with the DON, on [DATE] at 5:20 PM, revealed she had initiated staff education on [DATE]. After receiving comprehensive education provided by the Regional Nurse Consultant on [DATE], the management team re-educated staff with the completion date for full-time clinical staff to be [DATE]. 9. Review of the education provided to all Physicians with privileges to included; clarification of the process for notifying the Physician of new admits and obtaining orders, and the Interim Care Plan and Professional Standards. Further review, revealed there was follow up letters sent to each Physician related to the educations provided. 10. Review of the Audit of personnel files for CPR certification revealed the Audit was completed on [DATE] with the Regional Nurse Consultant review on [DATE]. Data from the audit revealed seventeen (17) staff without the hands on skill component for CPR certification. 11. Review of the Audit of personnel files for CPR certifications revealed sixteen (16) of the seventeen (17) identified staff without hands on skill component CPR certifications had obtained certifications with the hands on skills component. Interview with the DON, on [DATE] at 5:20 PM, revealed she was a Certified American Heart CPR Instructor. Further interview revealed, she had conducted four (4) CPR classes for staff that included the hands on skills component. Per interview, one staff still remained out of compliance with the CPR certification hands on component and would not be allowed to work until appropriate certification was obtained. 12. Review of the Daily New Admission Log, revealed new admissions were reviewed daily for compliance with Physician Notification, Physician Orders, Interim Care Plan, Advance Directive, and Resident Rights beginning [DATE]. Interview with the DON on [DATE] at 5:20 PM, revealed areas of concern were identified when the audits were initiated on [DATE]; however, after staff received education, data collected had improved. Further interview revealed any issues identified would be immediately corrected with data reviewed with the QA committee weekly for four (4) weeks, then monthly with the results of the collected data to determine the need for additional education or the revision of the plan. 13. Review of documentation monitoring care delivery as outlined per the resident's care plan, revealed five (5) resident care plans per day per unit were reviewed by management staff beginning [DATE]. Interview with the DON, on [DATE] at 5:20 PM, revealed management staff had audited resident care plans daily. Further interview revealed five (5) care plans were audited on each unit daily since [DATE]. 14. Review of documentation of the Mock codes revealed they were conducted twice weekly on rotating shifts beginning [DATE]. Interview, on [DATE] at 5:50 PM with RN #1 and at 6:12 PM

Based on interview, record review, review of the facility's policies, Administrator job description, and Incident Reports, it was determined the facility's Administration failed to have an effective system in place to ensure policies and procedures were implemented to ensure the residents' environment remained as free from accident hazards as possible, ensure staff were trained and knowledgeable regarding the process for ensuring safety of residents on facility outings and ensure staff implemented residents' care plans. (Refer to F-282, F-323) Resident #1 was to attend a facility outing on 10/03/14, and was assisted out of his/her motorized wheelchair with a self-releasing seat belt, for which he/she was care planned to have for security, into a manual wheelchair, without a self-releasing seat belt. Staff assisted Resident #1 onto the facility's van; however, did not ensure the resident was securely restrained with a seat belt prior to the van moving. During the transportation at approximately 2:15 PM, the van suddenly stopped for a traffic light and Resident #1 "flew" out of the manual wheelchair onto the van floor. Registered Nurse (RN) #1, who was present on the van, immediately assessed Resident #1 and he/she was transported to the hospital emergency room where he/she was diagnosed with [REDACTED]. The resident returned to the facility at 4:52 PM on 10/03/14. The facility's Administrator's failure to have an effective system in place to ensure policies and procedures were implemented to ensure the residents' environment remained as free from accident hazards as possible, ensure staff were trained and knowledgeable regarding the process for ensuring safety of residents on facility outings, and ensure staff implemented residents' care plans was likely to cause risk for serious injury, harm, impairment, or death. Immediate Jeopardy was identified on 10/22/14 and determined to exist on 10/03/14. The facility was notified of the Immediate Jeopardy on 10/22/14. The facility provided an acceptable credible Allegation of Compliance (AOC) on 10/29/14, alleging removal of the Immediate Jeopardy on 10/25/14. The Immediate Jeopardy was verified to be removed on 10/25/14, as alleged, with remaining non-compliance at 42 CFR 483.75 Administration, F-490 at a Scope and Severity (S/S) of a "D", while the facility develops and implements a Plan of Correction (POC), and the facility's Quality Assurance continues to monitor to ensure compliance with systemic changes. The findings include: Review of the Administrator's Job Description, updated December 2011, revealed the Administrator was responsible for leading and directing the overall operations of the facility in accordance with residents' needs, government regulations and company policies. Continued review revealed the Administrator's management duties included, but were not limited to, hiring, training and developing, coaching, counseling and terminating facility staff as deemed necessary. In addition, the Job Description revealed the Administrator's duties included monitoring delivery of nursing care and ensuring residents' needs were addressed. Per the Job Description, the Administrator was responsible for the facility's Quality Assurance (QA) program and to maintain a working knowledge of and confirm compliance with all governmental regulations. Review of the facility's,"Safety Precautions for Activities" policy, revised January 2009, revealed the facility was to provide supervision, safety and a safe environment for all residents during any facility activities. Review of the facility's, "Outing Guidelines", undated, revealed the facility was to ensure the safety and well-being of residents, and staff were to "double check" residents' security for both residents who were ambulatory and residents who were being transported in a wheelchair on the facility's van. Per the Guidelines, staff should "not assume" residents had been secured properly on the van. Review of the "Accidents and Incidents-Investigating and Reporting" policy, revised April 2013, revealed the Nurse Supervisor/Charge Nurse and/or Department Director or Supervisor was to "promptly" initiate an investigation of an accident or incident and document the investigation. Per the Policy, all accidents involving residents were to be investigated and reported to the Administrator. Review of the facility's "Care Plans-Comprehensive" policy, revised October 2010, revealed care plan development was to include developing interventions which were targeted and meaningful to each resident. Review of the facility's Incident Report dated 10/03/14, revealed Resident #1 was in a wheelchair on his/her way to a facility outing when the resident fell out of the wheelchair into the aisle of the facility van, hitting his/her head on the van floor. According to the Incident Report, one (1) of the contributing factors Resident #1 fell out of the wheelchair was the resident had difficulty maintaining his/her sitting balance, related to [DIAGNOSES REDACTED]. Review of the hospital emergency room (ER) record dated 10/03/14 at 2:52 PM, revealed Resident #1 had sustained an injury to his/her head after a fall on the facility van. Review of the ER record revealed the ER Physician diagnosed Resident #1 with a large Hematoma to the right forehead area. Record review revealed Resident # 1 was totally dependent on assistance of two (2) staff for all transfers and, had an physician's orders [REDACTED].#1's Comprehensive Care Plan revealed the facility care planned the resident to have a self-releasing seat belt when up in a wheelchair. However, staff interviews revealed even though they were aware Resident #1 required a self-releasing seat belt when in a wheelchair, they had not ensured the resident was properly restrained with any type of seat belt prior to movement of the facility van on 10/03/14. Staff failed to "double check" residents' security and "not assume" residents had been secured properly on the van per the facility's guidelines for resident outings. Staff interviews revealed the facility had not formally trained them on assisting residents who were attending outings and ensuring residents' safety while on the outings. Staff interviews also revealed staff thought the resident's self releasing seatbelt was only for use when Resident #1 was in his/her motorized wheelchair. Interview with the Director of Nursing (DON) on 10/21/14 at 2:00 PM and on 10/22/14 at 4:05 PM, revealed the Activity Director "informally" went over the facility's "Outing Guidelines" with staff before each outing. According to the DON, she was aware of Resident #1's ordered and care planned self-releasing seat belt when in a wheelchair. However, she reported she thought the self-releasing seat belt was for only when Resident #1 was in his/her motorized wheelchair, not when he/she was in a manual wheelchair. The DON revealed the facility had no policy specific to staff following residents' care plans; however, it was the expectation staff would do so. Interview and record review revealed the facility failed to conduct an investigation related to the incident per the facility's policy which stated staff would "promptly" initiate an investigation of an accident or incident and document the investigation. Record review revealed the investigation of the accident was not initiated until 10/10/14, seven (7) days later. Continued interview with the Director of Nursing (DON) on 10/21/14 at 2:00 PM and on 10/22/14 at 4:05 PM, revealed when the facility first learned of the accident involving Resident #1 it was unclear what had happened on the van for the resident to fall out of the wheelchair. She stated she thought Resident #1 had possibly removed both (shoulder and lap) seat belts by himself/herself after the van started moving, and did not know until later staff had not ensured the seat belts were in place prior to the van moving. Per interview, on 10/03/14 after Resident #1's accident, the facility completed an Incident Report; however, an investigation was not initiated until 10/10/14, to determine the cause of the fall. Even though the facility's policy stated facility staff were to "promptly" initiate an investigation of an accident. The DON indicated the facility did not conduct an investigation on 10/03/14 because staff thought the incident involving Resident #1's fall was not abuse or neglect and was just an accident. However, the facility's policy was specific to investigating accidents and incidents, not abuse or neglect. Continued interview with the DON revealed the nurse completing the facility's "Event Manager", the computer system used for accidents/incidents, determined the "contributing factor" for the fall on 10/03/14 was the resident having difficulty maintaining his/her sitting balance. However, the DON indicated she did not know how this was determined by the nurse. Interview with the Administrator on 10/21/14 at 2:45 PM revealed she first became aware of the incident involving Resident #1 on 10/03/14 when the Activity Director called her from the ER. She stated she thought Resident #1's seat belts had possibly malfunctioned, and when the van returned to the facility all the seat belts on the van were inspected and found to be intact and functioning properly. She stated after learning of the incident involving Resident #1's fall on the bus, an Incident Report was completed. The Administrator indicated on 10/03/14, she was aware an investigation had not been initiated that day to determine the cause of Resident #1's fall, as per the policy, as it was not abuse or neglect and just an accident. However, the facility's policy was specific to investigating accidents and incidents, not abuse or neglect. She stated the facility's management team met on 10/03/14, after learning of Resident #1's accident, and developed a new form titled, "Outing Safety Checklist" to be used for all residents' outings to ensure safety of the residents. The Administrator stated the management team felt that they needed to put a system in place to ensure all residents' seat belts were fastened prior to movement of the van, other than the current system of the Activity Director verbally asking if the seat belts were fastened. She reported eight (8) staff members were in-serviced on the new form on 10/03/14; however, no further in-services had been performed until Corporate's approval of the new checklist was received. The Administrator acknowledged her duties and responsibilities located in her Job Description; however, stated she did not feel her staff were not trained and educated regarding the care of residents during transport to ensure their safety. The facility provided an acceptable, credible Allegation of Compliance (AOC) on 10/29/14, with alleged removal of Immediate Jeopardy (IJ), effective 10/25/14. Review of the AOC revealed the facility implemented the following: 1. The initial investigation of Resident #1's fall was started by the Director of Nursing (DON) on 10/10/14. The investigation included: Resident #1 was assessed by the Assistant Director of Nursing (ADON) on 10/10/14; staff statements were obtained 10/10/14 through 10/14/14 by the Administrator, Director of Nursing (DON), Social Services Director (SSD) and ADON; resident's statements were obtained 10/10/14 through 10/14/14 by the Administrator, DON, ADON, or SSD, from the residents who were on the van when the 10/03/14 incident involving Resident #1 occurred; "the wheelchair placement area" on the van with the "failed seat belt function", was placed out of service on 10/10/14 by the Maintenance Director. 2. Contacts, which started on 10/03/14 by the Administrator,were made to several agencies to get all seat belts on the van assessed for proper function and safety. An officer with the Kentucky State Police (KSP) Vehicle Enforcement provided education/training on 10/24/14 for eight (8) nursing administration staff, two (2) nursing staff, one (1) Medical Records staff person, three (3) Quality of Life (Activity) Staff, the Chaplain, seven (7) administrative staff, two (2) housekeeping staff, and the Rehabilitation (Rehab) Services Manager, who were all designated transport staff, regarding pre-trip vehicle inspection and properly securing resident passengers on the van. Return demonstration was completed by these staff at the training that was held on 10/24/14. All the designated transport staff were to complete a demonstration to the Administrator prior to going on another outing to ensure understanding of proper safety belt function. Any new designated transport staff will demonstrate to the Administrator proper safety belt application prior to going on an outing with the residents. 3. A new process was put in place to ensure residents' safety while on the van which included a safety check off sheet implemented on 10/3/14 by the Administrator. The facility also implemented changes to the "Outings Guidelines" which included: staff utilizing the "Pre-Trip Vehicle Safety Form", which was revised 10/22/14, prior every outing to ensure safety of residents; and a copy of the Certified Nursing Assistant (CNA) "care guide" for each resident would be taken on every outing to ensure residents' care plans were followed. The designated transport staff and two (2) van drivers received education/training on the new process on 10/03/14, by the ADON. The designated transport staff was educated on the updated "Pre-Trip Vehicle Safety Form", which began on 10/22/14 and was completed on 10/24/14. Resident #1 was provided with a transport wheelchair, to include a self-release seat belt, on 10/23/14 that met resident care needs and ensured the residents safety during transport in the facility van. An investigation of the 10/03/14 incident involving Resident #1 was completed by the DON on 10/15/14. 4. The new "Outing Guidelines" process which included the "Pre-Trip Vehicle Safety Form" and copy of the CNA "care guide" for each resident, that were to be taken and followed on all outings, would also ensure residents' care plans were followed on the outing when the residents were on the van. All Department Managers received education/training on 10/22/14, regarding the new "Outing Guidelines" process provided by the SCC. 5. All residents were assessed by the DON, ADON, or Registered Nurse (RN) Supervisor on 10/22/14, for electric wheelchair usage, to determine if residents' safety needs were met, along with any care planned safety devices for safety needs during transport in the facility van, as outlined by residents' care plans. 6. All residents were assessed. Residents with a Brief Interview Mental Status (BIMS) score greater than eight (8), were interviewed beginning 10/22/14 and completed on 10/23/14, by the Administrator, DON, ADON, SSD, Registered Dietician (RD), Chaplain or Medical Records staff for any concerns. Residents with a BIMS score less than eight (8) were physically assessed by the DON, ADON, Unit Managers, or RN supervisor. The assessments, interviews and questionnaires were reviewed by the Administrator or Signature Care Consultant (SCC) on 10/23/14. 7. All personnel files were audited 10/22/14 by Human Resources staff, Chaplain or Nursing Supervisor for any concerns, with results given to the SCC on 10/23/14, for review. Additionally, all accident/incident reports from July to 10/22/14 were reviewed on 10/23/14 by the DON, ADON, SDC or SCC to identify any concerns and ensure incident reports and a thorough investigation was completed, with no concerns identified. 8. All residents' care plans and CNA care plans were reviewed and updated as needed to include residents' wheelchair safety devices, on 10/22/14 by the DON, ADON, Nursing Supervisor or Minimum Data Set (MDS) Nurses to ensure each resident's care plan and CNA care plan reflected the current care needs of the resident. 9. Facility environmental rounds were completed by the Housekeeping Director, Activity Director or Administrator on 10/22/14, to ensure the residents' environment was free of accidents and hazards. 10. On 10/22/14, the SCC educated the facility's management staff which included the Administrator, DON, ADON, RN Supervisors, MDS, Quality of Life (Activity) Director, HR staff, Environmental Services Director (ESD), SSD, Admissions Director, Medical Records and Chaplain on the facility's care plan policy, accident/incident policy and the revised "Outing Guidelines" process. These staff could not return to work until the education was provided, post-test administered and a score of one hundred percent was obtained. If they did not score one hundred percent on the post-test, the staff person was immediately re-educated and post-test re-administered. The process continued until all the above management staff obtained one hundred percent on the post-test. All post-tests were reviewed for compliance by the SCC. 11. The management staff which included, the Administrator, DON, ADON, RN Supervisor, MDS, Quality of Life (Activity) Director, HR staff, ESD, SSD, Admissions Director, Medical Records staff, or Chaplain, after completion of the education, re-educated all facility staff on the facility's care plan policy, accident/incident policy and the revised "Outing Guidelines" process starting on 10/22/14. By 10/24/14, one hundred and twenty-six (126) of the facility's one hundred and eighty-nine (189) staff had been re-educated. All employees who had not received the education were sent a certified letter on 10/27/14, providing notification to staff not to return to work until education was completed, with no staff allowed to work until education was provided. All staff provided the re-education completed an abuse post-test and a one-hundred percent score had to be obtained, or the staff were immediately re-educated and the post-test was re-administered. This process was to continue until staff obtained a score of one hundred percent on the post-test. This education was to be included during orientation for all newly hired staff who would not be allowed to work until the education was provided, the post-test administered and a score of one hundred percent obtained. The facility does not employ or utilize agency staffing. 12. A nurse from the facility's regional or corporate office was onsite beginning 10/22/14, and was to remain in the facility daily until the Immediate Jeopardy (IJ) was lifted. These nurses assisted with investigations, observed staff treatment of [REDACTED]. The facility's corporate Vice President (VP) of Operations, the Special Projects Administrator or the Director of Clinical Programs was to be in daily contact with the SCC and were to review allegations until the IJ was lifted. 13. Per the AOC, the DON, ADON, SDC or Nursing Supervisor would observe the care delivery for five (5) different residents on different units for a total of fifteen (15) residents for any concerns daily until removal of the IJ, then would perform the observations weekly for four (4) weeks. Results of the care delivery/observation audits were to be reported to the facility's Quality Assurance (QA) Committee weekly to determine the need for continued staff education or revision of plan. Concerns identified would be corrected immediately and reported to the Administrator to ensure investigations were completed and, if necessary reported as per the facility's guidelines. The Administrator, DON, or member of the facility's regional staff were to review all the resident care delivery audits daily to identify any concerns. Investigations of any concerns were to be initiated upon receipt of the concern starting on 10/23/14. The Administrator and one (1) of the following: VP of Operations; Special Projects Administrator; or SCC would review the investigations daily to ensure the above areas were covered. All the above was to continue until removal of the IJ. 14. The VP of Operations, SCC or Special Projects Administrator would provide administrative oversight of the facility daily until removal of the IJ beginning 10/22/14, after removal of the IJ administrative oversight by the above would continue weekly for four (4) weeks, then monthly. A QA meeting would be held weekly for four (4) weeks beginning 10/22/14, then monthly afterwards for recommendations and further follow up regarding the AOC. The QA Committee would determine at what frequency any ongoing audits would need to continue. The Administrator had the oversight to ensure an effective plan was in place to meet residents' well-being, as well as, an effective plan to identify facility concerns and implement a plan of correction to involve all staff of the facility. Corporate Administrative oversight of the QA Committee meeting would be completed by the Special Projects Administrator, Regional VP of Operations, or member of the regional staff daily until removal of the IJ beginning 10/22/14, then weekly for four (4) weeks, then monthly thereafter. The State Agency validated the implementation of the facility's AOC as follows: 1. Review of the facility's investigation report revealed: it was initiated 10/10/14 by the DON; Resident #1 was assessed by the ADON on 10/10/14, witness statements of staff and residents on the van had been obtained by the Administrator, DON, ADON and SSD; and per the Plant Operations Director (POD) written statement, the "wheelchair placement area" on the van with the "failed seat belt function" had been placed "out of service" as per the AOC. Interview with the SCC on 11/04/14 at 10:30 AM, revealed the van had not transported residents since the incident involving Resident #1 on 10/03/14, and he verified the facility's investigation completion as above. 2. Review of the statement signed by the Administrator, undated, revealed she contacted an officer with the KSP, who agreed to offer training regarding safety on the van. Continued review of the Administrator's written statement revealed the KSP officer provided the training on 10/24/14 at 10:30 AM. Review of the In-Service sign-in sheets, dated 10/24/14, revealed the officer provided instruction on "Outing Education and Safety" for twenty-four (24) facility staff who signed the in-service sheets. Observation on 11/05/14 at approximately 1:00 PM, revealed the Quality of Life (Activity) Director and the Chaplain performed a demonstration of what they had been trained on by the KSP officer. Interview on 11/05/14 with the Human Resources (HR) staff person at 11:07 AM, Activity Aide Assistant #1 at 1:56 PM, Activity Aide Assistant #2 at 2:08 PM and on 11/06/14 with the Activities Director at 12:19 PM and the DON at 12:47 PM revealed they had all received the training provided by the KSP officer on 10/24/14, completed return demonstration and had taken a post-test on which they had to score one hundred percent. Per the DON, any new staff designated to assist with outings would go through the same education, return demonstration and post-testing. 3. Review of the facility's, "Outing Guidelines Form", undated, revealed the facility had implemented the use of a the "Pre-Trip Vehicle Safety Form" which was to be completed by staff to double check the security of all residents and their wheelchairs when on the van. Continued review of the Form revealed a copy of residents' CNA care guides were to brought on each outing for every resident attending. The Form noted staff members were secure empty wheelchairs on the bus to ensure safety of residents. Interview on 11/05/14 with the HR staff person at 11:07 AM, Activity Assistant Aide #1 at 1:56 PM, Activity Assistant Aide #2 at 2:08 PM and on 11/06/14 with the Activities Director at 12:19 PM revealed they had all been educated on the new process for transportation of residents on outings. They all reported being educated on the updated "Pre-Trip Vehicle Safety Form" between 10/22/14 and 10/24/14. Interview on 11/06/14 at 12:47 PM with the DON revealed: she had also been educated on the updated "Pre-Trip Vehicle Safety Form"; Resident #1 was provided a wheelchair which had a self-releasing seat belt for outings; and she had completed a thorough investigation of the 10/03/14 incident involving Resident #1 on 10/15/14, which was sent to the State Survey Agency. Review of Resident #1's medical record revealed the resident was assessed by Occupational Therapy (OT) and was provided a transport wheelchair with a self-releasing seat belt on 10/23/14. Interview with the SCC on 11/06/14 at 1:58 PM, revealed revisions were made to the facility's, "Outings Guidelines" as per the AOC. He stated the "Outings Guidelines" process was a check off system for to ensure safety of residents on the facility's van. Continued interview revealed changes were made to the process to address vehicle safety and to ensure all residents were secure restrained in their seat belts, including residents in wheelchairs. He revealed the "Pre-Trip Vehicle Safety Form" was revised and the "Outings Guidelines" were revised to include the addition of bringing the residents' CNA care cards on outings. 4. Review of the facility's, "Outing Guidelines Form", undated, revealed the facility had implemented the use of a the "Pre-Trip Vehicle Safety Form" which was a check-off sheet to be completed by staff to double check the security of all residents and their wheelchairs when on the van, and noted a copy of each residents' CNA care guides was to brought on each outing for every resident attending. Review of the in-service titled, "Outing Guidelines" revealed the training was conducted by the SCC on 10/22/14. Interview on 11/05/14 with the Director of Housekeeping and Laundry at 2:27 PM and on 11/06/14 with the Activities Director at 11:19 AM and with the DON at 12:47 PM, revealed they had all been educated on the new "Outing Guidelines" process on 10/22/14. Interview with the SCC on 11/06/14 at 1:08 PM, revealed he provided the in-service training on 10/22/14 at 8:00 PM as per the AOC. The SCC revealed the in-service was completed with all of the department managers as per the AOC, who in turn provided the education to staff in their departments regarding the new "Outing Guidelines". 5. Review of the facility's "Census Board" Report dated 10/22/14, revealed residents were assessed for use of electric wheelchairs. Resident #1 and Resident #4 were determined to have the electric wheelchairs during the assessment. Interview on 11/05/14 with OT #1 at 11:43 AM and OT #2 at 1:47 PM revealed they assessed Resident #1 and Resident #4 and determined the residents needed special transport chairs for outings which the residents were provided with and their care plans updated to include this information. Review of Resident #1's and Resident #4's care plans revealed the care plans were updated to reflect the new transport chairs provided by OT. Interview with the SCC on 11/06/14 at 1:58 PM revealed the assessment of all resident's who had electric wheelchairs was performed as per the AOC on 10/22/14. He revealed Resident #1 and Resident #4 were assessed by OT to require special transport wheelchairs for outings. Per interview, Resident #1's transport wheelchair was equipped with a self-releasing seat belt as per the resident's care plan. 6. Review of the facility's interviews conducted with residents who had a BIMS score greater than eight (8) revealed the residents were asked to answer questions on a questionnaire regarding any concerns. Continued review of the resident interviews revealed the DON, ADON and SSD questioned the residents on 10/22/14. Review of the CNA Skin Care Alert for residents with a BIMS of less than eight (8) revealed physical assessments of those residents were completed by the DON, ADON, Unit Managers or RN Supervisor. Interview with the SCC on 11/06/14 at 1:58 PM, revealed resident interviews were conducted as per the AOC for residents with a BIMS of eight (8) or greater. The SCC revealed as per the AOC, residents with a BIMS of less than eight (8) were physically assessed for injury. Per interview, staff were also asked if they were aware of any concerns regarding residents. 7. Review of the facility's personnel file audits revealed all files were audited by the Chaplain, HR Director and LPN #5, Unit Manager, who signed and dated the completion of the review of the files on 10/23/14. The State Survey Agency reviewed five (5) personnel records with no concerns identified. Review of the facility's "Healthcare-Event" Incident/Accident Report audit sheet revealed it included review of all incidents from 07/22/14 through 10/22/14, with no concerns identified. Interview with the HR Director on 11/05/14 at 11:07 AM, revealed she, along with the Chaplain and LPN #5 reviewed all employee personnel files. Interview with the SCC on 11/06/14 at 1:08 PM, revealed all staffs' personnel files were checked as per the AOC with no concerns identified. Continued interview revealed the audits of the Incident/Accident forms were performed as per the AOC, with no concerns identified. Per interview, the audits would continued and the clinical team would address any issues. The SCC revealed the audits would also be performed on weekends and holidays. If any concerns were noted during the audits of the Incident/Accident Reports staff would notify the Administrator and DON. 8. Review of the facility's audits of residents' care plans and CNA Care Plans, which began on 10/22/14 with a completion date of 10/29/14, revealed all the residents' care plans and CNA Care Plans were reviewed and/or updated and revised as necessary to show the resident's current care needs. revisions in the comprehensive care plans, as well as, the Certified Nursing Assistance Care Plans. Interview, on 11/06/14 at 12:47 PM, with the DON revealed the ADON, Nursing Supervisor, MDS Nurse and herself had performed the care plan reviews and ensured the care plans reflected each resident's assessed needs. Interview with the SCC on 11/06/14 at 1:08 PM, revealed all residents' care plans and CNA Care Plans (care cards) were audited and reviewed by the DON, ADON, Nursing Supervisor or MDS Nurse to ensure they were correct according to the resident's assessed needs. He reported he along with the other Corporate Consultants looked over the completed care plans after the audit to ensure they were correct. 9. Review of the "Environmental Rounds" check sheet revealed the facility's department heads would be responsible for conducting the environmental rounds of the facility which began on 10/22/14. Review of the 10/22/14 "Environmental Rounds" check sheet revealed the rounds were completed by the Housekeeping Director, Activity Director or Administrator. Review of the "Environmental Rounds" schedule revealed department head managers were assigned to check the facility's environment for accident and safety hazards. Interview with the Director of Environmental Services, on 11/05/14 at 3:04 PM, revealed he had been assigned to conduct the "Environmental Rounds" checking for concerns related to safety of residents. We reported that if he noticed a concern while conducting the environmental tour, he would repair the problem himself. Interview with the Administrator on 11/06/14 at 3:35 PM, revealed the "Environmental Rounds" were completed by the Housekeeping Director, Activity Director or herself on 10/22/14 as per the AOC. She stated these continued to be performed by the facility's department head managers. 10. Review of the in-service sign-in sheets dated 10/22/14 revealed signatures for the Administrator, DON, ADON, RN Supervisor, MDS Nurse, Activity Director, HR Director, ESD, SSC, Admissions Director, Medical Records staff person and Chaplain. Continued review revealed the in-service was conducted by the SCC regarding the facility's care plan policies, incident/accident policy and the revised "Outing Guidelines" process. Review of the POS [REDACTED]. Interview on 11/05/14 with the HR Director at 11:07 AM, the Directo

Based on interview, record review, review of the facility's policy and procedures, Activities Director job description, and incident and investigation report it was determined the facility failed to have an effective system in place to maintain a safe environment and provide supervision and monitoring to prevent falls for one (1) of three (3) sampled residents (Resident #1). On 10/03/14, during a scheduled activity outing, Resident #1 was assisted out of his/her personal wheelchair which had a self-releasing seat belt, into a manual wheelchair without a self-releasing seat belt. Resident #1 was then assisted onto the facility van where staff locked the manual wheelchair into place; however, staff failed to ensure the resident had a seat belt in place and fastened on his/her wheelchair prior to the van moving. While being transported on the van, at approximately 2:15 PM, the van suddenly stopped at a red light, and Resident #1, who had no fastened seat belt in place "flew" out of his/her wheelchair onto the center aisle of the van, landing on his/her right side. Registered Nurse (RN) #1, who was in the van, assessed Resident #1 who was then transported to the hospital emergency room (ER) where he/she was diagnosed with [REDACTED]. The ER Physician documented being unable to fully examine Resident #1's right eye "due to the amount of swelling". The resident returned to the facility at 4:52 PM on 10/03/14. The facility's failure to have an effective system in place to maintain a safe environment and provide supervision and monitoring to prevent falls was likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 10/22/14 and was determined to exist on 10/03/14. An acceptable credible Allegation of Compliance (AOC) was received on 10/29/14, which alleged removal of the Immediate Jeopardy on 10/25/14. On 11/06/14, the State Survey Agency verified the Immediate Jeopardy was removed on 10/25/14 as alleged with remaining non-compliance at 42 CFR 483.25 Quality of Care, F-323 at a Scope and Severity (S/S) of a "D", while the facility develops and implements a Plan of Correction (POC) and the facility's Quality Assurance monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy titled "Safety Precautions for Activities", revised January 2009, revealed it was the intent of the facility to provide supervision, safety and a safe environment for all residents during activity programs and while in activity areas. The Policy revealed the Activity staff assumed responsibility for the supervision of a resident while they were engaged in activity programs. Review of the facility's, "Outing Guidelines", undated, revealed the safety and well-being of residents was "always" the facility's "first priority". Per the Guidelines, staff should "double check" the security of residents, and/or wheelchairs of residents being transported in a wheelchair on the facility's van. The Guidelines stated staff were to "not assume" residents had been secured properly on the van. Review of the Activities Director job description, updated December 2011, revealed the Director was to initiate and promote activities within the facility and outside the facility, as weather permitted, ensuring the safety and well-being of each resident at all times. Continued review of the job description revealed the Activities Director was to also coordinate and verify assistance was provided to residents as necessary. Review of the facility's policy titled, "Accidents and Incidents-Investigating and Reporting", revised April 2013, revealed "all accidents or incidents involving residents" should be investigated and reported to the Administrator. Continued review revealed the Nurse Supervisor/Charge Nurse and/or Department Director or Supervisor should promptly initiate and document investigation of the accident or incident. Record review for Resident #1 revealed a "late entry" Nurse's Note dated 10/03/14 timed 6:00 PM which noted Resident #1 was non-ambulatory and used a motorized wheelchair for mobility. Continued review revealed Resident #1 was assisted out of his/her motorized wheelchair, and into a "non-motorized" wheelchair for an outing on 10/03/14 at approximately 1:30 PM. Per the Note, Resident #1's wheelchair was "strapped to" the van; however, his/her "seat belt was not sufficiently latched". The Note revealed Resident #1 "came out" of the wheelchair when the van stopped suddenly and "bumped" his/her head on the van floor "resulting in a Hematoma dark in color". Further review revealed Resident #1 was assessed and transported to the hospital ER at approximately 2:20 PM. Review of the hospital ER record dated 10/03/14 at 2:52 PM, revealed Resident #1 had sustained an injury to his/her head after "striking" his/her head "on something" when falling out of his/her wheelchair while being transported on the facility's van. Review of the "Triage Assessment" revealed Resident #1 had "bruising" that was "dark purple, yellow" on his/her forehead and right eye. Review of the ER Physician's documentation revealed Resident #1 had "sustained injury" to his/her head which included a Hematoma with swelling and tenderness. The ER Physician noted Resident #1 also had neck pain, upper and lower back pain, left shoulder pain and headache, and radiology scans were ordered. Continued review of the ER Physician's documentation revealed Morphine (narcotic pain reliever) 4 milligrams (mg) was administered per intramuscular (IM) injection at 3:02 PM, with decreased pain noted at 3:58 PM. Review of the Computerized Tomography (CT) scan of Resident #1's head and neck revealed a "large" right anterior scalp Hematoma to the right forehead area measuring approximately 4.5 centimeters (cm) by 2.6 cm. Additionally, review of the ER Physician's documentation revealed he was unable to fully examine Resident #1's right eye due to the swelling, and recommended a follow-up appointment with an Ophthalmologist. Further review of the ER record revealed Resident #1 was diagnosed with [REDACTED]. Review of the facility's Incident Report dated 10/03/14, revealed Resident #1 was in a wheelchair for an outing and fell out of the wheelchair into the aisle of the facility van, hitting his/her head on the floor of the van. Per the Incident Report, RN #1 immediately assessed Resident #1, and the resident was then transferred to the ER for evaluation and treatment. Continued review of the Incident Report revealed one (1) of the contributing factors for the fall was Resident #1 had difficulty maintaining his/her sitting balance related to his/her [DIAGNOSES REDACTED]. However, record review revealed the facility failed to investigate the accident "promptly", per the facility's policy, in order to perform a root cause analysis and attempt to determine the cause of the resident's fall. Review of the facility's investigation revealed the investigation was not initiated until 10/10/14, seven (7) days later. Review of the facility's "Final Investigation" document, undated, revealed on 10/03/14, a State Adult Protective Services (APS) Agency worker came to the facility to investigate an "allegation of caretaker neglect". Per the Document, the facility initiated an investigation after interviewing staff and learning the APS worker saw and talked to Resident #1 on 10/10/14, who had experienced a fall on the facility's van on 10/03/14 which resulted in the resident "hitting" his/her head. The Document stated Resident #1 was interviewed and stated on 10/03/14, his/her "seat belt was not fastened"; however, he/she had not told anyone. Continued review revealed when the van came to a sudden stop at a traffic light, Resident #1 fell forward out of his/her wheelchair, was assessed by RN #1 and taken to the hospital ER. The Document revealed the facility substantiated Resident #1's fall on 10/03/14, and "initiated" a checklist to ensure that all proper steps" were taken before "departure to and from future" facility outings. Record review revealed the facility admitted Resident #1 on 01/14/12, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 09/02/14, revealed the facility assessed Resident #1 to have a Brief Interview for Mental Status (BIMS) score of eight (8), indicating moderate cognitive impairment. Continued review of the MDS Assessment revealed the facility assessed Resident #1 to be totally dependent on two (2) staff for all transfers and to require a wheelchair for mobility. Review of Resident #1's Physician order [REDACTED]. Review of the Comprehensive Care Plan (CCP), dated 10/31/13, revealed the facility care planned Resident # 1 as at risk for a fall related injury with interventions which included the resident having a self-releasing seat belt to when up in the wheelchair for "security" related to poor upper body balance. Interview with Certified Nursing Assistant (CNA) #1 on 10/21/14 at 1:30 PM and 11/05/14 at 10:40 PM, revealed she and CNA #2 assisted with transferring Resident #1 from his/her own motorized wheelchair to a manual wheelchair prior to his/her boarding the facility van on 10/03/14. CNA #1 stated all residents in motorized wheelchairs were transferred to manual wheelchairs when they were going to be out on the facility's van. She stated this was because the manual wheelchairs could be fastened and secured to the van floor and motorized wheelchairs could not be securely locked into place on the floor of the van. CNA #1 revealed she was aware Resident #1 did not have a self-releasing seat belt when she transferred him/her to the manual wheelchair, and stated she did not "tell anybody" because she "thought" they already knew. According to CNA #1 she and CNA #2 assisted with lifting Resident #1 into the facility van; however, they never actually boarded the van, as they were driving to the outing in a separate vehicle. CNA #1 indicated the Activities Director was at the back of the van to assist with residents' wheelchairs. Per CNA #1, there was also a nurse on the van, and the nurse and Activities Director should have locked Resident #1's wheelchair and other residents' wheelchairs into place and ensured all the residents' seat belts were securely fastened. Per interview, CNA #1 had never received any formal training on attending an activity outing with residents riding on the van, but had assisted with previous outings and was aware of the "Outing Guidelines" which the Activity Director had gone over before the outings. CNA #1 stated she was aware of staff "double check" the security of residents prior to movement of the van, and not to assume residents had been secured properly on the van. However, as indicated previously she and CNA #2 had not boarded the van. Interview with Registered Nurse (RN) #1 on 10/21/14 at 4:45 PM, revealed she had sat in the front of the bus and remembered checking the seatbelts of the residents who sat in the front of the bus when the Activities Director asked if "everybody's" seatbelt was fastened prior to the movement of the van. RN #1 stated she did not remember seeing anyone fastening Resident #1's seatbelt, and stated she was not aware the resident was to have a self-releasing seat belt. She stated she did not "traditionally" go out on the van for residents' outings and had never received any formal training on what to do. RN #1 reported the Activity Director only "quickly" reviewed the Guidelines with her prior to the outing. According to RN #1, she never assisted residents on the van who were in wheelchairs with seat belt application, the aides or Activity Director normally did that. Per interview, she remembered it was raining on 10/03/14, when the van suddenly stopped and Resident #1 "flew" out of his/her wheelchair onto the floor. She stated she assessed Resident #1, and the resident was neurologically intact; however, was complaining of right shoulder and head pain. According to RN #1, the Activities Director wanted to return to the facility, but she told her to take Resident #1 "immediately" to the ER so a "doctor" could examine him/her which was done. Interview with the Activities Director on 10/16/14 at 3:05 PM, revealed she was present at the back of the bus to assist Resident #1 from off the van's wheelchair lift on 10/03/14, for the scheduled outing. The Activities Director stated she remembered fastening Resident #1's manual wheelchair into the four (4) floor locks; however, did not specifically remember fastening and securing Resident #1 with the two (2) seatbelts, one (1) of which went horizontally, and the other laterally, prior to the movement of the van. The Activities Director revealed she "loudly" inquired if "everybody's seat belt" was on prior to moving the van on 10/03/14, with no on voicing they weren't secured. The Activities Director stated however, she did not visually inspect all the residents' seat belts prior to the movement of the van. She reported always having "support staff" on the van to monitor the needs of the residents and a nurse was present on the van that day. Per interview, she assumed the nurse had checked to make sure all of the residents' seat belts were securely fastened. Interview with Resident #1 on 10/21/14 at 2:45 PM, revealed he/she did not recall staff applying a seat belt to him/her prior to the van moving. Resident #1 stated he/she went out on the van to go shopping "all the time", but this was the first time something like this had happened. Interview on 10/16/14 at 1:45 PM with Activities Assistant Aide #1 and at 2:00 PM with Activities Assistant Aide #2, revealed they both assisted with residents on activity outings. Activities Assistant Aide #1 revealed however, she had received no formal training on safety of residents when they were on the van for an outing, and reported also not having been trained on safety of residents with wheelchairs and seat belt use on the van. Activities Assistant Aide #2 revealed she had received safety training regarding residents using the van several years previously when another company owned the facility, but had not been formally trained since then. Interview with the Director of Nursing (DON) on 10/21/14 at 2:00 PM and on 10/22/14 at 4:05 PM, revealed the Activities Director was supposed to "informally" go over the facility's "Outing Guidelines" with staff prior to an outing. She stated the facility was "unclear" what happened on 10/03/14 and, thought Resident #1's fall was an accident. The DON revealed an Incident Report had been completed on 10/03/14 after the facility was notified of Resident #1's fall. She stated facility staff did not do an investigation to perform "root cause analysis" and determine the cause of the fall until 10/10/14. Per the DON, the facility did not perceive the incident involving Resident #1 as any type of abuse/neglect, and therefore did not perform an investigation, as it was considered to just be an accident. However, review of the facility's policy revealed "all accidents or incidents involving residents" should be investigated and the investigation should be initiated promptly. She stated the "Event Manager", the computer system the facility utilized for accidents/incidents, determined the "contributing factor" was Resident #1 had difficulty maintaining his/her sitting balance. Per interview, she was aware Resident #1 required the self-releasing seat belt which he/she was care planned for, but thought the seat belt was only for use in his/her motorized wheelchair, not for a manual wheelchair used on outings. The DON reported she was not aware Resident #1's van seat belts were not applied. She indicated she thought the seat belts were in place prior to the van moving and Resident #1 had released them. Interview with the Administrator on 10/21/14 at 2:45 PM, revealed she first became aware of the incident when the Activities Director called her from theER on [DATE]. She stated she "immediately" notified the DON and Assistant Director of Nursing (ADON) to have a full assessment completed on all of the residents who went on the outing when they returned to the facility. The Administrator revealed at first she thought Resident #1's seat belt may have malfunctioned, so the seat belts on the van were inspected upon return to the facility for any tears, rips, worn or torn areas, and the seat belts were found to be in intact and functioning properly. She stated the management team met on 10/03/14, following the incident and a new form was developed titled "Outing Safety Checklist" to be utilized for outing safety. Per interview, an in-service was held on 10/03/14 to discuss the new checklist which was attended by eight (8) staff members; however, no further in-services had been held because the facility was waiting for Corporate's approval. However, she indicated an investigation had not been initiated on 10/03/14 to determine the cause of Resident #1's fall, as the facility did not think the incident was abuse/neglect, and was just an accident. However, review of the facility's policy revealed "all accidents or incidents involving residents" should be investigated and the investigation should be initiated promptly. The facility provided an acceptable, credible Allegation of Compliance (AOC) on 10/29/14, with alleged removal of Immediate Jeopardy (IJ), effective 10/25/14. Review of the AOC revealed the facility implemented the following: 1. The initial investigation of Resident #1's fall was started by the Director of Nursing (DON) on 10/10/14. The investigation included: Resident #1 was assessed by the Assistant Director of Nursing (ADON) on 10/10/14; staff statements were obtained 10/10/14 through 10/14/14 by the Administrator, Director of Nursing (DON), Social Services Director (SSD) and ADON; resident's statements were obtained 10/10/14 through 10/14/14 by the Administrator, DON, ADON, or SSD, from the residents who were on the van when the 10/03/14 incident involving Resident #1 occurred; "the wheelchair placement area" on the van with the "failed seat belt function", was placed out of service on 10/10/14 by the Maintenance Director. 2. Contacts, which started on 10/03/14 by the Administrator,were made to several agencies to get all seat belts on the van assessed for proper function and safety. An officer with the Kentucky State Police (KSP) Vehicle Enforcement provided education/training on 10/24/14 for eight (8) nursing administration staff, two (2) nursing staff, one (1) Medical Records staff person, three (3) Quality of Life (Activity) Staff, the Chaplain, seven (7) administrative staff, two (2) housekeeping staff, and the Rehabilitation (Rehab) Services Manager, who were all designated transport staff, regarding pre-trip vehicle inspection and properly securing resident passengers on the van. Return demonstration was completed by these staff at the training that was held on 10/24/14. All the designated transport staff were to complete a demonstration to the Administrator prior to going on another outing to ensure understanding of proper safety belt function. Any new designated transport staff will demonstrate to the Administrator proper safety belt application prior to going on an outing with the residents. 3. A new process was put in place to ensure residents' safety while on the van which included a safety check off sheet implemented on 10/3/14 by the Administrator. The facility also implemented changes to the "Outings Guidelines" which included: staff utilizing the "Pre-Trip Vehicle Safety Form", which was revised 10/22/14, prior every outing to ensure safety of residents; and a copy of the Certified Nursing Assistant (CNA) "care guide" for each resident would be taken on every outing to ensure residents' care plans were followed. The designated transport staff and two (2) van drivers received education/training on the new process on 10/03/14, by the ADON. The designated transport staff was educated on the updated "Pre-Trip Vehicle Safety Form", which began on 10/22/14 and was completed on 10/24/14. Resident #1 was provided with a transport wheelchair, to include a self-release seat belt, on 10/23/14 that met resident care needs and ensured the residents safety during transport in the facility van. An investigation of the 10/03/14 incident involving Resident #1 was completed by the DON on 10/15/14. 4. The new "Outing Guidelines" process which included the "Pre-Trip Vehicle Safety Form" and copy of the CNA "care guide" for each resident, that were to be taken and followed on all outings, would also ensure residents' care plans were followed on the outing when the residents were on the van. All Department Managers received education/training on 10/22/14, regarding the new "Outing Guidelines" process provided by the SCC. 5. All residents were assessed by the DON, ADON, or Registered Nurse (RN) Supervisor on 10/22/14, for electric wheelchair usage, to determine if residents' safety needs were met, along with any care planned safety devices for safety needs during transport in the facility van, as outlined by residents' care plans. 6. All residents were assessed. Residents with a Brief Interview Mental Status (BIMS) score greater than eight (8), were interviewed beginning 10/22/14 and completed on 10/23/14, by the Administrator, DON, ADON, SSD, Registered Dietician (RD), Chaplain or Medical Records staff for any concerns. Residents with a BIMS score less than eight (8) were physically assessed by the DON, ADON, Unit Managers, or RN supervisor. The assessments, interviews and questionnaires were reviewed by the Administrator or Signature Care Consultant (SCC) on 10/23/14. 7. All personnel files were audited 10/22/14 by Human Resources staff, Chaplain or Nursing Supervisor for any concerns, with results given to the SCC on 10/23/14, for review. Additionally, all accident/incident reports from July to 10/22/14 were reviewed on 10/23/14 by the DON, ADON, SDC or SCC to identify any concerns and ensure incident reports and a thorough investigation was completed, with no concerns identified. 8. All residents' care plans and CNA care plans were reviewed and updated as needed to include residents' wheelchair safety devices, on 10/22/14 by the DON, ADON, Nursing Supervisor or Minimum Data Set (MDS) Nurses to ensure each resident's care plan and CNA care plan reflected the current care needs of the resident. 9. Facility environmental rounds were completed by the Housekeeping Director, Activity Director or Administrator on 10/22/14, to ensure the residents' environment was free of accidents and hazards. 10. On 10/22/14, the SCC educated the facility's management staff which included the Administrator, DON, ADON, RN Supervisors, MDS, Quality of Life (Activity) Director, HR staff, Environmental Services Director (ESD), SSD, Admissions Director, Medical Records and Chaplain on the facility's care plan policy, accident/incident policy and the revised "Outing Guidelines" process. These staff could not return to work until the education was provided, post-test administered and a score of one hundred percent was obtained. If they did not score one hundred percent on the post-test, the staff person was immediately re-educated and post-test re-administered. The process continued until all the above management staff obtained one hundred percent on the post-test. All post-tests were reviewed for compliance by the SCC. 11. The management staff which included, the Administrator, DON, ADON, RN Supervisor, MDS, Quality of Life (Activity) Director, HR staff, ESD, SSD, Admissions Director, Medical Records staff, or Chaplain, after completion of the education, re-educated all facility staff on the facility's care plan policy, accident/incident policy and the revised "Outing Guidelines" process starting on 10/22/14. By 10/24/14, one hundred and twenty-six (126) of the facility's one hundred and eighty-nine (189) staff had been re-educated. All employees who had not received the education were sent a certified letter on 10/27/14, providing notification to staff not to return to work until education was completed, with no staff allowed to work until education was provided. All staff provided the re-education completed an abuse post-test and a one-hundred percent score had to be obtained, or the staff were immediately re-educated and the post-test was re-administered. This process was to continue until staff obtained a score of one hundred percent on the post-test. This education was to be included during orientation for all newly hired staff who would not be allowed to work until the education was provided, the post-test administered and a score of one hundred percent obtained. The facility does not employ or utilize agency staffing. 12. A nurse from the facility's regional or corporate office was onsite beginning 10/22/14, and was to remain in the facility daily until the Immediate Jeopardy (IJ) was lifted. These nurses assisted with investigations, observed staff treatment of [REDACTED]. The facility's corporate Vice President (VP) of Operations, the Special Projects Administrator or the Director of Clinical Programs was to be in daily contact with the SCC and were to review allegations until the IJ was lifted. 13. Per the AOC, the DON, ADON, SDC or Nursing Supervisor would observe the care delivery for five (5) different residents on different units for a total of fifteen (15) residents for any concerns daily until removal of the IJ, then would perform the observations weekly for four (4) weeks. Results of the care delivery/observation audits were to be reported to the facility's Quality Assurance (QA) Committee weekly to determine the need for continued staff education or revision of plan. Concerns identified would be corrected immediately and reported to the Administrator to ensure investigations were completed and, if necessary reported as per the facility's guidelines. The Administrator, DON, or member of the facility's regional staff were to review all the resident care delivery audits daily to identify any concerns. Investigations of any concerns were to be initiated upon receipt of the concern starting on 10/23/14. The Administrator and one (1) of the following: VP of Operations; Special Projects Administrator; or SCC would review the investigations daily to ensure the above areas were covered. All the above was to continue until removal of the IJ. 14. The VP of Operations, SCC or Special Projects Administrator would provide administrative oversight of the facility daily until removal of the IJ beginning 10/22/14, after removal of the IJ administrative oversight by the above would continue weekly for four (4) weeks, then monthly. A QA meeting would be held weekly for four (4) weeks beginning 10/22/14, then monthly afterwards for recommendations and further follow up regarding the AOC. The QA Committee would determine at what frequency any ongoing audits would need to continue. The Administrator had the oversight to ensure an effective plan was in place to meet residents' well-being, as well as, an effective plan to identify facility concerns and implement a plan of correction to involve all staff of the facility. Corporate Administrative oversight of the QA Committee meeting would be completed by the Special Projects Administrator, Regional VP of Operations, or member of the regional staff daily until removal of the IJ beginning 10/22/14, then weekly for four (4) weeks, then monthly thereafter. The State Agency validated the implementation of the facility's AOC as follows: 1. Review of the facility's investigation report revealed: it was initiated 10/10/14 by the DON; Resident #1 was assessed by the ADON on 10/10/14, witness statements of staff and residents on the van had been obtained by the Administrator, DON, ADON and SSD; and per the Plant Operations Director (POD) written statement, the "wheelchair placement area" on the van with the "failed seat belt function" had been placed "out of service" as per the AOC. Interview with the SCC on 11/04/14 at 10:30 AM, revealed the van had not transported residents since the incident involving Resident #1 on 10/03/14, and he verified the facility's investigation completion as above. 2. Review of the statement signed by the Administrator, undated, revealed she contacted an officer with the KSP, who agreed to offer training regarding safety on the van. Continued review of the Administrator's written statement revealed the KSP officer provided the training on 10/24/14 at 10:30 AM. Review of the In-Service sign-in sheets, dated 10/24/14, revealed the officer provided instruction on "Outing Education and Safety" for twenty-four (24) facility staff who signed the in-service sheets. Observation on 11/05/14 at approximately 1:00 PM, revealed the Quality of Life (Activity) Director and the Chaplain performed a demonstration of what they had been trained on by the KSP officer. Interview on 11/05/14 with the Human Resources (HR) staff person at 11:07 AM, Activity Aide Assistant #1 at 1:56 PM, Activity Aide Assistant #2 at 2:08 PM and on 11/06/14 with the Activities Director at 12:19 PM and the DON at 12:47 PM revealed they had all received the training provided by the KSP officer on 10/24/14, completed return demonstration and had taken a post-test on which they had to score one hundred percent. Per the DON, any new staff designated to assist with outings would go through the same education, return demonstration and post-testing. 3. Review of the facility's, "Outing Guidelines Form", undated, revealed the facility had implemented the use of a the "Pre-Trip Vehicle Safety Form" which was to be completed by staff to double check the security of all residents and their wheelchairs when on the van. Continued review of the Form revealed a copy of residents' CNA care guides were to brought on each outing for every resident attending. The Form noted staff members were secure empty wheelchairs on the bus to ensure safety of residents. Interview on 11/05/14 with the HR staff person at 11:07 AM, Activity Assistant Aide #1 at 1:56 PM, Activity Assistant Aide #2 at 2:08 PM and on 11/06/14 with the Activities Director at 12:19 PM revealed they had all been educated on the new process for transportation of residents on outings. They all reported being educated on the updated "Pre-Trip Vehicle Safety Form" between 10/22/14 and 10/24/14. Interview on 11/06/14 at 12:47 PM with the DON revealed: she had also been educated on the updated "Pre-Trip Vehicle Safety Form"; Resident #1 was provided a wheelchair which had a self-releasing seat belt for outings; and she had completed a thorough investigation of the 10/03/14 incident involving Resident #1 on 10/15/14, which was sent to the State Survey Agency. Review of Resident #1's medical record revealed the resident was assessed by Occupational Therapy (OT) and was provided a transport wheelchair with a self-releasing seat belt on 10/23/14. Interview with the SCC on 11/06/14 at 1:58 PM, revealed revisions were made to the facility's, "Outings Guidelines" as per the AOC. He stated the "Outings Guidelines" process was a check off system for to ensure safety of residents on the facility's van. Continued interview revealed changes were made to the process to address vehicle safety and to ensure all residents were secure restrained in their seat belts, including residents in wheelchairs. He revealed the "Pre-Trip Vehicle Safety Form" was revised and the "Outings Guidelines" were revised to include the addition of bringing the residents' CNA care cards on outings. 4. Review of the facility's, "Outing Guidelines Form", undated, revealed the facility had implemented the use of a the "Pre-Trip Vehicle Safety Form" which was a c

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to have an effective system in place to ensure residents' Comprehensive Care Plans were implemented to ensure safety of residents through provision of necessary assistive devices for one (1) of three (3) sampled residents (Resident #1). During an activity outing on 10/03/14, Resident #1 was transferred from his/her own motorized wheelchair with a self-releasing seat belt, which he/she was care planned to have related to poor upper body balance, into a manual wheelchair with no self-releasing seat belt. Resident #1 was assisted onto the facility van and his/her manual wheelchair was locked into place on the van floor; however, staff failed to ensure Resident #1 had a seat belt in place prior to movement of the van. At approximately 2:15 PM during the transportation to the activity outing, the van suddenly stopped at a red light, and Resident #1 "flew" out of the manual wheelchair, in which he/she had been unrestrained, onto the center aisle of the van landing on his/her right side. Registered Nurse (RN) #1 who was in the van, immediately assessed Resident # 1, and he/she was transported to the hospital emergency room (ER), where the resident was diagnosed with [REDACTED]. The resident returned to the facility at 4:52 PM on 10/03/14. (Refer to F-323) The facility's failure to have an effective system in place to ensure residents' Comprehensive Care Plans were implemented regarding provision of assistive devices to ensure the safety of residents was likely to cause serious injury, harm, impairment or death. The Immediate Jeopardy was identified on 10/22/14 and was determined to exist on 10/03/14. The facility provided an acceptable credible Allegation of Compliance (AOC) on 10/29/14 which alleged removal of the Immediate Jeopardy on 10/25/14. The Immediate Jeopardy was verified to be removed on 10/25/14, as alleged, with remaining non-compliance in the area of 42 CFR 483.20, Resident Assessment, F-282 at a Scope and Severity of a "D" while the facility develops and implements a Plan of Correction (POC), and the facility's Quality Assurance monitors the effectiveness of the systemic changes to ensure compliance. The findings include: Review of the facility's policy titled, "Care Plans-Comprehensive", revised October 2010, revealed care plan interventions were designed after careful consideration between each resident's problem areas and the causes. Per the Policy, care plan development was to include developing interventions which were targeted and meaningful to each resident. Interview with the Director of Nursing (DON) on 10/16/14 at 2:00 PM, revealed although the facility's care plans policies did not address staff following care plan interventions, it was her expectation for this to be done. Record review revealed the facility admitted Resident #1 on 01/14/12, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 09/02/14, revealed the facility assessed Resident #1 to be moderately cognitively impaired. Continued review of the MDS Assessment revealed the facility assessed Resident #1 as being dependent on two (2) staff assist for all transfers. Review of Resident #1's physician's orders [REDACTED]. Review of Resident #1's Comprehensive Care Plan (CCP), dated 10/31/13, revealed Resident #1 was care planned to be at risk for a fall related injury related to requiring assistance with transfers. Continued review of the CCP revealed interventions which included the self-releasing seat belt, ordered on [DATE], to be placed on Resident #1 when he/she was up in the wheelchair for his/her safety and security related to poor upper body balance. Review of the Nurse's Notes revealed a "late entry" Note dated 10/03/14 timed 6:00 PM, which which stated Resident #1 was assisted out of his/her motorized wheelchair for an outing that day at approximately 1:30 PM, and into a manual wheelchair. The Note revealed once on the facility's van Resident #1's manual wheelchair was locked into place on the van floor, but the resident's "seat belt was not sufficiently latched", and the resident was thrown from the wheelchair onto the van floor when the van suddenly stopped for a red light. Further review revealed Resident #1 "bumped" his/her head, was transferred to the ER and had a Hematoma "dark in color". Review of the hospital ER record dated 10/03/14 at 2:52 PM, revealed Resident #1 was diagnosed with [REDACTED]. Interview, on 10/21/14 at 2:45 PM, with Resident #1 revealed he/she did not have a self-releasing seat belt when in a manual wheelchair for facility outings. Resident #1 stated she did not feel secure without having his/her self-releasing seat belt on. Per interview, Resident #1 reported he/she went on outings "all the time" to go shopping; however, this was the first time something like this had happened. Resident #1 stated he/she did not recall staff putting a seat belt on him/her prior to the van moving on the day of his/her fall. Interview, on 10/21/14 at 1:30 PM, with Certified Nursing Assistant (CNA) #1 revealed Resident #1 usually had a self-releasing seat belt on when up in his/her motorized wheelchair. CNA #1 revealed Resident #1's CNA Care Plan noted he/she was supposed to have a seat belt. She stated on 10/03/14, she and CNA #2 assisted Resident #1 from his/her motorized wheelchair on 10/03/14, into a manual wheelchair with no seat belt attached to go on a facility outing. Per interview, even though she was aware Resident #1 needed a self-releasing seat belt, she did not say anything to the Activity Director or RN #1 as she thought they knew the resident needed it. Interview, on 10/21/14 at 4:45 PM, with RN #1 revealed she was not aware Resident #1 wore a self-releasing seat belt, and stated she did not know the resident was not wearing one (1) in the manual wheelchair. Interview, on 10/16/14 at 3:05 PM, with the Activities Director revealed on 10/03/14, she had assisted residents in wheelchairs, including Resident #1 onto the van and locked the wheelchairs into place on the van floor. The Activity Director indicated she was not aware Resident #1 used a self-releasing seat belt when in a wheelchair. Interview, on 10/22/14 at 3:30 PM, with Licensed Practical Nurse (LPN) #1, who was the Unit Manager on Resident #1's unit, revealed the self-releasing seat belt which Resident #1 was care planned for was to be worn when he/she was up in a wheelchair for the resident's sense of security in the motorized wheelchair in the facility. LPN #1 stated it would not be her expectation for Resident #1 to have a self-releasing seat belt when up in a manual wheelchair as it was for the motorized wheelchair. However, review of the care plan revealed the self-releasing seat belt was noted to be in use when Resident #1 was in a wheelchair, with no specification for use only in the motorized wheelchair. Interview with RN #4, an MDS Nurse on 10/22/14 at 2:50 PM, revealed Resident #1 was care planned for a self-releasing seat belt when in his/her motorized wheelchair. RN #4 stated she was not aware Resident #1 was ever in a manual wheelchair, but if he/she was the seat belt should have been in place for his/her security, as per the care plan. Interview with the Director of Nursing on 10/21/14 at 2:00 PM and 10/22/14 at 4:05 PM, revealed Resident #1 did not have a self-releasing seat belt in place on 10/03/14 when the incident occurred. The DON revealed her expectation was for staff to follow residents' care plan interventions. However, at the time of the incident on 10/03/14, the facility was unclear about what had happened on the van that day, whether Resident #1 had a lap belt in place or not, and how Resident #1 ended up coming out of the wheelchair on the van. She indicated if Resident #1 was care planned to have a self-releasing seat belt when up in the wheelchair, then the resident should have had one (1) in place as per the care plan. The DON stated however, she thought the self-releasing seat belt was only for when Resident #1 was in his/her motorized wheelchair, not if he/she was in a manual wheelchair, even though this was not specified in his/her care plan. The facility provided an acceptable, credible Allegation of Compliance (AOC) on 10/29/14, with alleged removal of Immediate Jeopardy (IJ), effective 10/25/14. Review of the AOC revealed the facility implemented the following: 1. The initial investigation of Resident #1's fall was started by the Director of Nursing (DON) on 10/10/14. The investigation included: Resident #1 was assessed by the Assistant Director of Nursing (ADON) on 10/10/14; staff statements were obtained 10/10/14 through 10/14/14 by the Administrator, Director of Nursing (DON), Social Services Director (SSD) and ADON; resident's statements were obtained 10/10/14 through 10/14/14 by the Administrator, DON, ADON, or SSD, from the residents who were on the van when the 10/03/14 incident involving Resident #1 occurred; "the wheelchair placement area" on the van with the "failed seat belt function", was placed out of service on 10/10/14 by the Maintenance Director. 2. Contacts, which started on 10/03/14 by the Administrator,were made to several agencies to get all seat belts on the van assessed for proper function and safety. An officer with the Kentucky State Police (KSP) Vehicle Enforcement provided education/training on 10/24/14 for eight (8) nursing administration staff, two (2) nursing staff, one (1) Medical Records staff person, three (3) Quality of Life (Activity) Staff, the Chaplain, seven (7) administrative staff, two (2) housekeeping staff, and the Rehabilitation (Rehab) Services Manager, who were all designated transport staff, regarding pre-trip vehicle inspection and properly securing resident passengers on the van. Return demonstration was completed by these staff at the training that was held on 10/24/14. All the designated transport staff were to complete a demonstration to the Administrator prior to going on another outing to ensure understanding of proper safety belt function. Any new designated transport staff will demonstrate to the Administrator proper safety belt application prior to going on an outing with the residents. 3. A new process was put in place to ensure residents' safety while on the van which included a safety check off sheet implemented on 10/3/14 by the Administrator. The facility also implemented changes to the "Outings Guidelines" which included: staff utilizing the "Pre-Trip Vehicle Safety Form", which was revised 10/22/14, prior every outing to ensure safety of residents; and a copy of the Certified Nursing Assistant (CNA) "care guide" for each resident would be taken on every outing to ensure residents' care plans were followed. The designated transport staff and two (2) van drivers received education/training on the new process on 10/03/14, by the ADON. The designated transport staff was educated on the updated "Pre-Trip Vehicle Safety Form", which began on 10/22/14 and was completed on 10/24/14. Resident #1 was provided with a transport wheelchair, to include a self-release seat belt, on 10/23/14 that met resident care needs and ensured the residents safety during transport in the facility van. An investigation of the 10/03/14 incident involving Resident #1 was completed by the DON on 10/15/14. 4. The new "Outing Guidelines" process which included the "Pre-Trip Vehicle Safety Form" and copy of the CNA "care guide" for each resident, that were to be taken and followed on all outings, would also ensure residents' care plans were followed on the outing when the residents were on the van. All Department Managers received education/training on 10/22/14, regarding the new "Outing Guidelines" process provided by the SCC. 5. All residents were assessed by the DON, ADON, or Registered Nurse (RN) Supervisor on 10/22/14, for electric wheelchair usage, to determine if residents' safety needs were met, along with any care planned safety devices for safety needs during transport in the facility van, as outlined by residents' care plans. 6. All residents were assessed. Residents with a Brief Interview Mental Status (BIMS) score greater than eight (8), were interviewed beginning 10/22/14 and completed on 10/23/14, by the Administrator, DON, ADON, SSD, Registered Dietician (RD), Chaplain or Medical Records staff for any concerns. Residents with a BIMS score less than eight (8) were physically assessed by the DON, ADON, Unit Managers, or RN supervisor. The assessments, interviews and questionnaires were reviewed by the Administrator or Signature Care Consultant (SCC) on 10/23/14. 7. All personnel files were audited 10/22/14 by Human Resources staff, Chaplain or Nursing Supervisor for any concerns, with results given to the SCC on 10/23/14, for review. Additionally, all accident/incident reports from July to 10/22/14 were reviewed on 10/23/14 by the DON, ADON, SDC or SCC to identify any concerns and ensure incident reports and a thorough investigation was completed, with no concerns identified. 8. All residents' care plans and CNA care plans were reviewed and updated as needed to include residents' wheelchair safety devices, on 10/22/14 by the DON, ADON, Nursing Supervisor or Minimum Data Set (MDS) Nurses to ensure each resident's care plan and CNA care plan reflected the current care needs of the resident. 9. Facility environmental rounds were completed by the Housekeeping Director, Activity Director or Administrator on 10/22/14, to ensure the residents' environment was free of accidents and hazards. 10. On 10/22/14, the SCC educated the facility's management staff which included the Administrator, DON, ADON, RN Supervisors, MDS, Quality of Life (Activity) Director, HR staff, Environmental Services Director (ESD), SSD, Admissions Director, Medical Records and Chaplain on the facility's care plan policy, accident/incident policy and the revised "Outing Guidelines" process. These staff could not return to work until the education was provided, post-test administered and a score of one hundred percent was obtained. If they did not score one hundred percent on the post-test, the staff person was immediately re-educated and post-test re-administered. The process continued until all the above management staff obtained one hundred percent on the post-test. All post-tests were reviewed for compliance by the SCC. 11. The management staff which included, the Administrator, DON, ADON, RN Supervisor, MDS, Quality of Life (Activity) Director, HR staff, ESD, SSD, Admissions Director, Medical Records staff, or Chaplain, after completion of the education, re-educated all facility staff on the facility's care plan policy, accident/incident policy and the revised "Outing Guidelines" process starting on 10/22/14. By 10/24/14, one hundred and twenty-six (126) of the facility's one hundred and eighty-nine (189) staff had been re-educated. All employees who had not received the education were sent a certified letter on 10/27/14, providing notification to staff not to return to work until education was completed, with no staff allowed to work until education was provided. All staff provided the re-education completed an abuse post-test and a one-hundred percent score had to be obtained, or the staff were immediately re-educated and the post-test was re-administered. This process was to continue until staff obtained a score of one hundred percent on the post-test. This education was to be included during orientation for all newly hired staff who would not be allowed to work until the education was provided, the post-test administered and a score of one hundred percent obtained. The facility does not employ or utilize agency staffing. 12. A nurse from the facility's regional or corporate office was onsite beginning 10/22/14, and was to remain in the facility daily until the Immediate Jeopardy (IJ) was lifted. These nurses assisted with investigations, observed staff treatment of [REDACTED]. The facility's corporate Vice President (VP) of Operations, the Special Projects Administrator or the Director of Clinical Programs was to be in daily contact with the SCC and were to review allegations until the IJ was lifted. 13. Per the AOC, the DON, ADON, SDC or Nursing Supervisor would observe the care delivery for five (5) different residents on different units for a total of fifteen (15) residents for any concerns daily until removal of the IJ, then would perform the observations weekly for four (4) weeks. Results of the care delivery/observation audits were to be reported to the facility's Quality Assurance (QA) Committee weekly to determine the need for continued staff education or revision of plan. Concerns identified would be corrected immediately and reported to the Administrator to ensure investigations were completed and, if necessary reported as per the facility's guidelines. The Administrator, DON, or member of the facility's regional staff were to review all the resident care delivery audits daily to identify any concerns. Investigations of any concerns were to be initiated upon receipt of the concern starting on 10/23/14. The Administrator and one (1) of the following: VP of Operations; Special Projects Administrator; or SCC would review the investigations daily to ensure the above areas were covered. All the above was to continue until removal of the IJ. 14. The VP of Operations, SCC or Special Projects Administrator would provide administrative oversight of the facility daily until removal of the IJ beginning 10/22/14, after removal of the IJ administrative oversight by the above would continue weekly for four (4) weeks, then monthly. A QA meeting would be held weekly for four (4) weeks beginning 10/22/14, then monthly afterwards for recommendations and further follow up regarding the AOC. The QA Committee would determine at what frequency any ongoing audits would need to continue. The Administrator had the oversight to ensure an effective plan was in place to meet residents' well-being, as well as, an effective plan to identify facility concerns and implement a plan of correction to involve all staff of the facility. Corporate Administrative oversight of the QA Committee meeting would be completed by the Special Projects Administrator, Regional VP of Operations, or member of the regional staff daily until removal of the IJ beginning 10/22/14, then weekly for four (4) weeks, then monthly thereafter. The State Agency validated the implementation of the facility's AOC as follows: 1. Review of the facility's investigation report revealed: it was initiated 10/10/14 by the DON; Resident #1 was assessed by the ADON on 10/10/14, witness statements of staff and residents on the van had been obtained by the Administrator, DON, ADON and SSD; and per the Plant Operations Director (POD) written statement, the "wheelchair placement area" on the van with the "failed seat belt function" had been placed "out of service" as per the AOC. Interview with the SCC on 11/04/14 at 10:30 AM, revealed the van had not transported residents since the incident involving Resident #1 on 10/03/14, and he verified the facility's investigation completion as above. 2. Review of the statement signed by the Administrator, undated, revealed she contacted an officer with the KSP, who agreed to offer training regarding safety on the van. Continued review of the Administrator's written statement revealed the KSP officer provided the training on 10/24/14 at 10:30 AM. Review of the In-Service sign-in sheets, dated 10/24/14, revealed the officer provided instruction on "Outing Education and Safety" for twenty-four (24) facility staff who signed the in-service sheets. Observation on 11/05/14 at approximately 1:00 PM, revealed the Quality of Life (Activity) Director and the Chaplain performed a demonstration of what they had been trained on by the KSP officer. Interview on 11/05/14 with the Human Resources (HR) staff person at 11:07 AM, Activity Aide Assistant #1 at 1:56 PM, Activity Aide Assistant #2 at 2:08 PM and on 11/06/14 with the Activities Director at 12:19 PM and the DON at 12:47 PM revealed they had all received the training provided by the KSP officer on 10/24/14, completed return demonstration and had taken a post-test on which they had to score one hundred percent. Per the DON, any new staff designated to assist with outings would go through the same education, return demonstration and post-testing. 3. Review of the facility's, "Outing Guidelines Form", undated, revealed the facility had implemented the use of a the "Pre-Trip Vehicle Safety Form" which was to be completed by staff to double check the security of all residents and their wheelchairs when on the van. Continued review of the Form revealed a copy of residents' CNA care guides were to brought on each outing for every resident attending. The Form noted staff members were secure empty wheelchairs on the bus to ensure safety of residents. Interview on 11/05/14 with the HR staff person at 11:07 AM, Activity Assistant Aide #1 at 1:56 PM, Activity Assistant Aide #2 at 2:08 PM and on 11/06/14 with the Activities Director at 12:19 PM revealed they had all been educated on the new process for transportation of residents on outings. They all reported being educated on the updated "Pre-Trip Vehicle Safety Form" between 10/22/14 and 10/24/14. Interview on 11/06/14 at 12:47 PM with the DON revealed: she had also been educated on the updated "Pre-Trip Vehicle Safety Form"; Resident #1 was provided a wheelchair which had a self-releasing seat belt for outings; and she had completed a thorough investigation of the 10/03/14 incident involving Resident #1 on 10/15/14, which was sent to the State Survey Agency. Review of Resident #1's medical record revealed the resident was assessed by Occupational Therapy (OT) and was provided a transport wheelchair with a self-releasing seat belt on 10/23/14. Interview with the SCC on 11/06/14 at 1:58 PM, revealed revisions were made to the facility's, "Outings Guidelines" as per the AOC. He stated the "Outings Guidelines" process was a check off system for to ensure safety of residents on the facility's van. Continued interview revealed changes were made to the process to address vehicle safety and to ensure all residents were secure restrained in their seat belts, including residents in wheelchairs. He revealed the "Pre-Trip Vehicle Safety Form" was revised and the "Outings Guidelines" were revised to include the addition of bringing the residents' CNA care cards on outings. 4. Review of the facility's, "Outing Guidelines Form", undated, revealed the facility had implemented the use of a the "Pre-Trip Vehicle Safety Form" which was a check-off sheet to be completed by staff to double check the security of all residents and their wheelchairs when on the van, and noted a copy of each residents' CNA care guides was to brought on each outing for every resident attending. Review of the in-service titled, "Outing Guidelines" revealed the training was conducted by the SCC on 10/22/14. Interview on 11/05/14 with the Director of Housekeeping and Laundry at 2:27 PM and on 11/06/14 with the Activities Director at 11:19 AM and with the DON at 12:47 PM, revealed they had all been educated on the new "Outing Guidelines" process on 10/22/14. Interview with the SCC on 11/06/14 at 1:08 PM, revealed he provided the in-service training on 10/22/14 at 8:00 PM as per the AOC. The SCC revealed the in-service was completed with all of the department managers as per the AOC, who in turn provided the education to staff in their departments regarding the new "Outing Guidelines". 5. Review of the facility's "Census Board" Report dated 10/22/14, revealed residents were assessed for use of electric wheelchairs. Resident #1 and Resident #4 were determined to have the electric wheelchairs during the assessment. Interview on 11/05/14 with OT #1 at 11:43 AM and OT #2 at 1:47 PM revealed they assessed Resident #1 and Resident #4 and determined the residents needed special transport chairs for outings which the residents were provided with and their care plans updated to include this information. Review of Resident #1's and Resident #4's care plans revealed the care plans were updated to reflect the new transport chairs provided by OT. Interview with the SCC on 11/06/14 at 1:58 PM revealed the assessment of all resident's who had electric wheelchairs was performed as per the AOC on 10/22/14. He revealed Resident #1 and Resident #4 were assessed by OT to require special transport wheelchairs for outings. Per interview, Resident #1's transport wheelchair was equipped with a self-releasing seat belt as per the resident's care plan. 6. Review of the facility's interviews conducted with residents who had a BIMS score greater than eight (8) revealed the residents were asked to answer questions on a questionnaire regarding any concerns. Continued review of the resident interviews revealed the DON, ADON and SSD questioned the residents on 10/22/14. Review of the CNA Skin Care Alert for residents with a BIMS of less than eight (8) revealed physical assessments of those residents were completed by the DON, ADON, Unit Managers or RN Supervisor. Interview with the SCC on 11/06/14 at 1:58 PM, revealed resident interviews were conducted as per the AOC for residents with a BIMS of eight (8) or greater. The SCC revealed as per the AOC, residents with a BIMS of less than eight (8) were physically assessed for injury. Per interview, staff were also asked if they were aware of any concerns regarding residents. 7. Review of the facility's personnel file audits revealed all files were audited by the Chaplain, HR Director and LPN #5, Unit Manager, who signed and dated the completion of the review of the files on 10/23/14. The State Survey Agency reviewed five (5) personnel records with no concerns identified. Review of the facility's "Healthcare-Event" Incident/Accident Report audit sheet revealed it included review of all incidents from 07/22/14 through 10/22/14, with no concerns identified. Interview with the HR Director on 11/05/14 at 11:07 AM, revealed she, along with the Chaplain and LPN #5 reviewed all employee personnel files. Interview with the SCC on 11/06/14 at 1:08 PM, revealed all staffs' personnel files were checked as per the AOC with no concerns identified. Continued interview revealed the audits of the Incident/Accident forms were performed as per the AOC, with no concerns identified. Per interview, the audits would continued and the clinical team would address any issues. The SCC revealed the audits would also be performed on weekends and holidays. If any concerns were noted during the audits of the Incident/Accident Reports staff would notify the Administrator and DON. 8. Review of the facility's audits of residents' care plans and CNA Care Plans, which began on 10/22/14 with a completion date of 10/29/14, revealed all the residents' care plans and CNA Care Plans were reviewed and/or updated and revised as necessary to show the resident's current care needs. revisions in the comprehensive care plans, as well as, the Certified Nursing Assistance Care Plans. Interview, on 11/06/14 at 12:47 PM, with the DON revealed the ADON, Nursing Supervisor, MDS Nurse and herself had performed the care plan reviews and ensured the care plans reflected each resident's assessed needs. Interview with the SCC on 11/06/14 at 1:08 PM, revealed all residents' care plans and CNA Care Plans (care cards) were audited and reviewed by the DON, ADON, Nursing Supervisor or MDS Nurse to ensure they were correct according to the resident's assessed needs. He reported he along with the other Corporate Consultants looked over the completed care plans after the audit to ensure they were correct. 9. Review of the "Environmental Rounds" check sheet revealed the facility's department heads would be responsible for conducting the environmental rounds of the facility which began on 10/22/14. Review of the 10/22/14 "Environmental Rounds" check sheet revealed the rounds were completed by the Housekeeping Director, Activity Director or Administrator. Review of the "Environmental Rounds" schedule revealed department head managers were assigned to check the facility's environment for accident and safety hazards. Interview with the Director of Environmental Services, on 11/05/14 at 3:04 PM, revealed he had been assigned to conduct the "Environmental Rounds" checking for concerns related to safety of residents. We reported that if he noticed a concern while conducting the environmental tour, he would repair the problem himself. Interview with the Administrator on 11/06/14 at 3:35 PM, revealed the "Environmental Rounds" were completed by the Housekeeping Director, Activity Director or herself on 10/22/14 as per the AOC. She stated these continued to be performed by the facility's department head managers. 10. Review of the in-service sign-in sheets dated 10/22/14 revealed signatures for the Administrator, DON, ADON, RN Supervisor, MDS Nurse, Activity Director, HR Director, ESD, SSC, Admissions Director, Medical Records staff person and Chaplain. Continued review revealed the in-service was conducted by the SCC regarding the facility's care plan policies, incident/accident policy and the revised "Outing Guidelines" process. Review of the POS [REDACTED]. Interview on 11/05/14 with the HR Director at 11:07 AM, the Director of Environmental Services at 3:04 PM and on 11/06/14 with the Activity Director at 12:20 PM, with the DON at 12:47 PM, with the SSD at approximately 1:15 PM, with the SDC at 1:35 PM, with the Administrator at 3:35 PM, revealed they were all in-serviced by the SCC on 10/22/14, regarding the facility's care plan policy, revised "Outing Guidelines" process and accident/incident policy prior to returning to work that day. They reported having to receive a score of one hundred percent on the post-test. 11. Review of the in-service sign-in sheets and documentation revealed all the in-services began on 10/22/14 and were completed by 11/03/14. Review of the certified mail receipts, dated for 10/27/14, revealed letters were mailed to staff who were not scheduled to work during the in-services. Review of staffs' post-tests revealed scores of one-hundred percent. Interview on 11/05/14 with the HR Director at 11:07 AM, the Director of Environmental Services at 3:04 PM and on 11/06/14 with the Activity Director at 12:20 PM, with the DON at 12:47 PM, with the SSD at approximately 1:15 PM, with the SDC at 1:35 PM, with the Administrator at 3:35 PM, revealed they all had assisted with in-servicing staff after their training on 10/22/14, regarding the facility's care plan policy, accident/incident policy and revised "Outings Guidelines" process. They stated post-tests were administered to all the staff after the in-service training with staff having to score one hundred percent or be re-educated until the score was obtained. Per interview, no staff person was allowed to work until they had received the in-service and scored one hundred percent on the post-test. Interview on 11/05/14 with Certified Nursing Assistant (CNA) #1 at 10:45 AM, with CNA #2 at 11:26 AM, with Activity Aide Assistant #1 at 1:56 PM, with Activity Aide Assistant #2 at 2:08 PM and the Director of Housekeeping and Laundry at 2:27 PM, and on 11/06/14 with CNA #3 at 8:57 AM, with CNA #4 at 9:17 AM, with CNA #5 at 9:30 AM, with the Activities Director at 11:19 AM, with CNA #7 at 12:10 PM, revealed they all reported having been in-serviced on the care plan policy, accidents/incidents policy and the revised "Outing Guidelines" process. They stated they had not been allowed to work until they h

Based on observation, interview, record review and review of the facility's policy it was determined the facility's Administration failed to ensure the facility was administered in a manner which enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychological well-being of each resident. The Administrator failed to ensure the facility had an effective Quality Assessment and Assurance Program that developed and implemented appropriate plans of action to correct quality deficiencies. This was evidenced by repeat deficiencies related to the facility's failure to ensure the physician was notified with a significant change in residents' physical condition physical status and failure to fully assess and monitor residents' physical change in condition. This failure resulted in repeat noncompliance at 42 CFR 483.10 Resident Rights F-157 and 42 CFR 483.25 Quality of Care F-309. In addition, the Administration failed to have an effective system to ensure the Comprehensive Plans of Care were revised to include effective interventions in regards to assessing and monitoring of residents who experienced a change in condition. (Refer to F-280) On 11/05/12 Resident #37 was noted to have swelling/puffiness and redness to the left hip and pain with movement. There was no documented evidence the Physician was notified of this change in condition or that the plan of care was revised to ensure further assessment and monitoring. Interviews with facility staff revealed, on 11/07/12, the resident had a bruise-like discolored area to the inner left thigh however, failed to communicate this change to a nurse. On the morning of 11/08/12, a Hospice Nurse and Aide both noted Resident #37 had bruising from the left hip to the pubic area, however, review of facility documentation revealed no assessment or monitoring of the resident's change in condition by facility staff until 11/08/12 at 9:00 PM when Resident #37 was noted to have pain/discomfort to the left leg/hip, the left foot was noted to be turned inward and appeared shorter then the right leg and there was discoloration to the outer left hip, back of left leg, front of labia, and inside the left leg. The facility's administration failed to ensure that on 11/05/12 and 11/08/12 when facility staff noted changes of condition to Resident #37's left leg/hip that the resident's Physician was notified. The Physician was not notified until 11/09/12, when an x-ray revealed the resident had a left [MEDICAL CONDITION]. Based on the above findings it was determined the facility's failure to have an effective system in place to ensure the facility was administered in a manner that enabled it to use its resources effectively and efficiently was likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy (IJ) was identified on 12/05/12 and determined to exist on 11/05/12. An acceptable credible Allegation of Compliance (AOC), related to the Immediate Jeopardy, was received on 12/11/12. On 12/14/12, the State Agency verified the Immediate Jeopardy was removed on 12/11/12 as alleged, prior to exit, with remaining non-compliance at 42 CFR 483.75 Administration, F-490 at a Scope and Severity (S/S) of a "D" while the facility develops and implements the Plan of Correction (POC) and the facility's Quality Assurance monitors the effectiveness of the systemic changes. The findings include: (Refer to F-157) The facility failed to ensure the physician was notified of a significant change in a residents physical status. This was a repeat deficiency which was cited during a Standard Survey conducted 10/03/12 for deficiencies related to failure to notify the physician when a resident was noted to have a nodule in the vaginal area. During this survey, it was identified the facility failed to notify the physician changes of condition to Resident #37's left leg/hip beginning 11/05/12 through 11/08/12, until 11/09/12 when an x-ray revealed the resident had a left [MEDICAL CONDITION]. (Refer to F-280) The facility failed to ensure comprehensive plans of care were reviewed and revised when a change in condition was noted for Residents #37 and #41. The facility failed to update the care plan for Resident #37 after the resident was assessed on 11/05/12 for having pain and puffiness in the left hip area for interventions to include continued monitoring and assessment of the area to prevent further pain and ensure the resident received the appropriate care and services. Three days later, on 11/08/12, Resident #37 was assessed by the nurse with pain/discomfort in the left hip/leg area and discoloration to the left hip, back of the left leg, front of the labia, and inside of the left leg, and the left foot was turned inward and the left leg was noted being shorter than the right leg. Review of the Comprehensive Care Plan revealed no documented evidence the care plan was revised related to the resident's change in condition other than an order to administer 400 milligrams [MEDICATION NAME] every six hours as needed. On the morning of 11/09/12 Resident #37 was noted to have bruising which was dark purple to the resident's left hip, groin, and "private" area and the resident cried out in pain. The APRN was contacted and an order obtained for an x-ray which revealed Resident #37 had a left [MEDICAL CONDITION]. In addition, the facility failed to revise Resident #41's care plan after the resident was readmitted to the facility and had oxygen in use. Also, the facility failed to revise Resident #2's care plan when he/she was placed in contact precautions after being diagnosed with [REDACTED]. (Refer to F-309) The facility failed to ensure each resident received the necessary care and services to attain or maintain the highest practicable physical well-being for two (2) of forty-one (41) sampled residents (Residents #37 and #41) as evidenced by Resident #37 had a left [MEDICAL CONDITION] of unknown origin and Resident #41's use of oxygen upon re-admission from the hospital. This was a repeat deficiency for the facility which was cited during a Standard Survey conducted 10/03/12 for deficiencies related to failure to assess and monitor a resident after a nodule in the vaginal area was identified. Interview, on 12/14/12 at 3:00 PM, with the Administrator revealed the facility had been conducting audits of three skin assessments per unit per week to validate accuracy of skin assessments and documentation of these skin assessments to include appropriate physician and family notification. Further interview revealed these audits were turned into her, she reviewed them and problems had been identified and changes had been made since the compliance date of 10/30/12 from the survey ending 10/03/12. She stated the changes she had implemented included contracting with a consulting group on 11/20/12, to come to the facility two (2) days per week to help with problem solving. Continued interview revealed she implemented another new process in which she conducted walking rounds and had monitors go to each unit for thirty minutes. Further interview revealed these walking rounds would be used as teachable moments. According to the Administrator, she lead the PIC and it was continuously reviewing the problems identified. The administrator indicated the nurse on 11/05/12 did not follow the process for the MD notification and documentation she had been educated on as far as putting her assessment on the alert charting, 24 hour report, and notifying the Physician. She indicated when the nurse's findings were not on the 24 Hour Report, no one was aware to monitor the site. The facility provided an acceptable credible Allegation of Compliance (AOC) on 12/11/12 that alleged removal of the IJ effective 12/11/12. Review of the AOC revealed the facility implemented the following: 1) Head-to-toe skin assessments were performed on all residents from 12/05/12 through 12/06/12 by licensed nurses to identify any others with indication of any change of condition/puffiness, swelling or redness. Any notable findings were communicated to the attending Physician and responsible party. Notable findings included, but were not limited to, Pressure Ulcers, Arterial Ulcers, Diabetic Neuropathic Ulcers, [MEDICAL CONDITION] Ulcers, Surgical Wounds, Skin Tears, Lacerations, Abrasions, Bruises, Burns, Rashes, or a Lesion associated with bleeding, itching, burning, puffiness or swelling, discoloration and/or raised skin areas. The findings were documented by the licensed nurse, and communicated to the Physician and family for further follow-up. The licensed nurse was responsible to document findings in the residents' medical record and the 24 hour report. 2) On 12/05/12 and 12/06/12 facility licensed nurses conducted an audit that reviewed all current residents' progress notes and the 24 hour reports for the previous thirty (30) days (11/05/12 to current) to validate changes in resident condition were identified and addressed with the Physician and responsible party notification. This audit also included validating any changes in resident condition including updating the care plan. 3) The Administrator (Executive Director) communicated the change in the process for Physician notification by the facility to Hospice on 11/30/12 and again on 12/03/12. 4) Physician orders, condition change forms, alert charting lists, stop and watch forms, and 24 hour sift reports would be audited daily starting on 12/06/12 and ongoing by the Director of Nursing Services (DNS), Assistant Director of Nursing Services (ADNS), or Quality Assurance (QA) Registered Nurse (RN), Monday through Friday; and by the Weekend Supervisor RN on Saturdays and Sundays for any residents with a change in condition to validate appropriate identification of changes in resident condition, notification of the Physician and responsible party, and care plan revision. 5) Shift to shift report was observed daily on each unit beginning 12/10/12 and ongoing by the DNS, ADNS, QA Nurse, Unit Managers (UM), three (3) to eleven (11) Supervisor, Weekend Supervisor, RN Case Manager, District Clinical RN Consultant to validate proper use of the 24 hour report and follow-up to resident change in condition. 6) The Guidelines for Physician Notification of Change of Condition/Clinical Problems in Center Residents was placed on the Treatment Administration Record (TAR) on all units 12/06/12 for quick reference for the nurses. 7) On 12/04/12 the Staff Development Coordinator (SDC) initiated education with all facility licensed nursing staff related to change in condition of resident status. Inservice dates were 12/04/12, 12/05/12, 12/06/12 and ongoing until all facility clinical staff had received the education. Education was provided by the SDC, ADNS', three (3) to eleven (11) RN Supervisor, Weekend RN, DNS, or QA RN. No nursing staff would be allowed to work until they had received the education. The inservices included: Situation Background Assessment Recommendation/Request (SBAR) form, 24 hour report form, alert charting system, notification of the Physician and responsible party, assessing for a possible [MEDICAL CONDITION], State Registered Nursing Staff (SRNA) utilizing the Stop and Watch forms, Licensed Nurse notification to Hospice for recommendations for a resident with a change in condition, then notify Physician of the change in condition and notify family. 8) A Performance Improvement Committee (PIC) meeting was held on 12/05/12 and again on 12/06/12. The Medical Director was notified of the Immediate Jeopardy via telephone and approved the plan developed by the PIC on 12/05/12. The PIC reviewed and approved the Allegation of Compliance (AOC). The PIC was to ensure validation of the AOC by: beginning 12/06/12, initial and daily audits of the Physician orders, condition change forms, alert charting lists, Stop and Watch forms, and shift to shift observations were being reviewed by the DNS, ADNS', QA RN, and/or Weekend Supervisor RN on Saturday and Sunday to identify issues, trends or patterns and take corrective action as necessary. The QA RN would be responsible to report trends from the audits to the weekly PIC committee for review and further recommendations. The PIC would create corrective action plans for any areas of concern identified on the audits. The PIC committee would meet weekly or more often as necessary until the facility had removed the Immediate Jeopardy. Once the Immediate Jeopardy was removed the facility would return to routine monthly PIC committee meetings. 9) The District and/or Regional team would provide RN clinical oversight a minimum of three (3) days per week beginning the week of 12/02/12. 10) The facility contracted an outside clinical consulting group on 11/20/12 to conduct onsite facility clinical oversight two (2) days per week beginning 12/02/12. The State Survey Agency validated the implementation of the facility's AOC as follows: Review of the skin assessment forms revealed all facility residents had skin assessments performed from 12/05/12 through 12/06/12 by licensed nurses, except three (3) who refused and one (1) that was end of life. Audit review revealed newly identified areas were reported to the physician and responsible party. Record review revealed the facility performed the audits as identified on the facility's AOC: An audit of resident progress notes and the 24 hour reports for the last 30 days was performed on 12/05/12 - 12/06/12. Daily audits of Physician orders, condition change forms, alert charting lists, stop and watch forms, and 24 hour shift reports started on 12/06/12. Problems identified were given to the Unit Managers for follow-up. The Shift to Shift audits were initiated by the facility on 12/10/12. Observation of the Treatment Administration Record (TAR) on each unit revealed they had Guidelines for Physician Notification of Change of Condition/Clinical Problems in the front. Interview, on 12/13/12 at 11:05 AM, with the Staff Development Coordinator (SDC) revealed she had completed education with facility staff related to the SBAR form, 24 hour report form, alert charting system, notification of the Physician and responsible party, assessing for a possible [MEDICAL CONDITION], State Registered Nursing Staff (SRNA) utilizing the Stop and Watch forms, Licensed Nurse notification to Hospice for recommendations for a resident with a change in condition, then notify Physician of the change in condition and notify family. Interview, on 12/13/12 at 11:00 AM, with the Executive Director (ED), Vice President of Clinical Operations, Director of District Operations, Director of Nursing Services (DNS), Quality Assurance (QA) RN, and contracted Nurse Consultant revealed the District and/or Regional team would provide RN clinical oversight a minimum of three (3) days per week beginning the week of 12/02/12. In addition, the facility had contracted with an outside clinical consulting group on to conduct onsite facility clinical oversight two (2) days per week. Interviews with licensed nursing staff on 12/12/12 at 11:50 AM with Licensed Practical Nurse (LPN) #40, at 3:00 PM with Registered Nurse (RN) #11, at 3:15 PM with LPN #13; on 12/14/12 (7:00 AM to 3:00 PM shift) at 9:50 AM with LPN #3, at 2:00 PM with LPN #9, at 2:17 PM with LPN #16, at 2:45 PM with LPN #32, at 2:53 PM with LPN #15; on 12/14/12 (3:00 PM to 11:00 PM shift) at 5:35 PM with LPN #2, at 6:00 PM with LPN #31; and, on 12/14/12 (11:00 PM to 7:00 AM shift) at 3:42 PM with LPN #19 and at 4:32 PM with LPN #38 revealed they were all aware the "Guidelines for Physician Notification of Change of Condition/Clinical Problems in Center Residents" was on the Treatment Administration Record (TAR); they had received education on the Situation Background Assessment Recommendation/Request (SBAR) form; the 24 hour report form; the alert charting system; notification of the Physician and responsible party; assessing residents for a possible [MEDICAL CONDITION]; the State Registered Nursing Staff (SRNA) utilizing the Stop and Watch forms; and after notification to Hospice for recommendations for a resident with a change in condition, that they were to then notify the Physician of the change in condition and obtain orders, then notify the family. All licensed nurses interviewed confirmed that the shift to shift reports were being audited by Unit Managers, Assistant Director of Nursing Services (ADNS), 3:00 PM to 11:00 PM Supervisor, Quality Assurance Registered Nurse, and Weekend Supervisor. Interview, on 12/12/12 at 10:05 AM with State Registered Nursing Assistants (SRNAs) #8 and #9; on 12/14/12 at 9:15 AM with SRNA #37, at 9:15 AM with SRNA #38, at 2:33 PM with SRNA #27, at 3:00 PM with SRNA #32, at 3:40 PM with SRNA #39, at 4:00 PM with SRNA #13, at 4:19 PM with SRNA #34, at 4:28 PM with SRNA #35, at 5:15 PM with SRNAs #33 and #36 revealed they had all received education on the Stop and Watch form for communicating changes in residents' condition to the nurses. Interview, on 12/14/12 at 9:25 AM with LPN #39 and at 9:30 AM with LPN #16 revealed the SRNAs had received training on the Stop and Watch form. Interview, on 12/11/12 at 12:20 PM, with the Director of Nursing Services (DNS) revealed education had been performed with facility staff in regards to the "skin sheet", Stop and Watch form, 24 hour report form, and proper notification of the Physician and family. She stated nurses had been re-educated to confer with Hospice, however they were to notify the Physician and responsible party. In an additional interview, on 12/14/12 at 5:00 PM, with the DNS revealed in the facility's daily clinical review they were monitoring: the notification of change to the Physician and family, care plan updates, 24 hour report forms, alert charting forms, condition change forms, and Stop and Watch forms. She stated any concerns are followed up on by the Unit Managers (UM). The DNS stated she ensures the UMs complete the follow up via another meeting at the end of the day. According to the DNS, shift reports were being audited every day. She stated the audits were to ensure nurses were utilizing the 24 hour report form, alert charting, and any Stop and Watch forms to ensure the following shift was updated on residents' condition changes. Interview, on 12/14/12 at 11:40 AM, with RN #10/Assistant Director of Nursing Services (ADNS) for A and B units, revealed she audited progress notes, SBAR forms, Physician orders, condition change forms, alert charting lists, stop and watch forms, and 24 hour shift reports for the past thirty (30) days, and also ensured the care plan was updated. In an additional interview with RN #10/ADNS at 5:20 PM revealed she had monitored the shift to shift reports to ensure nurses were utilizing the 24 hour report form, the alert charting form, and any Stop and Watch forms to ensure the oncoming shift was aware of any changes in residents' condition. Interview, on 12/14/12 at 2:00 PM, with RN #2/ADNS (for C and D units) revealed he had performed audits of progress notes, SBAR forms, Physician orders, condition change forms, alert charting lists, stop and watch forms, and 24 hour shift reports for the past thirty (30) days. Interview, on 12/14/12 at 6:15 PM with the Weekend Supervisor RN revealed he had audited shift to shift reports to ensure the 24 hour report form, the alert charting and any Stop and Watch forms were being utilized to pass on residents' condition changes to the oncoming shift. He stated he had performed audits of the Physician orders, SBAR forms, condition change forms, alert charting lists, stop and watch forms, and 24 hour shift reports. Interview, on 12/14/12 at 6:10 PM, with the Medical Director revealed she had been notified of the Immediate Jeopardy by telephone and had approved the Allegation of Compliance (AOC) after discussion with the facility. She stated the Performance Improvement Committee (PIC) had been meeting weekly since the Immediate Jeopardy was identified and she was involved with these meetings. Interview, on 12/14/12 at 7:15 PM, with the ED and Quality Assurance (QA) RN revealed the Executive Director communicated the change in the process for Physician notification by the facility to Hospice. She stated Hospice had been educated that the facility's nurses would contact the Physician. The QA RN verified that audits were being performed as per the AOC, such as shift to shift report audits to ensure the 24 hour report form and alert charting information was being utilized. The QA RN indicated if audits were performed at shift change then the 24 hour report, alert charting, SBAR forms, and Stop and Watch forms were being audited to ensure a change in a resident's condition is being passed along. According to the QA RN, the results of all the audits on the 24 hour report form, SBAR form, alert charting form, condition change form, care plan updates, Physician orders, Physician and family notification, and Stop and Watch forms were taken to the morning clinical meeting and discussed. The QA RN stated if a problem was identified then staff were educated by the person doing the audit. The QA RN stated he reported the results of the audits and any trends to the weekly PIC meeting. The ED stated education was performed as per the AOC. She stated through the use of the new three (3) part SBAR form and Stop and Watch form that communication was now "shored" up. She stated staff had been educated to ensure a Stop and Watch form was filled out with any change in a resident's condition. An additional interview, on 12/14/12 at 8:00 PM, with the ED revealed the PIC had been meeting weekly. According to the ED, the PIC was performing what was indicated in the AOC (i.e.-validating the AOC by: reviewing initial and daily audits of the Physician orders, condition change forms, alert charting lists, Stop and Watch forms; and shift to shift observations were being reviewed to identify issues, trends or patterns and to take the corrective action as necessary). Corrective action plans for any areas of concern identified on the audits would be implemented.

Based on observation interview, record review, and review of the facility's policy, it was determined the facility failed to have an effective system to ensure each resident received the necessary care and services to attain or maintain the highest practicable physical well-being for one (1) of nineteen (19) sampled residents (Residents #37). Facility staff noted changes of condition to Resident #37's left leg/hip on both 11/05/12, 11/07/12, and 11/08/12. On 11/05/12 Resident #37 had swelling/puffiness, redness to the left hip and pain with movement; however, the facility's nurse failed to communicate the identified change in Resident #37 condition on the facility's 24 hour report to alert other staff. Interviews with facility staff revealed, on 11/07/12, the resident had a bruise like discolored area to the inner left thigh; however, staff failed to communicate this change with the nurse. On the morning of 11/08/12, a Hospice Nurse and Aide both noted Resident #37 had bruising from the left hip to the pubic area, but documentation revealed no assessment was completed by facility staff until 11/08/12 at 9:00 PM. At that time, it was documented Resident #37 had pain/discomfort to the left leg/hip, the left foot was turned inward and appeared shorter than the right leg and there was discoloration to the outer left hip, back of left leg, front of labia, inside left leg. Further review of the documentation revealed the facility's nurse failed to document the findings on the facility's skin assessment sheet per the facility's process. Resident #37's Physician was not contacted until 11/09/12. An x-ray was ordered which revealed the resident had a fractured left hip. The facility's failure to ensure each resident received the necessary care and services related to assessing and identifying changes in residents' condition was likely to cause risk for serious injury, harm, or impairment or death. The Immediate Jeopardy was identified on 12/05/12, and determined to exist on 11/05/12. The facility was notified of the Immediate Jeopardy on 12/05/12. The facility provided an acceptable credible Allegation of Compliance (AOC) on 12/11/12 with the facility alleging removal of the Immediate Jeopardy on 12/11/12. The Immediate Jeopardy was verified to be removed on 12/11/12, prior to exiting the facility on 12/14/12, with remaining non-compliance at 42 CFR 483.25, Quality of Care, F-309 Necessary Care and Services, with a Scope and Severity of "D", while the facility develops and implements a Plan of Correction, and the facility's Quality Assurance continues to monitor to ensure assessments and recognition of changes in residents' conditions. The findings include: Review of the facility's policy titled, "Condition Change of a Resident", revised 10/31/06, revealed the rationale was "resident change of condition is identified for proper treatment implementation". Review revealed the Physician was to be notified during office hours and generally no later than the next regular office day. Further review of the policy revealed licensed nurses were to monitor and reassess the resident's condition and update the care plan. Interview, on 12/04/12 at 2:05 PM, with the Director of Nursing Services (DNS) revealed the twenty-four (24) hour report was a communication tool for shift to shift reporting. She stated anyone could write on the report. According to the DNS, if there was a change of condition in a resident, it would be appropriate to put this information on the 24 hour report to alert staff to assess. Additional interview, on 12/11/12 at 12:20 PM, with the DNS revealed the facility also utilized a Stop and Watch form as a communication tool to report changes in residents. She stated the whole point of this form was to get ahead of an increased change in condition. The DNS indicated anyone could complete the form and the completed form was to be given to the nurse. Review of Resident #37's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a Significant Change Minimum Data Set (MDS) Assessment, dated 09/25/12, revealed the facility assessed the resident as being severely cognitively impaired and required limited to extensive assistance with all Activities of Daily Living (ADLs). Interview, on 12/06/12 at 2:10 PM, with State Registered Nursing Assistant (SRNA) #19 revealed on 11/03/12 she observed Resident #37 sitting on the floor in the hallway and then pulling himself/herself off the floor using the rail and then the resident walked to his/her room. SRNA #19 stated she did not complete the Stop and Watch form related to this observation because she would only complete this form if she noticed a major change in the resident. In addition, she stated she did not document the episode on the 24 hour report; however, she stated she should have. Interview, on 11/28/12 at 5:10 PM, with SRNA #20 revealed on 11/05/12 she worked the 3:00 PM to 11:00 PM shift. She stated she went into Resident #37's room with SRNA #23 and was repositioning Resident #37 in bed when the resident started "hollering" when they moved his/her legs up. She indicated she undid the resident's brief and noticed the left hip was red, swollen and looked like it was inflamed. She indicated the resident did not complain of pain unless moved. According to SRNA #20, she was not aware of any falls and she told the nurse about what she had observed regarding the resident's hip area. Further interview, on 12/10/12 at 3:30 PM, revealed it would have been appropriate to have completed the Stop and Watch Form related to the change of condition; however, she stated she told the nurse instead of completing the form. Interview, on 11/29/12 at 8:00 PM, with SRNA #23 revealed on 11/05/12 she went into Resident #37's room and the resident moaned loudly when his/her leg was moved but was not sure which leg. SRNA #23 indicated when the resident was changed at other times during her shift the resident would complain of pain. SRNA #23 stated she did not put this information on the 24 hour report form because they had told the nurse. Interview, on 12/03/12 at 5:10 PM, with SRNA #31 revealed she worked 11/05/12 on the 3:00 PM to 11:00 PM shift and was called into Resident #37's room by SRNA #20 to observe the resident. She stated when the resident's leg was raised he/she yelled out, which was unusual for the resident. She indicated she did not put this information on the 24 hour report. SRNA #31 stated this change should have been put on the 24 hour report. Record review of the Nurse's Progress Note, dated 11/05/12 at 9:00 PM, revealed the resident complained of pain to the left hip/leg and the resident's left hip area was puffy, had no redness, no discoloration and his/her lower extremities were equal in length. Review revealed the nurse called the Hospice Nurse. Interview, on 11/29/12 at 8:30 PM, with LPN #26 revealed on 11/05/12 the SRNA's came and told her the resident was complaining of pain. She stated when she assessed the resident pain was noted in both legs but more in the left leg and when the leg was moved the resident moaned. LPN #26 stated she gave the resident Tylenol and was not aware of any more complaints of pain. According to the LPN, she went back and checked the site at 10:00 PM and there was no change. LPN #26 stated she did not put her assessment findings on the 24 hour report, but "probably" should have. Further interview, on 12/05/12 at 2:30 AM, revealed the resident was in Hospice so she did not notify the Physician, because she had been instructed to call Hospice and notify them of any changes. The LPN stated she should have noted her assessment findings on the 24 hour report which was used to ensure follow-up of changes in condition. Further review revealed no documented evidence of the facility nurse's assessment of Resident #37's left hip area. Review of the facility's 24 Hour Report revealed no documented evidence related to Resident #37's change of condition on 11/05/12. Interview, on 11/30/12 at 3:30 PM, with the Unit Manager (UM), on the unit where the resident resided, revealed on 11/05/12 the LPN should have put the change of condition to Resident #37's left hip area on the 24 hour report. She stated without the information on the 24 hour report there would not have been a reason to assess the resident. Review of the Hospice On Call Nursing Record, dated 11/05/12 and timed 7:52 PM, revealed a phone call was received from the facility's nurse to report Resident #37's calf was hurting, but was not warm, red, or [MEDICAL CONDITION]. Review further revealed the facility's nurse also reported the resident was very active over the weekend and thought he/she was just sore. Interview, on 11/30/12 at 12:15 PM, with Hospice Nurse #3 revealed the facility nurse called on 11/05/12 and reported the resident's left calf was hurting and did not indicate any other problems. According to the Hospice Nurse, if she had been told the left hip was swollen she would have made a visit to assess the site to determine if further treatment was needed, such as, requesting an x-ray. Interview, on 12/05/12 at 10:23 AM, with the APRN related to the resident's change of condition on 11/05/12 revealed she would want to be notified if there was puffiness/swelling to the left hip. Interview, on 11/29/12 at 3:15 PM, with LPN #9 revealed she worked the morning of 11/06/12 and did not get a report of any change of condition to Resident #37. She stated, after reviewing the 11/05/12 Progress Note by LPN #26, the information should have been put on the 24 hour report. LPN #9 indicated the 24 hour report was used to communicate findings to all shifts. She stated if she had been made aware of a change of condition to the resident's left hip she would have assessed Resident #37's left hip area. Record review of the Nurse's Progress Notes for 11/06/12 revealed no documented evidence of any nursing assessment of the resident's left hip area. Interview, on 11/29/12 at 2:15 PM, with SRNA #27 revealed on the morning of 11/07/12, when they were getting the resident up for a shower the resident "hollered" and she noticed a small bruise on the resident's inner left thigh. SRNA #27 stated she told the nurse of the pain on the resident's left side, but when the nurse asked Resident #37 he/she denied pain. Interview, on 11/29/12 at 2:45 PM, with SRNA #26 revealed on the morning of 11/07/12, when they were transferring the resident for a shower he/she seemed to be in pain. She stated she noticed the resident had a small discolored area on the inner left thigh. According to the SRNA, the nurse and the Unit Manager came in to assess the resident. Interview, on 11/29/12 at 3:15 PM, with LPN #9 revealed on the morning of 11/07/12 she and the Unit Manager assessed Resident #37's left thigh. She indicated the left thigh had a small area of faint purple discoloration, it did not appear to be a bruise. LPN #9 stated it looked like spider veins. The LPN stated the resident denied pain and there was no swelling to the area. She stated she did not document this assessment anywhere and was unaware of any prior discoloration to the area. Interview, on 11/30/12 at 3:30 PM, with the Unit Manager (UM) revealed she observed Resident #37 with LPN #9 on 11/07/12 and assessed the upper left thigh area. She stated the resident's inner left thigh discoloration appeared to be like a Varicose Vein that was thin and elongated. The UM stated she was not aware of the area before this assessment. She indicated the resident had no complaints of pain and she had no concerns about the area at that time. Review of the Nurse's Progress Notes, dated 11/07/12, revealed no documented evidence related to the discolored area to the resident's inner left thigh observed by the SRNAs, LPN #9, and the UM. Interview, on 11/30/12 at 5:05 PM and on 12/04/12 at 10:20 AM, with SRNA #20 revealed during the 3:00 PM to 7:00 PM shift on 11/07/12, she and SRNA #29 changed the resident at the beginning of the shift, and noticed bruising to the inner part of the thigh and vaginal area. The SRNA stated the area was green/purple in color and she estimated the area to be approximately six (6) inches in length and a couple of inches wide. She stated Resident #37 would "holler" when they repositioned him/her during the shift. SRNA #20 stated since the bruising was already there she assumed it had been reported to the nurse as she was told, in report by SRNA #26 and SRNA #27, it was found on day shift and had been reported to the nurse. Interview, on 11/30/12 at 5:40 PM, with SRNA #29 revealed she worked the evening of 11/07/12 with SRNA #20 and when they changed Resident #37, the resident was in pain when moved and Resident #37 grabbed at his/her hip. She indicated she observed discoloration to the resident's left inner thigh, dark enough that it stood out. She stated it looked like something that could have resulted from an injury. She stated she reported to the nurse that Resident #37 was in a lot of pain; however, was not sure if she told the nurse about the discoloration. Review of the facility's 24 Hour Report for 11/07/12 revealed no documented evidence of the pain or bruising to the resident's left inner thigh area observed by the SRNAs. Interview, on 12/04/12 at 4:00 AM, with SRNA #30 revealed she worked the 11:00 PM to 7:00 AM on 11/07/12 and 11/08/12. SRNA #30 stated on 11/07/12, Resident #37 seemed to be in more pain in the leg/hip and moaned more then usual. She stated she could tell something was unusual with the resident. SRNA #30 stated she reported this information to LPN #26. Interview, on 12/01/12 at 5:44 PM, with LPN #26 revealed she worked on 11/07/12 from 3:00 PM until 7:00 AM. She stated she did not observe the resident's hip area during her shift; however, had moved Resident #37's leg. LPN #26 stated the resident did not complain of pain and she did not recall the SRNAs reporting Resident #37 had any bruising or pain during the shift. Review of the Nurse's Progress Notes for 11/07/12 revealed no documented evidence of an assessment of the resident's left hip area for pain or discoloration. Review of the Hospice Certified Nursing Assistant (CNA) Visit Record, dated 11/08/12, revealed Hospice CNA #2 had visited the resident on from 8:30 AM to 9:30 AM. Review of the Visit Record revealed the CNA had reported to the Hospice Nurse that during Resident #37's bath she found bruising on the resident's vaginal area and on the inside of his/her thighs. Interview, on 11/30/12 at 1:50 PM, with Hospice CNA #2 revealed she had visited Resident #37 the morning of 11/08/12, to give him/her the regularly scheduled bath. She stated during the bath she noticed bruising all over the vaginal area and down the inside of the resident's thighs. According to the CNA, it was worse on the left side. She stated when she tried to turn the resident, he/she "moaned and groaned". The Hospice CNA indicated from her experience, the resident could have had a broken hip. She stated she reported her observations to Hospice Nurse #2 who came and looked at the area. Interview, on 12/06/12 at 11:15 AM, with Hospice Nurse #2 revealed she was called into Resident #37's room on the morning of 11/08/12, by the Hospice CNA. She stated she remembered seeing the bruise on the resident's left hip and pubic area. According to the Hospice Nurse, the resident did seem to have pain when moved. Hospice Nurse #2 did not recall moving the leg to assess. She stated she did not measure the area. She indicated she did talk to someone at the facility to see if the resident had fallen; however, she could not recall who she had spoken to. Interview, on 12/03/12 at 3:10 PM, with SRNA #26 revealed when she did a check and change on Resident #37, on 11/08/12 on day shift, she noticed the discolored area, she had observed on 11/07/12, looked larger and darker. She stated the area was more purplish and had doubled in size, from about a nickel to about the size of a silver dollar and the resident seemed to be in pain whenever moved. She stated another aide (SRNA #28) reported to the observations to the nurse. Interview, on 12/02/12 at 12:45 PM, with SRNA #28 revealed, when working with SRNA #26 on 11/08/12 on the day shift, she noticed the resident had bruising to the inside thigh area of her left leg near the groin. SRNA #28 stated she reported the finding to the nurse, whom she thought might have have been LPN #9. Interview, on 11/29/12 at 3:15 PM, with LPN #9 revealed she worked on 11/08/12 on the day shift and did not assess the resident's left hip site during her shift. She stated no one reported the discoloration to the left thigh area had changed or that the resident was having any pain problems and if the SRNAs had thought there had been a change or the resident was having pain it should have been reported to her so she could have assessed the area. Review of Resident #37's Progress Notes, dated 11/08/12 revealed no documented evidence of an assessment of the resident's left hip until 9:00 PM that night. Interview, on 11/29/12 at 2:00 PM, with SRNA #19 revealed she worked evening shift on 11/08/12, and Resident #37 yelled when she was turning the resident over. She stated she and another SRNA put the resident on his/her back and went to get LPN #35. Interview, on 11/30/12 at 3:05 PM, with LPN #35 revealed she assessed the resident's left hip area on 11/08/12 and noted there was bruising to the vaginal area and left side. She stated she did not complete a skin assessment related to her findings, however this was done the next day by another nurse. She indicated she assessed the area because of a report of pain to the resident's left side. She stated she contacted Hospice and let them know about the pain a bruising, however did not notify the Physician. Further interview, on 12/06/12 at 2:30 PM, revealed she had assessed one leg being shorter than the other during her assessment on 11/08/12. She indicated calling the Physician was a judgement call and she was told in training if the resident had Hospice staff were supposed to call Hospice. She stated in Hospice had not called back she would have called the Physician to report her assessment findings. According to the LPN, if the Physician was contacted by Hospice she did not think she would had to notify the Physician also. Interview, on 12/05/12 at 10:23 AM, with the APRN revealed she would expect to be notified if there was bruising on the hips/buttocks of any sort, if it was significant whether the resident was Hospice or not. She stated that just because a resident had Hospice didn't mean we don't treat them. Review of Resident #37's Progress Note, dated 11/08/12 at 2100, revealed the resident complained of pain and discomfort in the left leg/hip. Review revealed the nurse called Hospice and got a new order for [MEDICATION NAME] (a pain reliever) 400 milligrams (mg) every six (6) hours as needed. The Note stated the resident's outer left hip, back of left upper leg, and the front of the labia and left leg had discoloration noted and the resident's left foot was turned inward and appeared shorter than the right leg. Review revealed the nurse called the Director of Nursing Services (DNS) and left a message. Review of the facility's 24 Hour Report revealed an entry on 11/08/12 for Resident #37 which noted a call to Hospice related to the resident being in a lot of pain and there being bruising to the labia, left hip, and inside the left leg. Review revealed a new order for [MEDICATION NAME] (a pain reliever) 400 mg every six (6) hours as needed was obtained. Interview, on 11/30/12 at 3:30 PM, with the Unit Manager (UM) regarding the Progress Note on 11/08/12 at 9:00 PM revealed even if a resident has Hospice nurses were supposed to notify the Physician at the same time. She stated the facility was ultimately responsible for the resident. According to the UM, the nurse should have completed a non-pressure skin sheet related to her findings to give the area a baseline. Review of the Hospice On Call Nursing Record dated 11/08/12 and timed 10:51 PM, revealed Hospice received a phone call from the facility nurse who reported Resident #37 was having a lot of pain; that every time they touched the leg the resident cried. Review revealed the resident had a big bruise in the vaginal and groin area. Interview, on 11/20/12 at 12:00 PM, with Hospice Nurse #1 revealed she was informed by the facility nurse on 11/08/12, that Resident #37 had a large bruise to the groin and vaginal area, and the resident complained of pain when the left leg was moved. The Hospice Nurse stated she asked if the resident had fallen and the facility nurse indicated she was not aware of a fall. She stated the nurse did not mention one leg was shorter than the other; she just reported the bruising and pain and wanted to get pain medication. Continued interview, on 12/06/12 at 12:25 PM, with Hospice Nurse #1 revealed if the facility nurse had told her one of the resident's legs was shorter than the other, she would have immediately thought it was a [MEDICAL CONDITION] and would have went and assessed the resident. The Hospice Nurse indicated all she was told was that the resident was in pain. She stated she would have requested an x-ray and pain medication stronger than [MEDICATION NAME]. An additional interview, on 11/30/12 at 6:10 PM, with the Unit Manager (UM) revealed she did a skin assessment on 11/09/12 at 8:00 AM with LPN #37 because of an unrelated skin issue identified the night before. She stated she had noticed a non-pressure skin sheet was not completed as per facility process. According to the UM, this should have have been completed when the area was first identified. Additionally, the UM stated she inserviced LPN #35 regarding the lack of documentation in regards to the non-pressure skin sheet. Record review revealed a Nurse's Progress Note dated 11/09/12 at 8:00 AM, which indicated the resident had discoloration, pale purple/yellow starting at the center of the left pelvic region and extending downward into the pubic area. Interview, on 12/06/12 at 11:05 AM, with LPN #37 revealed on the morning of 11/09/12 she assessed Resident #37 because of reported bruising and pain to the left hip area. She stated when she assessed the resident she observed bruising to the resident's (left) hip, groin, and "private" area which was dark purple and the resident would cry out in pain anytime she was touched in that area. She indicated the the left foot had some slight rotation inward. She stated she called the APRN and the Hospice and got an order for [REDACTED]. Review of the x-ray report, dated 11/09/12, revealed Resident #37 had a left [MEDICAL CONDITION]. Interview, on 12/04/12 at 2:05 PM, with the Quality Assurance (QA) Nurse and the Director of Nursing Services (DNS) revealed SRNAs informed the nurse regarding a change of condition and the nurse would put it on the 24 hour report. The QA Nurse stated if pain was a new type of pain he would expect that to be documented on the 24 Hour Report. He stated if there were changes to the Resident #37's left thigh this should have been reported to the nurse and the nurse should have assessed the area. The DNS stated the 24 Hour Report was a communication tool for shift to shift reporting; anyone could document on the report. When asked about the documented condition change noted in the 11/05/12 progress note and related interviews, the DNS stated if there was a change in the condition of the area it would have been appropriate for staff to put on the 24 Hour Report to alert nursing staff to assess the site. She stated there should have been follow-up documentation of the area. The DNS also stated the MD should have been notified and the facility was ultimately responsible for the resident. Further interview, on 12/14/12 at 7:15 PM, with the QA Nurse revealed when any change in a resident was observed staff could complete the Stop and Watch form, the 24 Hour Report, and give verbal communication as well. He stated when the SRNAs observed changes to the resident on 11/05/12, 11/07/12 on the evening shift and 11/08/12 day shift, they should have completed a Stop and Watch form to notify the nurse of the changes. According to the QA Nurse, SRNAs had the ability to document on the 24 Hour Report; however it would have been more effective to take the nurse to the resident's room and point out the condition change. The QA Nurse indicated because these changes were not communicated to the nurse there was no monitoring of the area, and the Physician was not made notified of the changes in Resident #37's condition. Further interview revealed the facility nurse should have documented on the "skin sheet", the bruising identified on the 11/08/12 9:00 PM Nurse's Progress Note. In addition, he stated the care plan should have been updated accordingly with the nurse's findings on 11/05/12 and 11/08/12 at 9:00 PM. Continued interview, on 12/11/12 at 12:20 PM, with the DNS revealed staff did not monitor and assess the resident's changes in condition according to her expectation because for whatever reason staff did not utilize the communication tools available to alert other staff of the changes. She stated the documented changes identified on 11/05/12 should have been recorded on the 24 Hour Report to alert staff of the pain and puffiness. She indicated the bruising and pain to Resident #37's left hip/leg, reported by the aides on 11/07/12 and 11/08/12, should have been documented on the 24 Hour Report by the SRNAs. The DNS stated the SRNAs could also have utilized the Stop and Watch form, which had been in place for several months, that was another communication tool available to all staff to report changes. She stated the SRNAs should have completed the Stop and Watch form to communicate to the nurse the swelling and pain identified on 11/05/12, and the bruising and pain observed on 11/07/12 and 11/08/12. According to the DNS, the nurses should have conferred with Hospice about the changes in condition documented on 11/05/12 and 11/08/12 and then notified the Physician of the changes. She stated the care plan should have been revised with interventions related to the 11/05/12 and 11/08/12 assessment findings of bruising and the resident's left leg appearing to be shorter than the right. She stated the nurse should have documented her assessment findings on a "skin sheet" for a baseline and completed an event report so the area would have been assessed and charted on for seventy-two (72) hours. Interview, on 12/14/12 at 7:15 PM, with the facility's Executive Director (ED) revealed there was a misunderstanding by the nurse related to Physician notification and documentation of Resident #37's change of condition identified on 11/05/12. She stated the nurse did not follow the facility's process she had been educated on. The ED stated the nurse didn't put the change in condition on the alert charting or 24 Hour Report or notify the Physician of the change. According to the ED, staff were supposed to put changes on the 24 Hour Report for follow-up. She stated no one monitored the area as it had not been placed on the 24 Hour Report. The ED stated that on 11/08/12 at 9:00 PM, the nurse notified Hospice of the change in Resident #37's condition, however should have also notified the Physician. In addition, she stated the nurse should have documented her assessment findings on the "skin sheet". The facility provided an acceptable credible Allegation of Compliance (AOC) on 12/11/12 that alleged removal of the IJ effective 12/11/12. Review of the AOC revealed the facility implemented the following: 1) Head-to-toe skin assessments were performed on all residents from 12/05/12 through 12/06/12 by licensed nurses to identify any others with indication of any change of condition/puffiness, swelling or redness. Any notable findings were communicated to the attending Physician and responsible party. Notable findings included, but were not limited to, Pressure Ulcers, Arterial Ulcers, Diabetic Neuropathic Ulcers, [MEDICAL CONDITION] Ulcers, Surgical Wounds, Skin Tears, Lacerations, Abrasions, Bruises, Burns, Rashes, or a Lesion associated with bleeding, itching, burning, puffiness or swelling, discoloration and/or raised skin areas. The findings were documented by the licensed nurse, and communicated to the Physician and family for further follow-up. The licensed nurse was responsible to document findings in the residents' medical record and the 24 hour report. 2) On 12/05/12 and 12/06/12 facility licensed nurses conducted an audit that reviewed all current residents' progress notes and the 24 hour reports for the previous thirty (30) days (11/05/12 to current) to validate changes in resident condition were identified and addressed with the Physician and responsible party notification. This audit also included validating any changes in resident condition including updating the care plan. 3) The Administrator (Executive Director) communicated the change in the process for Physician notification by the facility to Hospice on 11/30/12 and again on 12/03/12. 4) Physician orders, condition change forms, alert charting lists, stop and watch forms, and 24 hour sift reports would be audited daily starting on 12/06/12 and ongoing by the Director of Nursing Services (DNS), Assistant Director of Nursing Services (ADNS), or Quality Assurance (QA) Registered Nurse (RN), Monday through Friday; and by the Weekend Supervisor RN on Saturdays and Sundays for any residents with a change in condition to validate appropriate identification of changes in resident condition, notification of the Physician and responsible party, and care plan revision. 5) Shift to shift report was observed daily on each unit beginning 12/10/12 and ongoing by the DNS, ADNS, QA Nurse, Unit Managers (UM), three (3) to eleven (11) Supervisor, Weekend Supervisor, RN Case Manager, District Clinical RN Consultant to validate proper use of the 24 hour report and follow-up to resident change in condition. 6) The Guidelines for Physician Notification of Change of Condition/Clinical Problems in Center Residents was placed on the Treatment Administration Record (TAR) on all units 12/06/12 for quick reference for the nurses. 7) On 12/04/12 the Staff Development Coordinator (SDC) initiated education with all facility licensed nursing staff related to change in condition of resident status. Inservice dates were 12/04/12, 12/05/12, 12/06/12 and ongoing until all facility clinical staff had received the education. Education was provided by the SDC, ADNS', three (3) to eleven (11) RN Supervisor, Weekend RN, DNS, or QA RN. No nursing staff would be allowed to work until they had received the education. The inservices included: Situation Background Assessment Recommendation/Request (SBAR) form, 24 hour report form, alert charting system, notification of the Physician and responsible party, assessing for a possible [MEDICAL CONDITION], State Registered Nursing Staff (SRNA) utilizing the Stop and Watch forms, Licensed Nurse notification to Hospice for recommendations for a resident with a change in condition, then notify Physician of the change in condition and notify family. 8) A Performance Improvement Committee (PIC) meeting was held on 12/05/12 and again on 12/06/12. The Medical Director was notified of the Immediate Jeopardy via telephone and approved the plan developed by the PIC on 12/05/12. The PIC reviewed and approved the Allegation of Compliance (AOC). The PIC was to ensure validation of the AOC by: beginning 12/06/12, initial and daily audits of the Physician orders, condition change forms, alert charting lists, Stop and Watch forms, and shift to shift observations were being reviewed by the DNS, ADNS', QA RN, and/or Weekend Supervisor RN on Saturday and Sunday to identify issues, trends or patterns and take corrective action as necessary. The QA RN would be responsible to report trends from the audits to the weekly PIC committee for review and further recommendations. The PIC would create corrective action plans for any areas of concern identified on the audits. The PIC committee would meet

Based on observation, interview, record review and review of facility's policy it was determined the facility failed to have an effective system to ensure the comprehensive plan of care was reviewed and revised for two (2) of nineteen (19) sampled residents (Residents #37 and #41). The facility failed to update the care plan for Resident #37 after the resident was assessed on 11/05/12 for having pain and puffiness in the left hip area for interventions to include continued monitoring and assessment of the area to prevent further pain and ensure the resident received the appropriate care and services. Three days later, on 11/08/12, Resident #37 was assessed by the nurse with pain/discomfort in the left hip/leg area and discoloration to the left hip, back of the left leg, front of the labia, and inside of the left leg and the left foot was turned inward and the left leg being shorter than the right leg. Review of the Comprehensive Care Plan revealed no documented evidence the care plan was revised related to the resident's change in condition other than an order to administer 400 milligrams [MEDICATION NAME] every six hours as needed. On the morning of 11/09/12 Resident #37 was noted to have bruising which was dark purple to the resident's left hip, groin, and "private" area and the resident cried out in pain. The APRN was contacted and an order obtained for an x-ray which revealed Resident #37 had a left [MEDICAL CONDITION]. (Refer to F-157 and F-309) In addition, the facility failed to revise Resident #41's care plan after the resident was readmitted to the facility and had oxygen in use. Based on the above findings it was determined the facility's failure to revise the Comprehensive Plan of Care to ensure staff were aware of residents' care needs was likely to cause risk for serious injury, harm, impairment or death. The Immediate Jeopardy was identified on 12/05/12, and determined to exist on 11/05/12. The facility was notified of the Immediate Jeopardy on 12/05/12. The facility provided an acceptable credible Allegation of Compliance (AOC) on 12/11/12 with the facility alleging removal of the Immediate Jeopardy on 12/11/12. The Immediate Jeopardy was verified to be removed on 12/11/12, prior to exiting the facility on 12/14/12, with remaining non-compliance at 42 CFR 483.20, Resident Assessment F-280, with a Scope and Severity of "D", while the facility develops and implements a Plan of Correction, and the facility's Quality Assurance continues to monitor to ensure care plans are revised appropriately. The findings include: Review of facility policy titled "Comprehensive Plan of Care", revised date 08/31/12, revealed a Comprehensive Plan of Care was developed for each resident and was to be re-evaluated and modified as necessary to reflect changes in care, service, and treatment. Further review revealed the care plan was to be updated during the course of care delivery to reflect new problems or modify interventions as a result of a change of condition in a resident. Review of facility policy titled "Condition Change in a Resident", dated 10/31/06, revealed resident change of condition was identified for proper treatment implementation. The policy referenced three (3) times that the Care Plan should be updated with a change in condition. In addition, review of the Transmission-Based Precaution policy, dated 09/19/12, revealed once precautions are initiated, the care plan should be updated to reflect this status. Interview, on 12/10/12 at 3:00 PM, with the Minimum Data Set (MDS) Coordinator, regarding the care plan process, revealed the Comprehensive Care Plan is based on the MDS Assessment. She stated nursing staff were responsible for making changes/updates from one Comprehensive Assessment to the next. According to the MDS Coordinator, the care plan update would occur based on a change and the interventions already in place would determine what updates would be required. 1. Record review revealed Resident #37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Significant Change MDS, dated [DATE], revealed facility assessed the resident to be severely cognitively impaired. Further review of this MDS Assessment revealed the facility assessed the resident to require limited to extensive assistance with all Activities of Daily Living (ADLs). Review of Resident #37's Comprehensive Care Plan revealed a plan of care, dated 11/23/11, for extensive assistance with all Activities of Daily Living (ADLs) related to cognitive loss. Interview, on 11/28/12 at 5:10 PM, with State Registered Nursing Assistant (SRNA) #20 revealed she noticed Resident #37's left hip was red, swollen and inflamed on 11/05/12. Additional interview, on 12/10/12 at 3:30 PM revealed she told a nurse of Resident #37's change of condition on 11/05/12. Review of a Nursing Progress Note, dated 11/05/12 at 9:00 PM, revealed Resident #37 complained of pain to the left hip/leg. Continued review revealed the left hip area was puffy, with no redness, no discoloration, and the lower extremities were equal in length. The facility failed to revise the plan of care to include interventions for assessment and monitoring related to the resident's change in condition. Review of Resident #37's medical record revealed a Nursing Progress Note, dated 11/08/12 (three days later), that documented the resident complained of pain and discomfort in the left leg/hip. The Note stated Resident #37's outer left hip, back of left upper leg, and the front of the labia and left leg had discoloration noted and the resident's left foot was turned inward and appeared shorter than the right leg. Review revealed the Nurse documented she called Hospice and obtained a new order for [MEDICATION NAME] (a pain reliever) 400 milligrams (mg) every six (6) hours as needed. However, there was no documented evidence the Comprehensive Care Plan was updated to include interventions for assessment and monitoring related to the resident's change in condition. Interview, on 12/06/12 at 11:05 AM, with LPN #37 revealed on the morning of 11/09/12 she assessed Resident #37 because of reported bruising and pain to the area. She stated during her assessment she observed bruising which was dark purple to the resident's left hip, groin, and "private" area and the resident would cry out in pain anytime she was touched in that area. She stated she called the APRN an order for [REDACTED]. Review of the x-ray report, dated 11/09/12, revealed Resident #37's had a left [MEDICAL CONDITION]. Interview, on 12/06/12 at 2:30 PM, with LPN #35 revealed care plans were supposed to be updated immediately when a change was identified. She indicated she was just off orientation and knew she was supposed to update the care plan on the resident's complaint of pain. However, she stated she did not think she needed to update the care plan with her assessment findings of the bruising on the resident's outer left hip, back of left upper leg, and the front of the labia, or the left leg or of one leg being shorter than the other. Interview, on 12/10/12 at 3:00 PM, with the Minimum Data Set (MDS) Coordinator revealed if a nurse assessed a resident to have pain, bruising, one foot turned inward, and one leg shorter than the other, the nurse should have revised the care plan to include this information. She stated based on the findings identified in the assessments, it would have been appropriate to revise the care plan to include an intervention to encourage the resident not to get up until they had further evaluation and treatment, such as an x-ray. Interview, on 12/11/12 at 12:20 PM, with the Director on Nursing Services revealed her expectation of the nurse, regarding the documented assessment findings of 11/05/12 and 11/08/12 would have been that the care plan was revised to include nursing intervention, such as, continued observations of the area. She stated the nurses should have contacted the Physician regarding their assessments and then revised the care plan. 2. Review of Resident #41's medical record revealed an admission date of [DATE], and a readmission date of [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed the facility assessed Resident #41 to have not required oxygen use in the previous fourteen (14) days. Further review of the MDS revealed the facility assessed Resident #41 to have a Brief Interview for Mental Status (BIMS) score of twelve (12). Record review revealed a physician's orders [REDACTED]. Review of the record revealed Resident #41 was sent out to the hospital for evaluation on 11/28/12 related to "sudden onset chills". Review revealed the resident had an oxygen saturation level of seventy-nine (79) percent and shortness of air (SOA). Continued record review revealed the resident was readmitted to the facility on [DATE] with no documented evidence of oxygen use on readmission. Review of the admission orders [REDACTED] Observation, on 12/11/12 at 3:14 PM, on 12/11/12 at 4:40 PM, and on 12/12/12 at 8:50 AM, revealed Resident #41 to have oxygen in use per nasal cannula at two (2) liters per minute (LPM) via an oxygen concentrator. Interview, on 12/11/12 at 4:40 PM, with Resident #41 and his/her daughter revealed Resident #41 had been using oxygen continuously at the facility since his/her return from the hospital on [DATE]. Interview, on 12/12/12 at 8:50 AM with Occupational Therapist (OT) #1 revealed Resident #41 used oxygen "all the time now". Interview, on 12/12/12 at 9:30 AM, with SRNA #32 revealed she had observed Resident #41 using oxygen continuously since his/her return from the hospital. Interview, on 12/12/12 at 3:28 PM, with SRNA #33 revealed Resident #41 had been using oxygen since his/her return from the hospital. Interview, on 12/12/12 at 4:40 PM, with LPN #41 revealed she had observed Resident #41 using oxygen since his/her return from the hospital. In an additional interview, on 12/12/12 at 7:35 PM, LPN #41 stated a care plan should have been developed for the resident's use of oxygen. Interview, on 12/12/12 at 3:33 PM, Respiratory Therapist (RT) #1 revealed he had observed Resident #41 using oxygen since his/her return from the hospital. He stated he had also observed Resident #41 in the facility's hallways with portable oxygen in use. The RT stated when he assessed Resident #41 on 12/12/12, he/she needed oxygen related to upon exertion the resident showed "signs of dyspnea" (shortness of breath) and cyanosis (bluish discoloration of the skin and mucous membranes caused by a lack of oxygen in the blood). Interview, on 12/12/12 at 5:58 PM, the Director of Nursing Services (DNS) revealed a care plan should have been developed with nursing interventions for Resident #41's oxygen use. Continued review of Resident #41's record revealed no documented evidence on the Comprehensive Care Plan of the resident's use of or need for oxygen use. The facility provided an acceptable credible Allegation of Compliance (AOC) on 12/11/12 that alleged removal of the IJ effective 12/11/12. Review of the AOC revealed the facility implemented the following: 1) Head-to-toe skin assessments were performed on all residents from 12/05/12 through 12/06/12 by licensed nurses to identify any others with indication of any change of condition/puffiness, swelling or redness. Any notable findings were communicated to the attending Physician and responsible party. Notable findings included, but were not limited to, Pressure Ulcers, Arterial Ulcers, Diabetic Neuropathic Ulcers, [MEDICAL CONDITION] Ulcers, Surgical Wounds, Skin Tears, Lacerations, Abrasions, Bruises, Burns, Rashes, or a Lesion associated with bleeding, itching, burning, puffiness or swelling, discoloration and/or raised skin areas. The findings were documented by the licensed nurse, and communicated to the Physician and family for further follow-up. The licensed nurse was responsible to document findings in the residents' medical record and the 24 hour report. 2) On 12/05/12 and 12/06/12 facility licensed nurses conducted an audit that reviewed all current residents' progress notes and the 24 hour reports for the previous thirty (30) days (11/05/12 to current) to validate changes in resident condition were identified and addressed with the Physician and responsible party notification. This audit also included validating any changes in resident condition including updating the care plan. 3) The Administrator (Executive Director) communicated the change in the process for Physician notification by the facility to Hospice on 11/30/12 and again on 12/03/12. 4) Physician orders, condition change forms, alert charting lists, stop and watch forms, and 24 hour sift reports would be audited daily starting on 12/06/12 and ongoing by the Director of Nursing Services (DNS), Assistant Director of Nursing Services (ADNS), or Quality Assurance (QA) Registered Nurse (RN), Monday through Friday; and by the Weekend Supervisor RN on Saturdays and Sundays for any residents with a change in condition to validate appropriate identification of changes in resident condition, notification of the Physician and responsible party, and care plan revision. 5) Shift to shift report was observed daily on each unit beginning 12/10/12 and ongoing by the DNS, ADNS, QA Nurse, Unit Managers (UM), three (3) to eleven (11) Supervisor, Weekend Supervisor, RN Case Manager, District Clinical RN Consultant to validate proper use of the 24 hour report and follow-up to resident change in condition. 6) The Guidelines for Physician Notification of Change of Condition/Clinical Problems in Center Residents was placed on the Treatment Administration Record (TAR) on all units 12/06/12 for quick reference for the nurses. 7) On 12/04/12 the Staff Development Coordinator (SDC) initiated education with all facility licensed nursing staff related to change in condition of resident status. Inservice dates were 12/04/12, 12/05/12, 12/06/12 and ongoing until all facility clinical staff had received the education. Education was provided by the SDC, ADNS', three (3) to eleven (11) RN Supervisor, Weekend RN, DNS, or QA RN. No nursing staff would be allowed to work until they had received the education. The inservices included: Situation Background Assessment Recommendation/Request (SBAR) form, 24 hour report form, alert charting system, notification of the Physician and responsible party, assessing for a possible [MEDICAL CONDITION], State Registered Nursing Staff (SRNA) utilizing the Stop and Watch forms, Licensed Nurse notification to Hospice for recommendations for a resident with a change in condition, then notify Physician of the change in condition and notify family. 8) A Performance Improvement Committee (PIC) meeting was held on 12/05/12 and again on 12/06/12. The Medical Director was notified of the Immediate Jeopardy via telephone and approved the plan developed by the PIC on 12/05/12. The PIC reviewed and approved the Allegation of Compliance (AOC). The PIC was to ensure validation of the AOC by: beginning 12/06/12, initial and daily audits of the Physician orders, condition change forms, alert charting lists, Stop and Watch forms, and shift to shift observations were being reviewed by the DNS, ADNS', QA RN, and/or Weekend Supervisor RN on Saturday and Sunday to identify issues, trends or patterns and take corrective action as necessary. The QA RN would be responsible to report trends from the audits to the weekly PIC committee for review and further recommendations. The PIC would create corrective action plans for any areas of concern identified on the audits. The PIC committee would meet weekly or more often as necessary until the facility had removed the Immediate Jeopardy. Once the Immediate Jeopardy was removed the facility would return to routine monthly PIC committee meetings. 9) The District and/or Regional team would provide RN clinical oversight a minimum of three (3) days per week beginning the week of 12/02/12. 10) The facility contracted an outside clinical consulting group on 11/20/12 to conduct onsite facility clinical oversight two (2) days per week beginning 12/02/12. The State Survey Agency validated the implementation of the facility's AOC as follows: Review of the skin assessment forms revealed all facility residents had skin assessments performed from 12/05/12 through 12/06/12 by licensed nurses, except three (3) who refused and one (1) that was end of life. Audit review revealed newly identified areas were reported to the physician and responsible party. Record review revealed the facility performed the audits as identified on the facility's AOC: An audit of resident progress notes and the 24 hour reports for the last 30 days was performed on 12/05/12 - 12/06/12. Daily audits of Physician orders, condition change forms, alert charting lists, stop and watch forms, and 24 hour shift reports started on 12/06/12. Problems identified were given to the Unit Managers for follow-up. The Shift to Shift audits were initiated by the facility on 12/10/12. Interview, on 12/13/12 at 11:05 AM, with the Staff Development Coordinator (SDC) revealed she had completed education with facility staff related to the SBAR form, 24 hour report form, alert charting system, notification of the Physician and responsible party, assessing for a possible [MEDICAL CONDITION], State Registered Nursing Staff (SRNA) utilizing the Stop and Watch forms, Licensed Nurse notification to Hospice for recommendations for a resident with a change in condition, then notify Physician of the change in condition and notify family. Interview, on 12/13/12 at 11:00 AM, with the Executive Director (ED), Vice President of Clinical Operations, Director of District Operations, Director of Nursing Services (DNS), Quality Assurance (QA) RN, and contracted Nurse Consultant revealed the District and/or Regional team would provide RN clinical oversight a minimum of three (3) days per week beginning the week of 12/02/12. In addition, the facility had contracted with an outside clinical consulting group on to conduct onsite facility clinical oversight two (2) days per week. Interviews with licensed nursing staff on 12/12/12 at 11:50 AM with Licensed Practical Nurse (LPN) #40, at 3:00 PM with Registered Nurse (RN) #11, at 3:15 PM with LPN #13; on 12/14/12 (7:00 AM to 3:00 PM shift) at 9:50 AM with LPN #3, at 2:00 PM with LPN #9, at 2:17 PM with LPN #16, at 2:45 PM with LPN #32, at 2:53 PM with LPN #15; on 12/14/12 (3:00 PM to 11:00 PM shift) at 5:35 PM with LPN #2, at 6:00 PM with LPN #31; and, on 12/14/12 (11:00 PM to 7:00 AM shift) at 3:42 PM with LPN #19 and at 4:32 PM with LPN #38 revealed they were all aware the "Guidelines for Physician Notification of Change of Condition/Clinical Problems in Center Residents" was on the Treatment Administration Record (TAR); they had received education on the Situation Background Assessment Recommendation/Request (SBAR) form; the 24 hour report form; the alert charting system; notification of the Physician and responsible party; assessing residents for a possible [MEDICAL CONDITION]; the State Registered Nursing Staff (SRNA) utilizing the Stop and Watch forms; and after notification to Hospice for recommendations for a resident with a change in condition, that they were to then notify the Physician of the change in condition and obtain orders, then notify the family. All licensed nurses interviewed confirmed that the shift to shift reports were being audited by Unit Managers, Assistant Director of Nursing Services (ADNS), 3:00 PM to 11:00 PM Supervisor, Quality Assurance Registered Nurse, and Weekend Supervisor. Interview, on 12/12/12 at 10:05 AM with State Registered Nursing Assistants (SRNAs) #8 and #9; on 12/14/12 at 9:15 AM with SRNA #37, at 9:15 AM with SRNA #38, at 2:33 PM with SRNA #27, at 3:00 PM with SRNA #32, at 3:40 PM with SRNA #39, at 4:00 PM with SRNA #13, at 4:19 PM with SRNA #34, at 4:28 PM with SRNA #35, at 5:15 PM with SRNAs #33 and #36 revealed they had all received education on the Stop and Watch form for communicating changes in residents' condition to the nurses. Interview, on 12/14/12 at 9:25 AM with LPN #39 and at 9:30 AM with LPN #16 revealed the SRNAs had received training on the Stop and Watch form. Interview, on 12/11/12 at 12:20 PM, with the Director of Nursing Services (DNS) revealed education had been performed with facility staff in regards to the "skin sheet", Stop and Watch form, 24 hour report form, and proper notification of the Physician and family. She stated nurses had been re-educated to confer with Hospice, however they were to notify the Physician and responsible party. In an additional interview, on 12/14/12 at 5:00 PM, with the DNS revealed in the facility's daily clinical review they were monitoring: the notification of change to the Physician and family, care plan updates, 24 hour report forms, alert charting forms, condition change forms, and Stop and Watch forms. She stated any concerns are followed up on by the Unit Managers (UM). The DNS stated she ensures the UMs complete the follow up via another meeting at the end of the day. According to the DNS, shift reports were being audited every day. She stated the audits were to ensure nurses were utilizing the 24 hour report form, alert charting, and any Stop and Watch forms to ensure the following shift was updated on residents' condition changes. Interview, on 12/14/12 at 11:40 AM, with RN #10/Assistant Director of Nursing Services (ADNS) for A and B units, revealed she audited progress notes, SBAR forms, Physician orders, condition change forms, alert charting lists, stop and watch forms, and 24 hour shift reports for the past thirty (30) days, and also ensured the care plan was updated. In an additional interview with RN #10/ADNS at 5:20 PM revealed she had monitored the shift to shift reports to ensure nurses were utilizing the 24 hour report form, the alert charting form, and any Stop and Watch forms to ensure the oncoming shift was aware of any changes in residents' condition. Interview, on 12/14/12 at 2:00 PM, with RN #2/ADNS (for C and D units) revealed he had performed audits of progress notes, SBAR forms, Physician orders, condition change forms, alert charting lists, stop and watch forms, and 24 hour shift reports for the past thirty (30) days. Interview, on 12/14/12 at 6:15 PM with the Weekend Supervisor RN revealed he had audited shift to shift reports to ensure the 24 hour report form, the alert charting and any Stop and Watch forms were being utilized to pass on residents' condition changes to the oncoming shift. He stated he had performed audits of the Physician orders, SBAR forms, condition change forms, alert charting lists, stop and watch forms, and 24 hour shift reports. Interview, on 12/14/12 at 6:10 PM, with the Medical Director revealed she had been notified of the Immediate Jeopardy by telephone and had approved the Allegation of Compliance (AOC) after discussion with the facility. She stated the Performance Improvement Committee (PIC) had been meeting weekly since the Immediate Jeopardy was identified and she was involved with these meetings. Interview, on 12/12/12 at 3:00 PM, with the Executive Director (ED) revealed the facility had good support from the Corporate level. She stated the facility had contracted with a consulting group that was coming two (2) days per week to help with problem solving. The ED stated the contracted consulting group and the Corporate level staff coming would provide training as necessary if problems were identified. She stated the Medical Director was very supportive and in communication very often and attended the Performance Improvement Committee (PIC) meetings monthly. According to the ED, she leads the PIC and it was continuously reviewing the problems identified. Interview, on 12/14/12 at 7:15 PM, with the ED and Quality Assurance (QA) RN revealed the Executive Director communicated the change in the process for Physician notification by the facility to Hospice. She stated Hospice had been educated that the facility's nurses would contact the Physician. The QA RN verified that audits were being performed as per the AOC, such as shift to shift report audits to ensure the 24 hour report form and alert charting information was being utilized. The QA RN indicated if audits were performed at shift change then the 24 hour report, alert charting, SBAR forms, and Stop and Watch forms were being audited to ensure a change in a resident's condition is being passed along. According to the QA RN, the results of all the audits on the 24 hour report form, SBAR form, alert charting form, condition change form, care plan updates, Physician orders, Physician and family notification, and Stop and Watch forms were taken to the morning clinical meeting and discussed. The QA RN stated if a problem was identified then staff were educated by the person doing the audit. The QA RN stated he reported the results of the audits and any trends to the weekly PIC meeting. The ED stated education was performed as per the AOC. She stated through the use of the new three (3) part SBAR form and Stop and Watch form that communication was now "shored" up. She stated staff had been educated to ensure a Stop and Watch form was filled out with any change in a resident's condition. An additional interview, on 12/14/12 at 8:00 PM, with the ED revealed the PIC had been meeting weekly. According to the ED, the PIC was performing what was indicated in the AOC (i.e.-validating the AOC by: reviewing initial and daily audits of the Physician orders, condition change forms, alert charting lists, Stop and Watch forms; and shift to shift observations were being reviewed to identify issues, trends or patterns and to take the corrective action as necessary). Corrective action plans for any areas of concern identified on the audits would be implemented.

Based on observation, interview, record review and review of the facility's policy it was determined the facility failed to have an effective system in place to ensure the Physician was notified of a change in condition for one (1) of nineteen (19) sampled residents (Residents #37). Facility staff observed changes of condition to Resident #37's left leg/hip on 11/05/12, 11/07/12, and 11/08/12 but failed to notify the resident's Physician. On 11/05/12 documentation revealed Resident #37 had swelling/puffiness, redness to the left hip and pain with movement; however, there was no evidence the facility notified the resident's physician. On 11/07/12, Resident #37 was exhibiting pain when repositioned and bruising was noted to the inner left thigh per staff interviews. Review of the Resident Progress Notes, dated 11/08/12, revealed Resident #37 had complained of pain and discomfort in left leg/, and the left foot turned inward and appeared shorter then the right leg. Record review and interview revealed no evidence the Physician was notified of the resident's change in condition until 11/09/12. An x-ray was obtained on 11/09/12 which revealed the resident had a left [MEDICAL CONDITION]. The facility's failure to ensure an effective system was in place to ensure Physician notification of a change in condition was likely to cause risk for serious injury, harm, or impairment or death. The Immediate Jeopardy was identified on 12/05/12, and determined to exist on 11/05/12. The facility was notified of the Immediate Jeopardy on 12/05/12. The facility provided an acceptable credible Allegation of Compliance (AOC) on 12/11/12 with the facility alleging removal of the Immediate Jeopardy on 12/11/12. The Immediate Jeopardy was verified to be removed on 12/11/12, prior to exiting the facility on 12/14/12, with remaining non-compliance at 42 CFR 483.10, Resident Rights, F-157 Notification of Changes with a Scope and Severity of "D", while the facility develops and implements a Plan of Correction, and the facility's Quality Assurance continues to monitor to ensure Physicians are notified of changes in residents' conditions. The findings include: Review of the facility's policy titled, "Condition Change of a Resident", revised date 10/31/06, revealed the Physician was to be informed of resident events and/or change in resident's condition". Continued review of the policy revealed the Physician should be informed at the time the event occurs either directly or by pager. Further review revealed the nurse should notify the Physician of clinical problems; if the attending Physician was unavailable the nurse was to notify the alternate Physician or the Medical Director. Review of Resident #37's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Significant Change Minimum Data Set (MDS) Assessment, dated 09/25/12, revealed the facility assessed the resident as severely cognitively impaired. Continued review of the MDS revealed the facility assessed the resident as requiring limited to extensive assist with his/her Activities of Daily Living (ADLs). Interview, on 11/28/12 at 5:10 PM, with State Registered Nursing Assistant (SRNA) #20 revealed when she worked 11/05/12, on the 3:00 PM to 11:00 PM shift, Resident #37 started "hollering" when the bed was raised while she and SRNA #23 were repositioning the resident. She indicated when she undid the resident's brief she noticed the resident's left hip was red, swollen and inflamed. Additional interview, on 12/10/12 at 3:30 PM revealed she told a nurse (Licensed Practical Nurse (LPN) #26) of Resident #37's change of condition on 11/05/12. Record review of a Nursing Progress Note, dated 11/05/12 at 9:00 PM, revealed the resident complained of pain to the left hip/leg. Continued review revealed the left hip area was puffy, with no redness, no discoloration, and the lower extremities were equal in length. Further review revealed the nurse documented she called the Hospice Nurse. However, there was no documented evidence the nurse notified the Physician of the change in the resident's condition. Interview, on 11/29/12 at 8:30 PM, with LPN #26, revealed on 11/05/12 the SRNAs (SRNA #20 and SRNA #23) told her Resident #37 was complaining of pain while they were providing care. LPN #26 stated Resident #37 moaned while she assessed the resident and pain was noted in both legs; however, more in the left leg. She indicated there was no redness or warmth to the site. She stated she called Hospice regarding the changes; however, she did not call the Physician. LPN #26 stated she thought the process was to call Hospice and Hospice notified the Physician. Interview, on 12/05/12 at 10:23 AM, with the Advanced Practice Registered Nurse (APRN) related to the resident's change of condition on 11/05/12, revealed she would want to be notified if there was puffiness or swelling to the resident's left hip. However, record review revealed no documented evidence the Physician or the APRN were notified of the puffiness in Resident #37's left hip area or the pain in the resident's legs on 11/05/12. Interview, on 11/30/12 at 5:05 PM, with SRNA #20 revealed during the beginning of her 3:00 PM to 7:00 PM shift on 11/07/12 ( two days after Resident #37 was noted to have red, swollen and inflamed hip) she and SRNA #29 noticed green/purple bruising approximately six (6) inches in length and a couple of inches wide to Resident #37's inner part of the resident's thigh and vaginal area while providing care. SRNA #20 stated the resident would "holler" when they repositioned him/her. She indicated she assumed the bruising had already been reported to the nurses because she was told it was found by day shift. SRNA #20 stated she did not tell the nurse the resident was in pain; however, she stated should have. Interview, on 11/30/12 at 5:40 PM, with SRNA #29 revealed when she and SRNA #20 went into the resident's room on 11/07/12 to change Resident #37, he/she was in pain if moved. She stated Resident #37 would grab at his/her hips to protect them. She stated she checked the resident's hip and observed discoloration, dark enough that it stood out. She indicated she reported to the nurse (LPN #26) that the resident was in a lot of pain; however, was not sure if she told the nurse about the discoloration. Interview, on 12/04/12 at 4:00 AM, with SRNA #30 revealed she worked 11:00 PM to 7:00 AM shift on 11/07/12 and 11/08/12. SRNA #30 stated on 11/07/12, Resident #37 seemed to be in more pain in the leg/hip area. She indicated the resident moaned more than usual and she could tell something was unusual Resident #37. The SRNA stated she reported this to LPN #26. However, record review revealed no documented evidence the Physician was notified of this change in the resident's condition on 11/07/12. Interview, on 12/01/12 at 5:44 PM, with LPN #26 revealed she worked on 11/07/12 from 3:00 PM until 7:00 AM and did not observe Resident #37's hip area during the shift. The LPN stated the resident did not complain of pain and she did not recall the SRNAs reporting Resident #37 had any bruising or pain to the hip area during her shift. Interview, on 12/03/12 at 3:10 PM, with SRNA #26 revealed when she did a check and change on 11/08/12 on day shift she noticed the discolored area, which she had observed on 11/07/12, looked larger and darker. She stated it was more purplish and had doubled in size from about a nickel size to about the size of a silver dollar and the resident seemed to be in pain whenever he/she was moved. SRNA #26 stated SRNA #28 reported this information to the nurse. Interview, on 12/02/12 at 12:45 PM, with SRNA #28 revealed when working with SRNA #26 during the day shift 11/08/12 they noticed the resident had bruising to the inside thigh area of her left leg near the groin area and was unaware of any discoloration to the area before this time. She stated this was reported to the nurse, who she thought was LPN #9. Interview, on 11/29/12 at 3:15 PM, with LPN #9 revealed she did not assess Resident #37's left hip area on 11/08/12 and no one reported the discoloration to the left thigh area or that the resident was having pain. She indicated if the SRNAs had thought there had been a change in the resident's condition, or he/she was having pain it should have been reported to her. Interview, on 11/29/12 at 2:00 PM, with SRNA #19 revealed while she and another SRNA were turning Resident #37 during the evening shift on 11/08/12 the resident yelled so they informed LPN #35. Interview, on 11/30/12 at 3:05 PM and on 12/06/12 at 2:30 PM, with LPN #35 revealed she assessed Resident #37's hip/thigh area on 11/08/12 related to a report of pain to the resident's left side. She stated there was bruising to the resident's vaginal area and left side and she observed one leg was shorter than the other. She contacted Hospice about the pain and bruising, but did not contact the Physician because calling the Physician was a judgement call. She was told in training if a resident was in Hospice she was supposed to call Hospice, but if Hospice did not called back she was to call the Physician. She stated if the Physician was contacted by Hospice she did not think she would have to notify the Physician also. Record review revealed no documented evidence the facility notified the Physician of the resident's change in condition on 11/08/12. Interview, on 12/05/12 at 10:23 AM, with the APRN, related to the resident's change of condition on 11/08/12, revealed she would expect to be notified if there was bruising on the hips/buttocks of any sort if it was significant whether a resident had Hospice or not. She stated that just because a resident had Hospice didn't mean "we don't treat them". Review of Resident #37's Nursing Progress Note, dated 11/08/12 at 9:00 PM, revealed the resident complained of pain and discomfort in the left leg/hip area, Hospice was called and a new order for [MEDICATION NAME] (a pain reliever) 400 milligrams (mg) every six (6) hours as needed was obtained. Continued review revealed Resident #37's outer left hip, back of left upper leg, and the front of the labia and left leg had discoloration noted and the resident's left foot was turned inward and appeared shorter than the right leg. However, there was no documented evidence the Physician was notified of the change in condition. Interview, on 12/06/12 at 11:05 AM, with LPN #37 revealed on the morning of 11/09/12 she assessed Resident #37 because of reported bruising and pain to the area. She stated during her assessment she observed bruising which was dark purple to the resident's left hip, groin, and "private" area. She stated the resident would cry out in pain anytime she was touched in that area. She stated she called the APRN and Hospice and got an order for [REDACTED]. Review of the x-ray report, dated 11/09/12, revealed Resident #37 had a left [MEDICAL CONDITION]. Interview, on 11/30/12 at 3:30 PM, with Unit Manager, regarding the Progress Note on 11/08/12 at 9:00 PM, revealed even if a resident was in Hospice, nurses were supposed to notify the Physician. She stated the facility was ultimately responsible for the resident. Interview, on 12/04/12 at 2:05 PM, with the Director of Nursing Services (DNS) revealed the Physician should have been notified if there was a change in a resident's condition. Continued interview, on 12/11/12 at 12:20 PM, with the DNS revealed nurses should have conferred with Hospice regarding the changes in Resident #37's condition documented on 11/05/12 and 11/08/12 and then called the resident's Physician. Interview, on 12/14/12 at 7:15 PM, with the facility's Executive Director revealed there was a misunderstanding by the nurse, on Resident #37's change of condition identified on 11/05/12, related to Physician notification. She stated the nurse did not follow the facility's process she had been educated on when she didn't notify the Physician. She stated, in regards to the documented change of Resident #37's condition on 11/08/12 at 9:00 PM, the nurse notified Hospice; however, she should have also notified the Physician. The facility provided an acceptable credible Allegation of Compliance (AOC) on 12/11/12 that alleged removal of the IJ effective 12/11/12. Review of the AOC revealed the facility implemented the following: 1) Head-to-toe skin assessments were performed on all residents from 12/05/12 through 12/06/12 by licensed nurses to identify any others with indication of any change of condition/puffiness, swelling or redness. Any notable findings were communicated to the attending Physician and responsible party. Notable findings included, but were not limited to, Pressure Ulcers, Arterial Ulcers, Diabetic Neuropathic Ulcers, [MEDICAL CONDITION] Ulcers, Surgical Wounds, Skin Tears, Lacerations, Abrasions, Bruises, Burns, Rashes, or a Lesion associated with bleeding, itching, burning, puffiness or swelling, discoloration and/or raised skin areas. The findings were documented by the licensed nurse, and communicated to the Physician and family for further follow-up. The licensed nurse was responsible to document findings in the residents' medical record and the 24 hour report. 2) On 12/05/12 and 12/06/12 facility licensed nurses conducted an audit that reviewed all current residents' progress notes and the 24 hour reports for the previous thirty (30) days (11/05/12 to current) to validate changes in resident condition were identified and addressed with the Physician and responsible party notification. This audit also included validating any changes in resident condition including updating the care plan. 3) The Administrator (Executive Director) communicated the change in the process for Physician notification by the facility to Hospice on 11/30/12 and again on 12/03/12. 4) Physician orders, condition change forms, alert charting lists, stop and watch forms, and 24 hour sift reports would be audited daily starting on 12/06/12 and ongoing by the Director of Nursing Services (DNS), Assistant Director of Nursing Services (ADNS), or Quality Assurance (QA) Registered Nurse (RN), Monday through Friday; and by the Weekend Supervisor RN on Saturdays and Sundays for any residents with a change in condition to validate appropriate identification of changes in resident condition, notification of the Physician and responsible party, and care plan revision. 5) Shift to shift report was observed daily on each unit beginning 12/10/12 and ongoing by the DNS, ADNS, QA Nurse, Unit Managers (UM), three (3) to eleven (11) Supervisor, Weekend Supervisor, RN Case Manager, District Clinical RN Consultant to validate proper use of the 24 hour report and follow-up to resident change in condition. 6) The Guidelines for Physician Notification of Change of Condition/Clinical Problems in Center Residents was placed on the Treatment Administration Record (TAR) on all units 12/06/12 for quick reference for the nurses. 7) On 12/04/12 the Staff Development Coordinator (SDC) initiated education with all facility licensed nursing staff related to change in condition of resident status. Inservice dates were 12/04/12, 12/05/12, 12/06/12 and ongoing until all facility clinical staff had received the education. Education was provided by the SDC, ADNS', three (3) to eleven (11) RN Supervisor, Weekend RN, DNS, or QA RN. No nursing staff would be allowed to work until they had received the education. The inservices included: Situation Background Assessment Recommendation/Request (SBAR) form, 24 hour report form, alert charting system, notification of the Physician and responsible party, assessing for a possible [MEDICAL CONDITION], State Registered Nursing Staff (SRNA) utilizing the Stop and Watch forms, Licensed Nurse notification to Hospice for recommendations for a resident with a change in condition, then notify Physician of the change in condition and notify family. 8) A Performance Improvement Committee (PIC) meeting was held on 12/05/12 and again on 12/06/12. The Medical Director was notified of the Immediate Jeopardy via telephone and approved the plan developed by the PIC on 12/05/12. The PIC reviewed and approved the Allegation of Compliance (AOC). The PIC was to ensure validation of the AOC by: beginning 12/06/12, initial and daily audits of the Physician orders, condition change forms, alert charting lists, Stop and Watch forms, and shift to shift observations were being reviewed by the DNS, ADNS', QA RN, and/or Weekend Supervisor RN on Saturday and Sunday to identify issues, trends or patterns and take corrective action as necessary. The QA RN would be responsible to report trends from the audits to the weekly PIC committee for review and further recommendations. The PIC would create corrective action plans for any areas of concern identified on the audits. The PIC committee would meet weekly or more often as necessary until the facility had removed the Immediate Jeopardy. Once the Immediate Jeopardy was removed the facility would return to routine monthly PIC committee meetings. The State Survey Agency validated the implementation of the facility's AOC as follows: Review of the skin assessment forms revealed all facility residents had skin assessments performed from 12/05/12 through 12/06/12 by licensed nurses, except three (3) who refused and one (1) that was end of life. Audit review revealed newly identified areas were reported to the physician and responsible party. Record review revealed the facility performed the audits as identified on the facility's AOC: An audit of resident progress notes and the 24 hour reports for the last 30 days was performed on 12/05/12 - 12/06/12. Daily audits of Physician orders, condition change forms, alert charting lists, stop and watch forms, and 24 hour shift reports started on 12/06/12. Problems identified were given to the Unit Managers for follow-up. The Shift to Shift audits were initiated by the facility on 12/10/12. Observation of the Treatment Administration Record (TAR) on each unit revealed they had Guidelines for Physician Notification of Change of Condition/Clinical Problems in the front. Interview, on 12/13/12 at 11:05 AM, with the Staff Development Coordinator (SDC) revealed she had completed education with facility staff related to the SBAR form, 24 hour report form, alert charting system, notification of the Physician and responsible party, assessing for a possible [MEDICAL CONDITION], State Registered Nursing Staff (SRNA) utilizing the Stop and Watch forms, Licensed Nurse notification to Hospice for recommendations for a resident with a change in condition, then notify Physician of the change in condition and notify family. Interviews with licensed nursing staff on 12/12/12 at 11:50 AM with Licensed Practical Nurse (LPN) #40, at 3:00 PM with Registered Nurse (RN) #11, at 3:15 PM with LPN #13; on 12/14/12 (7:00 AM to 3:00 PM shift) at 9:50 AM with LPN #3, at 2:00 PM with LPN #9, at 2:17 PM with LPN #16, at 2:45 PM with LPN #32, at 2:53 PM with LPN #15; on 12/14/12 (3:00 PM to 11:00 PM shift) at 5:35 PM with LPN #2, at 6:00 PM with LPN #31; and, on 12/14/12 (11:00 PM to 7:00 AM shift) at 3:42 PM with LPN #19 and at 4:32 PM with LPN #38 revealed they were all aware the "Guidelines for Physician Notification of Change of Condition/Clinical Problems in Center Residents" was on the Treatment Administration Record (TAR); they had received education on the Situation Background Assessment Recommendation/Request (SBAR) form; the 24 hour report form; the alert charting system; notification of the Physician and responsible party; assessing residents for a possible [MEDICAL CONDITION]; the State Registered Nursing Staff (SRNA) utilizing the Stop and Watch forms; and after notification to Hospice for recommendations for a resident with a change in condition, that they were to then notify the Physician of the change in condition and obtain orders, then notify the family. All licensed nurses interviewed confirmed that the shift to shift reports were being audited by Unit Managers, Assistant Director of Nursing Services (ADNS), 3:00 PM to 11:00 PM Supervisor, Quality Assurance Registered Nurse, and Weekend Supervisor. Interview, on 12/12/12 at 10:05 AM with State Registered Nursing Assistants (SRNAs) #8 and #9; on 12/14/12 at 9:15 AM with SRNA #37, at 9:15 AM with SRNA #38, at 2:33 PM with SRNA #27, at 3:00 PM with SRNA #32, at 3:40 PM with SRNA #39, at 4:00 PM with SRNA #13, at 4:19 PM with SRNA #34, at 4:28 PM with SRNA #35, and at 5:15 PM with SRNAs #33 and #36 revealed they had all received education on the Stop and Watch form for communicating changes in residents' condition to the nurses. Interview, on 12/14/12 at 9:25 AM with LPN #39 and at 9:30 AM with LPN #16 revealed the SRNAs had received training on the Stop and Watch form. Interview, on 12/11/12 at 12:20 PM, with the Director of Nursing Services (DNS) revealed education had been performed with facility staff in regards to the "skin sheet", Stop and Watch form, 24 hour report form, and proper notification of the Physician and family. She stated nurses had been re-educated to confer with Hospice, and also notify the Physician and responsible party. An additional interview, on 12/14/12 at 5:00 PM, with the DNS revealed in the facility's daily clinical review they were monitoring: the notification of change to the Physician and family, care plan updates, 24 hour report forms, alert charting forms, condition change forms, and Stop and Watch forms. She stated any concerns were followed up on by the Unit Managers (UM). The DNS stated she ensured the UMs completed the follow up via another meeting at the end of the day. According to the DNS, shift reports were being audited every day. She stated the audits were to ensure nurses were utilizing the 24 hour report form, alert charting, and any Stop and Watch forms to ensure the following shift was updated on residents' condition changes. Interview, on 12/14/12 at 11:40 AM, with RN #10/Assistant Director of Nursing Services (ADNS) for A and B units, revealed she audited progress notes, SBAR forms, Physician orders, condition change forms, alert charting lists, stop and watch forms, and 24 hour shift reports for the past thirty (30) days, and also ensured the care plan was updated. In an additional interview with RN #10/ADNS at 5:20 PM revealed she had monitored the shift to shift reports to ensure nurses were utilizing the 24 hour report form, the alert charting form, and any Stop and Watch forms to ensure the oncoming shift was aware of any changes in residents' condition. Interview, on 12/14/12 at 2:00 PM, with RN #2/ADNS (for C and D units) revealed he had performed audits of progress notes, SBAR forms, Physician orders, condition change forms, alert charting lists, stop and watch forms, and 24 hour shift reports for the past thirty (30) days. Interview, on 12/14/12 at 6:15 PM with the Weekend Supervisor RN revealed he had audited shift to shift reports to ensure the 24 hour report form, the alert charting and any Stop and Watch forms were being utilized to pass on residents' condition changes to the oncoming shift. He stated he had performed audits of the Physician orders, SBAR forms, condition change forms, alert charting lists, stop and watch forms, and 24 hour shift reports. Interview, on 12/14/12 at 6:10 PM, with the Medical Director revealed she had been notified of the Immediate Jeopardy by telephone and had approved the Allegation of Compliance (AOC) after discussion with the facility. She stated the Performance Improvement Committee (PIC) had been meeting weekly since the Immediate Jeopardy was identified and she was involved with these meetings. Interview, on 12/14/12 at 7:15 PM, with the ED and Quality Assurance (QA) RN revealed the Executive Director communicated the change in the process for Physician notification by the facility to Hospice. She stated Hospice had been educated that the facility's nurses would contact the Physician. The QA RN verified that audits were being performed as per the AOC, such as shift to shift report audits to ensure the 24 hour report form and alert charting information was being utilized. The QA RN indicated if audits were performed at shift change then the 24 hour report, alert charting, SBAR forms, and Stop and Watch forms were being audited to ensure a change in a resident's condition is being passed along. According to the QA RN, the results of all the audits on the 24 hour report form, SBAR form, alert charting form, condition change form, care plan updates, Physician orders, Physician and family notification, and Stop and Watch forms were taken to the morning clinical meeting and discussed. The QA RN stated if a problem was identified then staff were educated by the person doing the audit. The QA RN stated he reported the results of the audits and any trends to the weekly PIC meeting. The ED stated education was performed as per the AOC. She stated through the use of the new three (3) part SBAR form and Stop and Watch form that communication was now "shored" up. She stated staff had been educated to ensure a Stop and Watch form was filled out with any change in a resident's condition. An additional interview, on 12/14/12 at 8:00 PM, with the ED revealed the PIC had been meeting weekly. According to the ED, the PIC was performing what was indicated in the AOC (i.e.-validating the AOC by: reviewing initial and daily audits of the Physician orders, condition change forms, alert charting lists, Stop and Watch forms; and shift to shift observations were being reviewed to identify issues, trends or patterns and to take the corrective action as necessary). Corrective action plans for any areas of concern identified on the audits would be implemented.

Based on observation, interview, record review, and review of facility policy and the facility's plan of correction for the 10/03/12 standard survey it was determined the facility failed to maintain a Quality Assessment and Assurance Program that developed and implemented appropriate plans of action to correct quality deficiencies. This was evidenced by repeated deficiencies related to the facility's failure to provide necessary care and services, and failure to ensure Physician notification. This failure resulted in continued noncompliance at 42 CFR 483.5 Resident Rights, F-157; 42 CFR 483.25 Quality of Care, F-309, and 42 CFR 483.75 Administration, F-520 at a scope and severity of a "J". The facility failed to ensure Resident #37 received the necessary care and services as evidenced by failure to assess and recognize a change in the resident's condition. Interviews revealed the resident had puffiness and pain in the left hip area on 11/05/12. The facility failed to notify the Physician of the puffiness and pain in the left hip area. The facility failed to ensure continued assessment and monitoring of this area. Interviews with staff revealed the left hip area continued to be painful to the resident, and the resident was observed by staff to have bruising in the area which changed in color and became larger. According to interview with a Hospice Registered Nurse (RN) when she observed the left hip area on the morning of 11/08/12 the bruising extended from the left hip to the pubic area. There was no documented evidence by the facility that the Physician was notified of Resident #37's condition change until 11/09/12 at 10:00 AM. An x-ray was ordered and obtained on 11/09/12, which revealed Resident #37 had a fractured left hip. The facility's failure to ensure each resident received the necessary care and services related to assessing, monitoring and identifying changes in residents' condition; the facility's failure to notify the physician of changes in residents' condition; and failure of the facility's Quality Assurance Program to effectively re-educate and monitor staff on communicating and notifying the Physician on resident changes of condition was likely to cause risk for serious injury, harm, or impairment or death. The facility was notified, on 12/05/12, of the Immediate Jeopardy at 42 CFR 483.10 Resident Rights (F157); 42 CFR 483.25 Quality of Care (F309); 42 CFR 483.75 Administration (F490) and (F520) with Substandard Quality of Care in the area of 42 CFR 483.25 Quality of Care (F309). The Immediate Jeopardy was determined to exist on 11/05/12. The facility provided an acceptable credible Allegation of Compliance (AOC) on 12/11/12 prior to exiting the facility on 12/14/12, with the facility alleging removal of the Immediate Jeopardy on 12/11/12. The Immediate Jeopardy was verified to be removed on 12/14/12, prior to exiting the facility, with remaining non-compliance at 42 CFR 483.75, Administration, F-520 Quality Assurance, with a Scope and Severity of "D", while the facility develops and implements a Plan of Correction, and the facility's Quality Assurance continues to monitor to ensure the effectiveness of staff education, monitoring developed, and revisions to policies and procedures. The findings include: The facility's Quality Assurance Program failed to ensure the systemic changes noted on the acceptable Plan of Correction, for the 10/03/12 standard survey, were effective in ensuring compliance with F157 and F309 in regards to State Registered Nursing Assistants (SRNAs) communicating resident changes of condition, and licensed nurses notifying Physicians of changes in condition of a resident and related audits to monitor and assess changes in condition. The facility failed to ensure implementation of the "Condition Change of a Resident" policy; failed to ensure the Physician was notified of changes in residents' condition; and, facility failed to ensure each resident received the necessary care and services to attain or maintain the highest practicable physical well-being. (Refer to F157, and F309). 1. Based on observation, interview, and record review, it was determined the facility failed to ensure the Physician was notified of a change in Resident #37's condition. This was a repeat deficiency which was cited during a Standard and Abbreviated Survey conducted 09/17/12 through 10/03/12 related to failure to notify the Physician when a resident had an area/nodule in the vaginal area that changed in color and appearance. Review of the facility's Plan of Correction (POC), with a compliance date of 10/30/12, revealed the licensed nurses were re-educated related to performing head to toe skin assessments, with emphasis on notable findings that required Physician and family notification. State Registered Nursing Assistants (SRNAs) were educated to report changes resident conditions. In addition, notices were posted at each nursing station for SRNAs to immediately report any change in a resident's skin condition. Additionally, according to the POC, the progress notes were to be reviewed Monday through Friday for appropriate notification. The results of the audits were to be reported to Performance Improvement Committee (PIC) for four (4) weeks, then monthly thereafter. Record review and interview revealed facility staff had observed changes of condition in Resident #37's left leg and hip area from 11/05/12 through 11/08/12, however failed to effectively communicate these changes to other staff and failed to notify the Physician of the changes in the resident's condition. The Physician was notified on 11/09/12 and orders were received for an x-ray of the area. Review of the Radiology Report revealed the resident had a left [MEDICAL CONDITION]. (Refer to F-157) 2. Based on observation, interview, record review and review of the facility policy the facility failed to have an effective system in place to ensure residents' received necessary care and services in regards to assessment and monitoring for one (1) resident (Resident #37) resulting in a repeat deficiency. Review of the facility's Plan of Correction (PoC), with a compliance date of 10/30/12, revealed five (5) SRNAs per week per unit for three (3) months were to be interviewed to validate new and/or unusual findings had been reported to the nurse, and that the nurse had appropriately assessed, documented, and made notification to the Physician and family. In addition, the Director of Nursing (DNS), Assistant Director of Nursing Services (ADNS), Staff Development Coordinator, would conduct an audit of three (3) skin assessments per unit per week for three months to validate skin assessment accuracy and one licensed nurse skin assessment would be observed weekly and documentation reviewed to determine accuracy and proper notification when appropriate. All weekly skin assessment documentation would be reviewed for one month to validate appropriate physician/family notification. Record review and interview revealed facility staff had observed changes of condition in Resident #37's left leg and hip from 11/05/12 through 11/08/12, however failed to assess and monitor these changes. Record review revealed an x-ray was obtained on 11/09/12 which indicated the resident had a [MEDICAL CONDITION]. (Refer to F-309). Interview, on 12/14/12 at 7:15 PM, with the Executive Director and the Quality Assurance Nurse revealed the when the nurses identified a change of condition, to Resident #37, they did not follow the facility's notification process to contact the Physician. They re-educated the nurses, when a change of condition was identified, to contact Hospice for recommendations and then contact the Physician. They have also informed Hospice of the change. The Executive Director further stated there was miscommunication. The nurse on 11/05/12 did not put the information regarding the resident's change of condition on the alert charting or the 24 hour report to communicate to other staff to follow-up. The Quality Assurance Nurse reported when the aides noted changes to Resident #37, left leg/hip area and increased pain, on 11/07/12 and 11/08/12 they should have completed the Stop and Watch form, written the findings on the 24 hour report, or they should have brought the nurse to the resident and pointed it out. Because this was not done, the site was not monitored (assessed) by the nurses and the Physician was not made aware. Further interview with the Quality Assurance Nurse revealed to prevent re-occurrence the facility put in place a shift to shift report audit to ensure nurses used the 24 hour report and alert charting for any resident condition change. In addition, the shift audit looked at alert charting documentation and if the SBAR form and Stop and Watch forms were utilized. At the morning clinical meetings they continued the audit process, by review of the 24 hour report sheet, alert charting, condition change forms, any care plan revisions, Physician Orders, the SBAR and Stop and Watch forms, and was proper notification completed if changes were identified. If problems were identified the person who performed the audit would re-educate staff and the expectation was it was corrected that day. The Unit Managers follow-up and report back at the PM meeting. The audit data was reviewed to identify problems/problematic trends and the results reported at the weekly Performance Improvement meeting and the monthly Quality Assurance Meeting. The facility provided an acceptable credible Allegation of Compliance (AOC) on 12/11/12 that alleged removal of the IJ effective 12/11/12. Review of the AOC revealed the facility implemented the following: 1) Head-to-toe skin assessments were performed on all residents from 12/05/12 through 12/06/12 by licensed nurses to identify any others with indication of any change of condition/puffiness, swelling or redness. Any notable findings were communicated to the attending Physician and responsible party. Notable findings included, but were not limited to, Pressure Ulcers, Arterial Ulcers, Diabetic Neuropathic Ulcers, [MEDICAL CONDITION] Ulcers, Surgical Wounds, Skin Tears, Lacerations, Abrasions, Bruises, Burns, Rashes, or a Lesion associated with bleeding, itching, burning, puffiness or swelling, discoloration and/or raised skin areas. The findings were documented by the licensed nurse, and communicated to the Physician and family for further follow-up. The licensed nurse was responsible to document findings in the residents' medical record and the 24 hour report. 2) On 12/05/12 and 12/06/12 facility licensed nurses conducted an audit that reviewed all current residents' progress notes and the 24 hour reports for the previous thirty (30) days (11/05/12 to current) to validate changes in resident condition were identified and addressed with the Physician and responsible party notification. This audit also included validating any changes in resident condition including updating the care plan. 3) The Administrator (Executive Director) communicated the change in the process for Physician notification by the facility to Hospice on 11/30/12 and again on 12/03/12. 4) Physician orders, condition change forms, alert charting lists, stop and watch forms, and 24 hour sift reports would be audited daily starting on 12/06/12 and ongoing by the Director of Nursing Services (DNS), Assistant Director of Nursing Services (ADNS), or Quality Assurance (QA) Registered Nurse (RN), Monday through Friday; and by the Weekend Supervisor RN on Saturdays and Sundays for any residents with a change in condition to validate appropriate identification of changes in resident condition, notification of the Physician and responsible party, and care plan revision. 5) Shift to shift report was observed daily on each unit beginning 12/10/12 and ongoing by the DNS, ADNS, QA Nurse, Unit Managers (UM), three (3) to eleven (11) Supervisor, Weekend Supervisor, RN Case Manager, District Clinical RN Consultant to validate proper use of the 24 hour report and follow-up to resident change in condition. 6) The Guidelines for Physician Notification of Change of Condition/Clinical Problems in Center Residents was placed on the Treatment Administration Record (TAR) on all units 12/06/12 for quick reference for the nurses. 7) On 12/04/12 the Staff Development Coordinator (SDC) initiated education with all facility licensed nursing staff related to change in condition of resident status. Inservice dates were 12/04/12, 12/05/12, 12/06/12 and ongoing until all facility clinical staff had received the education. Education was provided by the SDC, ADNS', three (3) to eleven (11) RN Supervisor, Weekend RN, DNS, or QA RN. No nursing staff would be allowed to work until they had received the education. The inservices included: Situation Background Assessment Recommendation/Request (SBAR) form, 24 hour report form, alert charting system, notification of the Physician and responsible party, assessing for a possible [MEDICAL CONDITION], State Registered Nursing Staff (SRNA) utilizing the Stop and Watch forms, Licensed Nurse notification to Hospice for recommendations for a resident with a change in condition, then notify Physician of the change in condition and notify family. 8) A Performance Improvement Committee (PIC) meeting was held on 12/05/12 and again on 12/06/12. The Medical Director was notified of the Immediate Jeopardy via telephone and approved the plan developed by the PIC on 12/05/12. The PIC reviewed and approved the Allegation of Compliance (AOC). The PIC was to ensure validation of the AOC by: beginning 12/06/12, initial and daily audits of the Physician orders, condition change forms, alert charting lists, Stop and Watch forms, and shift to shift observations were being reviewed by the DNS, ADNS', QA RN, and/or Weekend Supervisor RN on Saturday and Sunday to identify issues, trends or patterns and take corrective action as necessary. The QA RN would be responsible to report trends from the audits to the weekly PIC committee for review and further recommendations. The PIC would create corrective action plans for any areas of concern identified on the audits. The PIC committee would meet weekly or more often as necessary until the facility had removed the Immediate Jeopardy. Once the Immediate Jeopardy was removed the facility would return to routine monthly PIC committee meetings. 9) The District and/or Regional team would provide RN clinical oversight a minimum of three (3) days per week beginning the week of 12/02/12. 10) The facility contracted an outside clinical consulting group on 11/20/12 to conduct onsite facility clinical oversight two (2) days per week beginning 12/02/12. The State Survey Agency validated the implementation of the facility's AOC as follows: Review of the skin assessment forms revealed all facility residents had skin assessments performed from 12/05/12 through 12/06/12 by licensed nurses, except three (3) who refused and one (1) that was end of life. Audit review revealed newly identified areas were reported to the physician and responsible party. Record review revealed the facility performed the audits as identified on the facility's AOC: An audit of resident progress notes and the 24 hour reports for the last 30 days was performed on 12/05/12 - 12/06/12. Daily audits of Physician orders, condition change forms, alert charting lists, stop and watch forms, and 24 hour shift reports started on 12/06/12. Problems identified were given to the Unit Managers for follow-up. The Shift to Shift audits were initiated by the facility on 12/10/12. Observation of the Treatment Administration Record (TAR) on each unit revealed they had Guidelines for Physician Notification of Change of Condition/Clinical Problems in the front. Interview, on 12/13/12 at 11:05 AM, with the Staff Development Coordinator (SDC) revealed she had completed education with facility staff related to the SBAR form, 24 hour report form, alert charting system, notification of the Physician and responsible party, assessing for a possible [MEDICAL CONDITION], State Registered Nursing Staff (SRNA) utilizing the Stop and Watch forms, Licensed Nurse notification to Hospice for recommendations for a resident with a change in condition, then notify Physician of the change in condition and notify family. Interview, on 12/13/12 at 11:00 AM, with the Executive Director (ED), Vice President of Clinical Operations, Director of District Operations, Director of Nursing Services (DNS), Quality Assurance (QA) RN, and contracted Nurse Consultant revealed the District and/or Regional team would provide RN clinical oversight a minimum of three (3) days per week beginning the week of 12/02/12. In addition, the facility had contracted with an outside clinical consulting group on to conduct onsite facility clinical oversight two (2) days per week. Interviews with licensed nursing staff on 12/12/12 at 11:50 AM with Licensed Practical Nurse (LPN) #40, at 3:00 PM with Registered Nurse (RN) #11, at 3:15 PM with LPN #13; on 12/14/12 (7:00 AM to 3:00 PM shift) at 9:50 AM with LPN #3, at 2:00 PM with LPN #9, at 2:17 PM with LPN #16, at 2:45 PM with LPN #32, at 2:53 PM with LPN #15; on 12/14/12 (3:00 PM to 11:00 PM shift) at 5:35 PM with LPN #2, at 6:00 PM with LPN #31; and, on 12/14/12 (11:00 PM to 7:00 AM shift) at 3:42 PM with LPN #19 and at 4:32 PM with LPN #38 revealed they were all aware the "Guidelines for Physician Notification of Change of Condition/Clinical Problems in Center Residents" was on the Treatment Administration Record (TAR); they had received education on the Situation Background Assessment Recommendation/Request (SBAR) form; the 24 hour report form; the alert charting system; notification of the Physician and responsible party; assessing residents for a possible [MEDICAL CONDITION]; the State Registered Nursing Staff (SRNA) utilizing the Stop and Watch forms; and after notification to Hospice for recommendations for a resident with a change in condition, that they were to then notify the Physician of the change in condition and obtain orders, then notify the family. All licensed nurses interviewed confirmed that the shift to shift reports were being audited by Unit Managers, Assistant Director of Nursing Services (ADNS), 3:00 PM to 11:00 PM Supervisor, Quality Assurance Registered Nurse, and Weekend Supervisor. Interview, on 12/12/12 at 10:05 AM with State Registered Nursing Assistants (SRNAs) #8 and #9; on 12/14/12 at 9:15 AM with SRNA #37, at 9:15 AM with SRNA #38, at 2:33 PM with SRNA #27, at 3:00 PM with SRNA #32, at 3:40 PM with SRNA #39, at 4:00 PM with SRNA #13, at 4:19 PM with SRNA #34, at 4:28 PM with SRNA #35, at 5:15 PM with SRNAs #33 and #36 revealed they had all received education on the Stop and Watch form for communicating changes in residents' condition to the nurses. Interview, on 12/14/12 at 9:25 AM with LPN #39 and at 9:30 AM with LPN #16 revealed the SRNAs had received training on the Stop and Watch form. Interview, on 12/11/12 at 12:20 PM, with the Director of Nursing Services (DNS) revealed education had been performed with facility staff in regards to the "skin sheet", Stop and Watch form, 24 hour report form, and proper notification of the Physician and family. She stated nurses had been re-educated to confer with Hospice, however they were to notify the Physician and responsible party. In an additional interview, on 12/14/12 at 5:00 PM, with the DNS revealed in the facility's daily clinical review they were monitoring: the notification of change to the Physician and family, care plan updates, 24 hour report forms, alert charting forms, condition change forms, and Stop and Watch forms. She stated any concerns are followed up on by the Unit Managers (UM). The DNS stated she ensures the UMs complete the follow up via another meeting at the end of the day. According to the DNS, shift reports were being audited every day. She stated the audits were to ensure nurses were utilizing the 24 hour report form, alert charting, and any Stop and Watch forms to ensure the following shift was updated on residents' condition changes. Interview, on 12/14/12 at 11:40 AM, with RN #10/Assistant Director of Nursing Services (ADNS) for A and B units, revealed she audited progress notes, SBAR forms, Physician orders, condition change forms, alert charting lists, stop and watch forms, and 24 hour shift reports for the past thirty (30) days, and also ensured the care plan was updated. In an additional interview with RN #10/ADNS at 5:20 PM revealed she had monitored the shift to shift reports to ensure nurses were utilizing the 24 hour report form, the alert charting form, and any Stop and Watch forms to ensure the oncoming shift was aware of any changes in residents' condition. Interview, on 12/14/12 at 2:00 PM, with RN #2/ADNS (for C and D units) revealed he had performed audits of progress notes, SBAR forms, Physician orders, condition change forms, alert charting lists, stop and watch forms, and 24 hour shift reports for the past thirty (30) days. Interview, on 12/14/12 at 6:15 PM with the Weekend Supervisor RN revealed he had audited shift to shift reports to ensure the 24 hour report form, the alert charting and any Stop and Watch forms were being utilized to pass on residents' condition changes to the oncoming shift. He stated he had performed audits of the Physician orders, SBAR forms, condition change forms, alert charting lists, stop and watch forms, and 24 hour shift reports. Interview, on 12/14/12 at 6:10 PM, with the Medical Director revealed she had been notified of the Immediate Jeopardy by telephone and had approved the Allegation of Compliance (AOC) after discussion with the facility. She stated the Performance Improvement Committee (PIC) had been meeting weekly since the Immediate Jeopardy was identified and she was involved with these meetings. Interview, on 12/14/12 at 7:15 PM, with the ED and Quality Assurance (QA) RN revealed the Executive Director communicated the change in the process for Physician notification by the facility to Hospice. She stated Hospice had been educated that the facility's nurses would contact the Physician. The QA RN verified that audits were being performed as per the AOC, such as shift to shift report audits to ensure the 24 hour report form and alert charting information was being utilized. The QA RN indicated if audits were performed at shift change then the 24 hour report, alert charting, SBAR forms, and Stop and Watch forms were being audited to ensure a change in a resident's condition is being passed along. According to the QA RN, the results of all the audits on the 24 hour report form, SBAR form, alert charting form, condition change form, care plan updates, Physician orders, Physician and family notification, and Stop and Watch forms were taken to the morning clinical meeting and discussed. The QA RN stated if a problem was identified then staff were educated by the person doing the audit. The QA RN stated he reported the results of the audits and any trends to the weekly PIC meeting. The ED stated education was performed as per the AOC. She stated through the use of the new three (3) part SBAR form and Stop and Watch form that communication was now "shored" up. She stated staff had been educated to ensure a Stop and Watch form was filled out with any change in a resident's condition. An additional interview, on 12/14/12 at 8:00 PM, with the ED revealed the PIC had been meeting weekly. According to the ED, the PIC was performing what was indicated in the AOC (i.e.-validating the AOC by: reviewing initial and daily audits of the Physician orders, condition change forms, alert charting lists, Stop and Watch forms; and shift to shift observations were being reviewed to identify issues, trends or patterns and to take the corrective action as necessary). Corrective action plans for any areas of concern identified on the audits would be implemented.

Based on observation, interview, record review and review of facility's policy it was determined the facility failed to have an effective system to ensure the comprehensive plan of care was reviewed and revised for three (3) of nineteen (19) sampled residents (Residents #37, Resident #41 and Resident #2). The facility failed to update the care plan for Resident #37 after the resident was assessed on 11/05/12 for having pain and puffiness in the left hip area for interventions to include continued monitoring and assessment of the area to prevent further pain and ensure the resident received the appropriate care and services. Three days later, on 11/08/12, Resident #37 was assessed by the nurse with pain/discomfort in the left hip/leg area and discoloration to the left hip, back of the left leg, front of the labia, and inside of the left leg and the left foot was turned inward and the left leg being shorter than the right leg. Review of the Comprehensive Care Plan revealed no documented evidence the care plan was revised related to the resident's change in condition other than an order to administer 400 milligrams [MEDICATION NAME] every six hours as needed. On the morning of 11/09/12 Resident #37 was noted to have bruising which was dark purple to the resident's left hip, groin, and "private" area and the resident cried out in pain. The APRN was contacted and an order obtained for an x-ray which revealed Resident #37 had a left [MEDICAL CONDITION]. (Refer to F-157 and F-309) In addition, the facility failed to revise Resident #41's care plan after the resident was readmitted to the facility and had oxygen in use. Also, the facility failed to revise Resident #2's care plan when he/she was placed in contact precautions after being diagnosed with [REDACTED]. Based on the above findings it was determined the facility's failure to revise the Comprehensive Plan of Care to ensure staff were aware of residents' care needs was likely to cause risk for serious injury, harm, impairment or death. The Immediate Jeopardy was identified on 12/05/12, and determined to exist on 11/05/12. The facility was notified of the Immediate Jeopardy on 12/05/12. The facility provided an acceptable credible Allegation of Compliance (AOC) on 12/11/12 with the facility alleging removal of the Immediate Jeopardy on 12/11/12. The Immediate Jeopardy was verified to be removed on 12/11/12, prior to exiting the facility on 12/14/12, with remaining non-compliance at 42 CFR 483.20, Resident Assessment F-280, with a Scope and Severity of "D", while the facility develops and implements a Plan of Correction, and the facility's Quality Assurance continues to monitor to ensure care plans are revised appropriately. The findings include: Review of facility policy titled "Comprehensive Plan of Care", revised date 08/31/12, revealed a Comprehensive Plan of Care was developed for each resident and was to be re-evaluated and modified as necessary to reflect changes in care, service, and treatment. Further review revealed the care plan was to be updated during the course of care delivery to reflect new problems or modify interventions as a result of a change of condition in a resident. Review of facility policy titled "Condition Change in a Resident", dated 10/31/06, revealed resident change of condition was identified for proper treatment implementation. The policy referenced three (3) times that the Care Plan should be updated with a change in condition. In addition, review of the Transmission-Based Precaution policy, dated 09/19/12, revealed once precautions are initiated, the care plan should be updated to reflect this status. Interview, on 12/10/12 at 3:00 PM, with the Minimum Data Set (MDS) Coordinator, regarding the care plan process, revealed the Comprehensive Care Plan is based on the MDS Assessment. She stated nursing staff were responsible for making changes/updates from one Comprehensive Assessment to the next. According to the MDS Coordinator, the care plan update would occur based on a change and the interventions already in place would determine what updates would be required. 1. Record review revealed Resident #37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Significant Change MDS, dated [DATE], revealed facility assessed the resident to be severely cognitively impaired. Further review of this MDS Assessment revealed the facility assessed the resident to require limited to extensive assistance with all Activities of Daily Living (ADLs). Review of Resident #37's Comprehensive Care Plan revealed a plan of care, dated 11/23/11, for extensive assistance with all Activities of Daily Living (ADLs) related to cognitive loss. Interview, on 11/28/12 at 5:10 PM, with State Registered Nursing Assistant (SRNA) #20 revealed she noticed Resident #37's left hip was red, swollen and inflamed on 11/05/12. Additional interview, on 12/10/12 at 3:30 PM revealed she told a nurse of Resident #37's change of condition on 11/05/12. Review of a Nursing Progress Note, dated 11/05/12 at 9:00 PM, revealed Resident #37 complained of pain to the left hip/leg. Continued review revealed the left hip area was puffy, with no redness, no discoloration, and the lower extremities were equal in length. The facility failed to revise the plan of care to include interventions for assessment and monitoring related to the resident's change in condition. Review of Resident #37's medical record revealed a Nursing Progress Note, dated 11/08/12 (three days later), that documented the resident complained of pain and discomfort in the left leg/hip. The Note stated Resident #37's outer left hip, back of left upper leg, and the front of the labia and left leg had discoloration noted and the resident's left foot was turned inward and appeared shorter than the right leg. Review revealed the Nurse documented she called Hospice and obtained a new order for [MEDICATION NAME] (a pain reliever) 400 milligrams (mg) every six (6) hours as needed. However, there was no documented evidence the Comprehensive Care Plan was updated to include interventions for assessment and monitoring related to the resident's change in condition. Interview, on 12/06/12 at 11:05 AM, with LPN #37 revealed on the morning of 11/09/12 she assessed Resident #37 because of reported bruising and pain to the area. She stated during her assessment she observed bruising which was dark purple to the resident's left hip, groin, and "private" area and the resident would cry out in pain anytime she was touched in that area. She stated she called the APRN an order for [REDACTED]. Review of the x-ray report, dated 11/09/12, revealed Resident #37's had a left [MEDICAL CONDITION]. Interview, on 12/06/12 at 2:30 PM, with LPN #35 revealed care plans were supposed to be updated immediately when a change was identified. She indicated she was just off orientation and knew she was supposed to update the care plan on the resident's complaint of pain. However, she stated she did not think she needed to update the care plan with her assessment findings of the bruising on the resident's outer left hip, back of left upper leg, and the front of the labia, or the left leg or of one leg being shorter than the other. Interview, on 12/10/12 at 3:00 PM, with the Minimum Data Set (MDS) Coordinator revealed if a nurse assessed a resident to have pain, bruising, one foot turned inward, and one leg shorter than the other, the nurse should have revised the care plan to include this information. She stated based on the findings identified in the assessments, it would have been appropriate to revise the care plan to include an intervention to encourage the resident not to get up until they had further evaluation and treatment, such as an x-ray. Interview, on 12/11/12 at 12:20 PM, with the Director on Nursing Services revealed her expectation of the nurse, regarding the documented assessment findings of 11/05/12 and 11/08/12 would have been that the care plan was revised to include nursing intervention, such as, continued observations of the area. She stated the nurses should have contacted the Physician regarding their assessments and then revised the care plan. 2. Review of Resident #41's medical record revealed an admission date of [DATE], and a readmission date of [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed the facility assessed Resident #41 to have not required oxygen use in the previous fourteen (14) days. Further review of the MDS revealed the facility assessed Resident #41 to have a Brief Interview for Mental Status (BIMS) score of twelve (12). Record review revealed a physician's orders [REDACTED]. Review of the record revealed Resident #41 was sent out to the hospital for evaluation on 11/28/12 related to "sudden onset chills". Review revealed the resident had an oxygen saturation level of seventy-nine (79) percent and shortness of air (SOA). Continued record review revealed the resident was readmitted to the facility on [DATE] with no documented evidence of oxygen use on readmission. Review of the admission orders [REDACTED] Observation, on 12/11/12 at 3:14 PM, on 12/11/12 at 4:40 PM, and on 12/12/12 at 8:50 AM, revealed Resident #41 to have oxygen in use per nasal cannula at two (2) liters per minute (LPM) via an oxygen concentrator. Interview, on 12/11/12 at 4:40 PM, with Resident #41 and his/her daughter revealed Resident #41 had been using oxygen continuously at the facility since his/her return from the hospital on [DATE]. Interview, on 12/12/12 at 8:50 AM with Occupational Therapist (OT) #1 revealed Resident #41 used oxygen "all the time now". Interview, on 12/12/12 at 9:30 AM, with SRNA #32 revealed she had observed Resident #41 using oxygen continuously since his/her return from the hospital. Interview, on 12/12/12 at 3:28 PM, with SRNA #33 revealed Resident #41 had been using oxygen since his/her return from the hospital. Interview, on 12/12/12 at 4:40 PM, with LPN #41 revealed she had observed Resident #41 using oxygen since his/her return from the hospital. In an additional interview, on 12/12/12 at 7:35 PM, LPN #41 stated a care plan should have been developed for the resident's use of oxygen. Interview, on 12/12/12 at 3:33 PM, Respiratory Therapist (RT) #1 revealed he had observed Resident #41 using oxygen since his/her return from the hospital. He stated he had also observed Resident #41 in the facility's hallways with portable oxygen in use. The RT stated when he assessed Resident #41 on 12/12/12, he/she needed oxygen related to upon exertion the resident showed "signs of dyspnea" (shortness of breath) and cyanosis (bluish discoloration of the skin and mucous membranes caused by a lack of oxygen in the blood). Interview, on 12/12/12 at 5:58 PM, the Director of Nursing Services (DNS) revealed a care plan should have been developed with nursing interventions for Resident #41's oxygen use. Continued review of Resident #41's record revealed no documented evidence on the Comprehensive Care Plan of the resident's use of or need for oxygen use. 3. Observation, on 12/11/12 at 4:30 PM, revealed LPN #14 in Resident #2's room administering medications wearing gloves and no gown. Continued observation revealed Personal Protective Equipment (PPE), such as gloves and gowns to be in pouches in a plastic container on the door of the resident's room. Observation revealed a contact precaution sign was placed in one of the pouches of the plastic container that held the PPE. Interview with LPN #14, on 12/11/12 at 4:35 PM, revealed she was not aware the resident had been placed in contact isolation. She indicated she was aware the resident had an infected toe. Interview, on 12/11/12 at 4:35 PM, with the Assistant Director of Nursing (ADNS), who had overheard the interview with LPN #14, revealed the resident had been placed in contact isolation on 12/10/12. She stated that decision had been made during the morning meeting on 12/10/12. Continued interview with LPN #14 revealed that information, regarding the contact isolation, had not been communicated to her. Review of Resident #2's clinical record revealed a wound culture was obtained on 12/06/12 with the results reported to the facility on [DATE]. Review of the lab report revealed the wound culture findings included a heavy growth of Staph Aureus and Morganella. Review revealed the Physician was notified of these findings, and upon his visit to see the resident on 12/11/12, he ordered a different antibiotic treatment. Review of the Comprehensive Care Plan, revised on 10/04/12, revealed no documented evidence the care plan was revised to include the contact precaution, wound infection, and treatment. Interview with RN #14, on 12/14/12 at 6:10 PM, revealed she completed the Comprehensive Care Plans for Unit B, where Resident #2 resided. She stated she only revised the care plan during the quarterly review. She indicated if any changes occurred between those quarterly reviews, the staff nurses were supposed to revise the care plan to reflect those changes. She stated the nurse should have revised the care plan whenever the lab results were reported. However, interview with LPN #14, on 12/14/12 at 9:50 AM, revealed the resident was already on an antibiotic treatment and she was unaware the resident had been placed on contact precautions. She indicated the Physician came to see the resident, on 12/11/12 at 9:00 PM, but she was not the nurse who took off that order. The LPN indicated a three (3) part condition change form that would have included a care plan revision was not completed. The facility provided an acceptable credible Allegation of Compliance (AOC) on 12/11/12 that alleged removal of the IJ effective 12/11/12. Review of the AOC revealed the facility implemented the following: 1) Head-to-toe skin assessments were performed on all residents from 12/05/12 through 12/06/12 by licensed nurses to identify any others with indication of any change of condition/puffiness, swelling or redness. Any notable findings were communicated to the attending Physician and responsible party. Notable findings included, but were not limited to, Pressure Ulcers, Arterial Ulcers, Diabetic Neuropathic Ulcers, [MEDICAL CONDITION] Ulcers, Surgical Wounds, Skin Tears, Lacerations, Abrasions, Bruises, Burns, Rashes, or a Lesion associated with bleeding, itching, burning, puffiness or swelling, discoloration and/or raised skin areas. The findings were documented by the licensed nurse, and communicated to the Physician and family for further follow-up. The licensed nurse was responsible to document findings in the residents' medical record and the 24 hour report. 2) On 12/05/12 and 12/06/12 facility licensed nurses conducted an audit that reviewed all current residents' progress notes and the 24 hour reports for the previous thirty (30) days (11/05/12 to current) to validate changes in resident condition were identified and addressed with the Physician and responsible party notification. This audit also included validating any changes in resident condition including updating the care plan. 3) The Administrator (Executive Director) communicated the change in the process for Physician notification by the facility to Hospice on 11/30/12 and again on 12/03/12. 4) Physician orders, condition change forms, alert charting lists, stop and watch forms, and 24 hour sift reports would be audited daily starting on 12/06/12 and ongoing by the Director of Nursing Services (DNS), Assistant Director of Nursing Services (ADNS), or Quality Assurance (QA) Registered Nurse (RN), Monday through Friday; and by the Weekend Supervisor RN on Saturdays and Sundays for any residents with a change in condition to validate appropriate identification of changes in resident condition, notification of the Physician and responsible party, and care plan revision. 5) Shift to shift report was observed daily on each unit beginning 12/10/12 and ongoing by the DNS, ADNS, QA Nurse, Unit Managers (UM), three (3) to eleven (11) Supervisor, Weekend Supervisor, RN Case Manager, District Clinical RN Consultant to validate proper use of the 24 hour report and follow-up to resident change in condition. 6) The Guidelines for Physician Notification of Change of Condition/Clinical Problems in Center Residents was placed on the Treatment Administration Record (TAR) on all units 12/06/12 for quick reference for the nurses. 7) On 12/04/12 the Staff Development Coordinator (SDC) initiated education with all facility licensed nursing staff related to change in condition of resident status. Inservice dates were 12/04/12, 12/05/12, 12/06/12 and ongoing until all facility clinical staff had received the education. Education was provided by the SDC, ADNS', three (3) to eleven (11) RN Supervisor, Weekend RN, DNS, or QA RN. No nursing staff would be allowed to work until they had received the education. The inservices included: Situation Background Assessment Recommendation/Request (SBAR) form, 24 hour report form, alert charting system, notification of the Physician and responsible party, assessing for a possible [MEDICAL CONDITION], State Registered Nursing Staff (SRNA) utilizing the Stop and Watch forms, Licensed Nurse notification to Hospice for recommendations for a resident with a change in condition, then notify Physician of the change in condition and notify family. 8) A Performance Improvement Committee (PIC) meeting was held on 12/05/12 and again on 12/06/12. The Medical Director was notified of the Immediate Jeopardy via telephone and approved the plan developed by the PIC on 12/05/12. The PIC reviewed and approved the Allegation of Compliance (AOC). The PIC was to ensure validation of the AOC by: beginning 12/06/12, initial and daily audits of the Physician orders, condition change forms, alert charting lists, Stop and Watch forms, and shift to shift observations were being reviewed by the DNS, ADNS', QA RN, and/or Weekend Supervisor RN on Saturday and Sunday to identify issues, trends or patterns and take corrective action as necessary. The QA RN would be responsible to report trends from the audits to the weekly PIC committee for review and further recommendations. The PIC would create corrective action plans for any areas of concern identified on the audits. The PIC committee would meet weekly or more often as necessary until the facility had removed the Immediate Jeopardy. Once the Immediate Jeopardy was removed the facility would return to routine monthly PIC committee meetings. 9) The District and/or Regional team would provide RN clinical oversight a minimum of three (3) days per week beginning the week of 12/02/12. 10) The facility contracted an outside clinical consulting group on 11/20/12 to conduct onsite facility clinical oversight two (2) days per week beginning 12/02/12. The State Survey Agency validated the implementation of the facility's AOC as follows: Review of the skin assessment forms revealed all facility residents had skin assessments performed from 12/05/12 through 12/06/12 by licensed nurses, except three (3) who refused and one (1) that was end of life. Audit review revealed newly identified areas were reported to the physician and responsible party. Record review revealed the facility performed the audits as identified on the facility's AOC: An audit of resident progress notes and the 24 hour reports for the last 30 days was performed on 12/05/12 - 12/06/12. Daily audits of Physician orders, condition change forms, alert charting lists, stop and watch forms, and 24 hour shift reports started on 12/06/12. Problems identified were given to the Unit Managers for follow-up. The Shift to Shift audits were initiated by the facility on 12/10/12. Interview, on 12/13/12 at 11:05 AM, with the Staff Development Coordinator (SDC) revealed she had completed education with facility staff related to the SBAR form, 24 hour report form, alert charting system, notification of the Physician and responsible party, assessing for a possible [MEDICAL CONDITION], State Registered Nursing Staff (SRNA) utilizing the Stop and Watch forms, Licensed Nurse notification to Hospice for recommendations for a resident with a change in condition, then notify Physician of the change in condition and notify family. Interview, on 12/13/12 at 11:00 AM, with the Executive Director (ED), Vice President of Clinical Operations, Director of District Operations, Director of Nursing Services (DNS), Quality Assurance (QA) RN, and contracted Nurse Consultant revealed the District and/or Regional team would provide RN clinical oversight a minimum of three (3) days per week beginning the week of 12/02/12. In addition, the facility had contracted with an outside clinical consulting group on to conduct onsite facility clinical oversight two (2) days per week. Interviews with licensed nursing staff on 12/12/12 at 11:50 AM with Licensed Practical Nurse (LPN) #40, at 3:00 PM with Registered Nurse (RN) #11, at 3:15 PM with LPN #13; on 12/14/12 (7:00 AM to 3:00 PM shift) at 9:50 AM with LPN #3, at 2:00 PM with LPN #9, at 2:17 PM with LPN #16, at 2:45 PM with LPN #32, at 2:53 PM with LPN #15; on 12/14/12 (3:00 PM to 11:00 PM shift) at 5:35 PM with LPN #2, at 6:00 PM with LPN #31; and, on 12/14/12 (11:00 PM to 7:00 AM shift) at 3:42 PM with LPN #19 and at 4:32 PM with LPN #38 revealed they were all aware the "Guidelines for Physician Notification of Change of Condition/Clinical Problems in Center Residents" was on the Treatment Administration Record (TAR); they had received education on the Situation Background Assessment Recommendation/Request (SBAR) form; the 24 hour report form; the alert charting system; notification of the Physician and responsible party; assessing residents for a possible [MEDICAL CONDITION]; the State Registered Nursing Staff (SRNA) utilizing the Stop and Watch forms; and after notification to Hospice for recommendations for a resident with a change in condition, that they were to then notify the Physician of the change in condition and obtain orders, then notify the family. All licensed nurses interviewed confirmed that the shift to shift reports were being audited by Unit Managers, Assistant Director of Nursing Services (ADNS), 3:00 PM to 11:00 PM Supervisor, Quality Assurance Registered Nurse, and Weekend Supervisor. Interview, on 12/12/12 at 10:05 AM with State Registered Nursing Assistants (SRNAs) #8 and #9; on 12/14/12 at 9:15 AM with SRNA #37, at 9:15 AM with SRNA #38, at 2:33 PM with SRNA #27, at 3:00 PM with SRNA #32, at 3:40 PM with SRNA #39, at 4:00 PM with SRNA #13, at 4:19 PM with SRNA #34, at 4:28 PM with SRNA #35, at 5:15 PM with SRNAs #33 and #36 revealed they had all received education on the Stop and Watch form for communicating changes in residents' condition to the nurses. Interview, on 12/14/12 at 9:25 AM with LPN #39 and at 9:30 AM with LPN #16 revealed the SRNAs had received training on the Stop and Watch form. Interview, on 12/11/12 at 12:20 PM, with the Director of Nursing Services (DNS) revealed education had been performed with facility staff in regards to the "skin sheet", Stop and Watch form, 24 hour report form, and proper notification of the Physician and family. She stated nurses had been re-educated to confer with Hospice, however they were to notify the Physician and responsible party. In an additional interview, on 12/14/12 at 5:00 PM, with the DNS revealed in the facility's daily clinical review they were monitoring: the notification of change to the Physician and family, care plan updates, 24 hour report forms, alert charting forms, condition change forms, and Stop and Watch forms. She stated any concerns are followed up on by the Unit Managers (UM). The DNS stated she ensures the UMs complete the follow up via another meeting at the end of the day. According to the DNS, shift reports were being audited every day. She stated the audits were to ensure nurses were utilizing the 24 hour report form, alert charting, and any Stop and Watch forms to ensure the following shift was updated on residents' condition changes. Interview, on 12/14/12 at 11:40 AM, with RN #10/Assistant Director of Nursing Services (ADNS) for A and B units, revealed she audited progress notes, SBAR forms, Physician orders, condition change forms, alert charting lists, stop and watch forms, and 24 hour shift reports for the past thirty (30) days, and also ensured the care plan was updated. In an additional interview with RN #10/ADNS at 5:20 PM revealed she had monitored the shift to shift reports to ensure nurses were utilizing the 24 hour report form, the alert charting form, and any Stop and Watch forms to ensure the oncoming shift was aware of any changes in residents' condition. Interview, on 12/14/12 at 2:00 PM, with RN #2/ADNS (for C and D units) revealed he had performed audits of progress notes, SBAR forms, Physician orders, condition change forms, alert charting lists, stop and watch forms, and 24 hour shift reports for the past thirty (30) days. Interview, on 12/14/12 at 6:15 PM with the Weekend Supervisor RN revealed he had audited shift to shift reports to ensure the 24 hour report form, the alert charting and any Stop and Watch forms were being utilized to pass on residents' condition changes to the oncoming shift. He stated he had performed audits of the Physician orders, SBAR forms, condition change forms, alert charting lists, stop and watch forms, and 24 hour shift reports. Interview, on 12/14/12 at 6:10 PM, with the Medical Director revealed she had been notified of the Immediate Jeopardy by telephone and had approved the Allegation of Compliance (AOC) after discussion with the facility. She stated the Performance Improvement Committee (PIC) had been meeting weekly since the Immediate Jeopardy was identified and she was involved with these meetings. Interview, on 12/12/12 at 3:00 PM, with the Executive Director (ED) revealed the facility had good support from the Corporate level. She stated the facility had contracted with a consulting group that was coming two (2) days per week to help with problem solving. The ED stated the contracted consulting group and the Corporate level staff coming would provide training as necessary if problems were identified. She stated the Medical Director was very supportive and in communication very often and attended the Performance Improvement Committee (PIC) meetings monthly. According to the ED, she leads the PIC and it was continuously reviewing the problems identified. Interview, on 12/14/12 at 7:15 PM, with the ED and Quality Assurance (QA) RN revealed the Executive Director communicated the change in the process for Physician notification by the facility to Hospice. She stated Hospice had been educated that the facility's nurses would contact the Physician. The QA RN verified that audits were being performed as per the AOC, such as shift to shift report audits to ensure the 24 hour report form and alert charting information was being utilized. The QA RN indicated if audits were performed at shift change then the 24 hour report, alert charting, SBAR forms, and Stop and Watch forms were being audited to ensure a change in a resident's condition is being passed along. According to the QA RN, the results of all the audits on the 24 hour report form, SBAR form, alert charting form, condition change form, care plan updates, Physician orders, Physician and family notification, and Stop and Watch forms were taken to the morning clinical meeting and discussed. The QA RN stated if a problem was identified then staff were educated by the person doing the audit. The QA RN stated he reported the results of the audits and any trends to the weekly PIC meeting. The ED stated education was performed as per the AOC. She stated through the use of the new three (3) part SBAR form and Stop and Watch form that communication was now "shored" up. She stated staff had been educated to ensure a Stop and Watch form was filled out with any change in a resident's condition. An additional interview, on 12/14/12 at 8:00 PM, with the ED revealed the PIC had been meeting weekly. According to the ED, the PIC was performing what was indicated in the AOC (i.e.-validating the AOC by: reviewing initial and daily audits of the Physician orders, condition change forms, alert charting lists, Stop and Watch forms; and shift to shift observations were being reviewed to identify issues, trends or patterns and to take the corrective action as necessary). Corrective action plans for any areas of concern identified on the audits would be implemented.

Based on observation interview, record review, and review of the facility's policy, it was determined the facility failed to have an effective system to ensure each resident received the necessary care and services to attain or maintain the highest practicable physical well-being for one (1) of nineteen (19) sampled residents (Residents #37). Facility staff noted changes of condition to Resident #37's left leg/hip on both 11/05/12, 11/07/12, and 11/08/12. On 11/05/12 Resident #37 had swelling/puffiness, redness to the left hip and pain with movement; however, the facility's nurse failed to communicate the identified change in Resident #37 condition on the facility's 24 hour report to alert other staff. Interviews with facility staff revealed, on 11/07/12, the resident had a bruise like discolored area to the inner left thigh; however, staff failed to communicate this change with the nurse. On the morning of 11/08/12, a Hospice Nurse and Aide both noted Resident #37 had bruising from the left hip to the pubic area, but documentation revealed no assessment was completed by facility staff until 11/08/12 at 9:00 PM. At this time, it was documented Resident #37 had pain/discomfort to the left leg/hip, the left foot was turned inward and appeared shorter than the right leg and there was discoloration to the outer left hip, back of left leg, front of labia, inside left leg. Further review of the documentation revealed the facility's nurse failed to document the findings on the facility's skin assessment sheet per the facility's process. Resident #37's Physician was not contacted until 11/09/12. An x-ray was ordered which revealed the resident had a fractured left hip. The facility's failure to ensure each resident received the necessary care and services related to assessing and identifying changes in residents' condition was likely to cause risk for serious injury, harm, or impairment or death. The Immediate Jeopardy was identified on 12/05/12, and determined to exist on 11/05/12. The facility was notified of the Immediate Jeopardy on 12/05/12. The facility provided an acceptable credible Allegation of Compliance (AOC) on 12/11/12 with the facility alleging removal of the Immediate Jeopardy on 12/11/12. The Immediate Jeopardy was verified to be removed on 12/11/12, prior to exiting the facility on 12/14/12, with remaining non-compliance at 42 CFR 483.25, Quality of Care, F-309 Necessary Care and Services, with a Scope and Severity of "D", while the facility develops and implements a Plan of Correction, and the facility's Quality Assurance continues to monitor to ensure assessments and recognition of changes in residents' conditions. The findings include: Review of the facility's policy titled, "Condition Change of a Resident", revised 10/31/06, revealed the rationale was "resident change of condition is identified for proper treatment implementation". Review revealed the Physician was to be notified during office hours and generally no later than the next regular office day. Further review of the policy revealed licensed nurses were to monitor and reassess the resident's condition and update the care plan. Interview, on 12/04/12 at 2:05 PM, with the Director of Nursing Services (DNS) revealed the twenty-four (24) hour report was a communication tool for shift to shift reporting. She stated anyone could write on the report. According to the DNS, if there was a change of condition in a resident, it would be appropriate to put this information on the 24 hour report to alert staff to assess. Additional interview, on 12/11/12 at 12:20 PM, with the DNS revealed the facility also utilized a Stop and Watch form as a communication tool to report changes in residents. She stated the whole point of this form was to get ahead of an increased change in condition. The DNS indicated anyone could complete the form and the completed form was to be given to the nurse. Review of Resident #37's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a Significant Change Minimum Data Set (MDS) Assessment, dated 09/25/12, revealed the facility assessed the resident as being severely cognitively impaired and required limited to extensive assistance with all Activities of Daily Living (ADLs). Interview, on 12/06/12 at 2:10 PM, with State Registered Nursing Assistant (SRNA) #19 revealed on 11/03/12 she observed Resident #37 sitting on the floor in the hallway and then pulling himself/herself off the floor using the rail and then the resident walked to his/her room. SRNA #19 stated she did not complete the Stop and Watch form related to this observation because she would only complete this form if she noticed a major change in the resident. In addition, she stated she did not document the episode on the 24 hour report; however, she stated she should have. Interview, on 11/28/12 at 5:10 PM, with SRNA #20 revealed on 11/05/12 she worked the 3:00 PM to 11:00 PM shift. She stated she went into Resident #37's room with SRNA #23 and was repositioning Resident #37 in bed when the resident started "hollering" when they moved his/her legs up. She indicated she undid the resident's brief and noticed the left hip was red, swollen and looked like it was inflamed. She indicated the resident did not complain of pain unless moved. According to SRNA #20, she was not aware of any falls and she told the nurse about what she had observed regarding the resident's hip area. Further interview, on 12/10/12 at 3:30 PM, revealed it would have been appropriate to have completed the Stop and Watch Form related to the change of condition; however, she stated she told the nurse instead of completing the form. Interview, on 11/29/12 at 8:00 PM, with SRNA #23 revealed on 11/05/12 she went into Resident #37's room and the resident moaned loudly when his/her leg was moved but was not sure which leg. SRNA #23 indicated when the resident was changed at other times during her shift the resident would complain of pain. SRNA #23 stated she did not put this information on the 24 hour report form because they had told the nurse. Interview, on 12/03/12 at 5:10 PM, with SRNA #31 revealed she worked 11/05/12 on the 3:00 PM to 11:00 PM shift and was called into Resident #37's room by SRNA #20 to observe the resident. She stated when the resident's leg was raised he/she yelled out, which was unusual for the resident. She indicated she did not put this information on the 24 hour report. SRNA #31 stated this change should have been put on the 24 hour report. Record review of the Nurse's Progress Note, dated 11/05/12 at 9:00 PM, revealed the resident complained of pain to the left hip/leg and the resident's left hip area was puffy, had no redness, no discoloration and his/her lower extremities were equal in length. Review revealed the nurse called the Hospice Nurse. Interview, on 11/29/12 at 8:30 PM, with LPN #26 revealed on 11/05/12 the SRNA's came and told her the resident was complaining of pain. She stated when she assessed the resident pain was noted in both legs but more in the left leg and when the leg was moved the resident moaned. LPN #26 stated she gave the resident Tylenol and was not aware of any more complaints of pain. According to the LPN, she went back and checked the site at 10:00 PM and there was no change. LPN #26 stated she did not put her assessment findings on the 24 hour report, but "probably" should have. Further interview, on 12/05/12 at 2:30 AM, revealed the resident was in Hospice so she did not notify the Physician, because she had been instructed to call Hospice and notify them of any changes. The LPN stated she should have noted her assessment findings on the 24 hour report which was used to ensure follow-up of changes in condition. Further review revealed no documented evidence of the facility nurse's assessment of Resident #37's left hip area. Review of the facility's 24 Hour Report revealed no documented evidence related to Resident #37's change of condition on 11/05/12. Interview, on 11/30/12 at 3:30 PM, with the Unit Manager (UM), on the unit where the resident resided, revealed on 11/05/12 the LPN should have put the change of condition to Resident #37's left hip area on the 24 hour report. She stated without the information on the 24 hour report there would not have been a reason to assess the resident. Review of the Hospice On Call Nursing Record, dated 11/05/12 and timed 7:52 PM, revealed a phone call was received from the facility's nurse to report Resident #37's calf was hurting, but was not warm, red, or [MEDICAL CONDITION]. Review further revealed the facility's nurse also reported the resident was very active over the weekend and thought he/she was just sore. Interview, on 11/30/12 at 12:15 PM, with Hospice Nurse #3 revealed the facility nurse called on 11/05/12 and reported the resident's left calf was hurting and did not indicate any other problems. According to the Hospice Nurse, if she had been told the left hip was swollen she would have made a visit to assess the site to determine if further treatment was needed, such as, requesting an x-ray. Interview, on 12/05/12 at 10:23 AM, with the APRN related to the resident's change of condition on 11/05/12 revealed she would want to be notified if there was puffiness/swelling to the left hip. Interview, on 11/29/12 at 3:15 PM, with LPN #9 revealed she worked the morning of 11/06/12 and did not get a report of any change of condition to Resident #37. She stated, after reviewing the 11/05/12 Progress Note by LPN #26, the information should have been put on the 24 hour report. LPN #9 indicated the 24 hour report was used to communicate findings to all shifts. She stated if she had been made aware of a change of condition to the resident's left hip she would have assessed Resident #37's left hip area. Record review of the Nurse's Progress Notes for 11/06/12 revealed no documented evidence of any nursing assessment of the resident's left hip area. Interview, on 11/29/12 at 2:15 PM, with SRNA #27 revealed on the morning of 11/07/12, when they were getting the resident up for a shower the resident "hollered" and she noticed a small bruise on the resident's inner left thigh. SRNA #27 stated she told the nurse of the pain on the resident's left side, but when the nurse asked Resident #37 he/she denied pain. Interview, on 11/29/12 at 2:45 PM, with SRNA #26 revealed on the morning of 11/07/12, when they were transferring the resident for a shower he/she seemed to be in pain. She stated she noticed the resident had a small discolored area on the inner left thigh. According to the SRNA, the nurse and the Unit Manager came in to assess the resident. Interview, on 11/29/12 at 3:15 PM, with LPN #9 revealed on the morning of 11/07/12 she and the Unit Manager assessed Resident #37's left thigh. She indicated the left thigh had a small area of faint purple discoloration, it did not appear to be a bruise. LPN #9 stated it looked like spider veins. The LPN stated the resident denied pain and there was no swelling to the area. She stated she did not document this assessment anywhere and was unaware of any prior discoloration to the area. Interview, on 11/30/12 at 3:30 PM, with the Unit Manager (UM) revealed she observed Resident #37 with LPN #9 on 11/07/12 and assessed the upper left thigh area. She stated the resident's inner left thigh discoloration appeared to be like a Varicose Vein that was thin and elongated. The UM stated she was not aware of the area before this assessment. She indicated the resident had no complaints of pain and she had no concerns about the area at that time. Review of the Nurse's Progress Notes, dated 11/07/12, revealed no documented evidence related to the discolored area to the resident's inner left thigh observed by the SRNAs, LPN #9, and the UM. Interview, on 11/30/12 at 5:05 PM and on 12/04/12 at 10:20 AM, with SRNA #20 revealed during the 3:00 PM to 7:00 PM shift on 11/07/12, she and SRNA #29 changed the resident at the beginning of the shift, and noticed bruising to the inner part of the thigh and vaginal area. The SRNA stated the area was green/purple in color and she estimated the area to be approximately six (6) inches in length and a couple of inches wide. She stated Resident #37 would "holler" when they repositioned him/her during the shift. SRNA #20 stated since the bruising was already there she assumed it had been reported to the nurse as she was told, in report by SRNA #26 and SRNA #27, it was found on day shift and had been reported to the nurse. Interview, on 11/30/12 at 5:40 PM, with SRNA #29 revealed she worked the evening of 11/07/12 with SRNA #20 and when they changed Resident #37, the resident was in pain when moved and Resident #37 grabbed at his/her hip. She indicated she observed discoloration to the resident's left inner thigh, dark enough that it stood out. She stated it looked like something that could have resulted from an injury. She stated she reported to the nurse that Resident #37 was in a lot of pain; however, was not sure if she told the nurse about the discoloration. Review of the facility's 24 Hour Report for 11/07/12 revealed no documented evidence of the pain or bruising to the resident's left inner thigh area observed by the SRNAs. Interview, on 12/04/12 at 4:00 AM, with SRNA #30 revealed she worked the 11:00 PM to 7:00 AM on 11/07/12 and 11/08/12. SRNA #30 stated on 11/07/12, Resident #37 seemed to be in more pain in the leg/hip and moaned more then usual. She stated she could tell something was unusual with the resident. SRNA #30 stated she reported this information to LPN #26. Interview, on 12/01/12 at 5:44 PM, with LPN #26 revealed she worked on 11/07/12 from 3:00 PM until 7:00 AM. She stated she did not observe the resident's hip area during her shift; however, had moved Resident #37's leg. LPN #26 stated the resident did not complain of pain and she did not recall the SRNAs reporting Resident #37 had any bruising or pain during the shift. Review of the Nurse's Progress Notes for 11/07/12 revealed no documented evidence of an assessment of the resident's left hip area for pain or discoloration. Review of the Hospice Certified Nursing Assistant (CNA) Visit Record, dated 11/08/12, revealed Hospice CNA #2 had visited the resident on from 8:30 AM to 9:30 AM. Review of the Visit Record revealed the CNA had reported to the Hospice Nurse that during Resident #37's bath she found bruising on the resident's vaginal area and on the inside of his/her thighs. Interview, on 11/30/12 at 1:50 PM, with Hospice CNA #2 revealed she had visited Resident #37 the morning of 11/08/12, to give him/her the regularly scheduled bath. She stated during the bath she noticed bruising all over the vaginal area and down the inside of the resident's thighs. According to the CNA, it was worse on the left side. She stated when she tried to turn the resident, he/she "moaned and groaned". The Hospice CNA indicated from her experience, the resident could have had a broken hip. She stated she reported her observations to Hospice Nurse #2 who came and looked at the area. Interview, on 12/06/12 at 11:15 AM, with Hospice Nurse #2 revealed she was called into Resident #37's room on the morning of 11/08/12, by the Hospice CNA. She stated she remembered seeing the bruise on the resident's left hip and pubic area. According to the Hospice Nurse, the resident did seem to have pain when moved. Hospice Nurse #2 did not recall moving the leg to assess. She stated she did not measure the area. She indicated she did talk to someone at the facility to see if the resident had fallen; however, she could not recall who she had spoken to. Interview, on 12/03/12 at 3:10 PM, with SRNA #26 revealed when she did a check and change on Resident #37, on 11/08/12 on day shift, she noticed the discolored area, she had observed on 11/07/12, looked larger and darker. She stated the area was more purplish and had doubled in size, from about a nickel to about the size of a silver dollar and the resident seemed to be in pain whenever moved. She stated another aide (SRNA #28) reported to the observations to the nurse. Interview, on 12/02/12 at 12:45 PM, with SRNA #28 revealed, when working with SRNA #26 on 11/08/12 on the day shift, she noticed the resident had bruising to the inside thigh area of her left leg near the groin. SRNA #28 stated she reported the finding to the nurse, whom she thought might have have been LPN #9. Interview, on 11/29/12 at 3:15 PM, with LPN #9 revealed she worked on 11/08/12 on the day shift and did not assess the resident's left hip site during her shift. She stated no one reported the discoloration to the left thigh area had changed or that the resident was having any pain problems and if the SRNAs had thought there had been a change or the resident was having pain it should have been reported to her so she could have assessed the area. Review of Resident #37's Progress Notes, dated 11/08/12 revealed no documented evidence of an assessment of the resident's left hip until 9:00 PM that night. Interview, on 11/29/12 at 2:00 PM, with SRNA #19 revealed she worked evening shift on 11/08/12, and Resident #37 yelled when she was turning the resident over. She stated she and another SRNA put the resident on his/her back and went to get LPN #35. Interview, on 11/30/12 at 3:05 PM, with LPN #35 revealed she assessed the resident's left hip area on 11/08/12 and noted there was bruising to the vaginal area and left side. She stated she did not complete a skin assessment related to her findings, however this was done the next day by another nurse. She indicated she assessed the area because of a report of pain to the resident's left side. She stated she contacted Hospice and let them know about the pain a bruising, however did not notify the Physician. Further interview, on 12/06/12 at 2:30 PM, revealed she had assessed one leg being shorter than the other during her assessment on 11/08/12. She indicated calling the Physician was a judgement call and she was told in training if the resident had Hospice staff were supposed to call Hospice. She stated in Hospice had not called back she would have called the Physician to report her assessment findings. According to the LPN, if the Physician was contacted by Hospice she did not think she would had to notify the Physician also. Interview, on 12/05/12 at 10:23 AM, with the APRN revealed she would expect to be notified if there was bruising on the hips/buttocks of any sort, if it was significant whether the resident was Hospice or not. She stated that just because a resident had Hospice didn't mean we don't treat them. Review of Resident #37's Progress Note, dated 11/08/12 at 2100, revealed the resident complained of pain and discomfort in the left leg/hip. Review revealed the nurse called Hospice and got a new order for [MEDICATION NAME] (a pain reliever) 400 milligrams (mg) every six (6) hours as needed. The Note stated the resident's outer left hip, back of left upper leg, and the front of the labia and left leg had discoloration noted and the resident's left foot was turned inward and appeared shorter than the right leg. Review revealed the nurse called the Director of Nursing Services (DNS) and left a message. Review of the facility's 24 Hour Report revealed an entry on 11/08/12 for Resident #37 which noted a call to Hospice related to the resident being in a lot of pain and there being bruising to the labia, left hip, and inside the left leg. Review revealed a new order for [MEDICATION NAME] (a pain reliever) 400 mg every six (6) hours as needed was obtained. Interview, on 11/30/12 at 3:30 PM, with the Unit Manager (UM) regarding the Progress Note on 11/08/12 at 9:00 PM revealed even if a resident has Hospice nurses were supposed to notify the Physician at the same time. She stated the facility was ultimately responsible for the resident. According to the UM, the nurse should have completed a non-pressure skin sheet related to her findings to give the area a baseline. Review of the Hospice On Call Nursing Record dated 11/08/12 and timed 10:51 PM, revealed Hospice received a phone call from the facility nurse who reported Resident #37 was having a lot of pain; that every time they touched the leg the resident cried. Review revealed the resident had a big bruise in the vaginal and groin area. Interview, on 11/20/12 at 12:00 PM, with Hospice Nurse #1 revealed she was informed by the facility nurse on 11/08/12, that Resident #37 had a large bruise to the groin and vaginal area, and the resident complained of pain when the left leg was moved. The Hospice Nurse stated she asked if the resident had fallen and the facility nurse indicated she was not aware of a fall. She stated the nurse did not mention one leg was shorter than the other; she just reported the bruising and pain and wanted to get pain medication. Continued interview, on 12/06/12 at 12:25 PM, with Hospice Nurse #1 revealed if the facility nurse had told her one of the resident's legs was shorter than the other, she would have immediately thought it was a [MEDICAL CONDITION] and would have went and assessed the resident. The Hospice Nurse indicated all she was told was that the resident was in pain. She stated she would have requested an x-ray and pain medication stronger than [MEDICATION NAME]. An additional interview, on 11/30/12 at 6:10 PM, with the Unit Manager (UM) revealed she did a skin assessment on 11/09/12 at 8:00 AM with LPN #37 because of an unrelated skin issue identified the night before. She stated she had noticed a non-pressure skin sheet was not completed as per facility process. According to the UM, this should have have been completed when the area was first identified. Additionally, the UM stated she inserviced LPN #35 regarding the lack of documentation in regards to the non-pressure skin sheet. Record review revealed a Nurse's Progress Note dated 11/09/12 at 8:00 AM, which indicated the resident had discoloration, pale purple/yellow starting at the center of the left pelvic region and extending downward into the pubic area. Interview, on 12/06/12 at 11:05 AM, with LPN #37 revealed on the morning of 11/09/12 she assessed Resident #37 because of reported bruising and pain to the left hip area. She stated when she assessed the resident she observed bruising to the resident's (left) hip, groin, and "private" area which was dark purple and the resident would cry out in pain anytime she was touched in that area. She indicated the the left foot had some slight rotation inward. She stated she called the APRN and the Hospice and got an order for [REDACTED]. Review of the x-ray report, dated 11/09/12, revealed Resident #37 had a left [MEDICAL CONDITION]. Interview, on 12/04/12 at 2:05 PM, with the Quality Assurance (QA) Nurse and the Director of Nursing Services (DNS) revealed SRNAs informed the nurse regarding a change of condition and the nurse would put it on the 24 hour report. The QA Nurse stated if pain was a new type of pain he would expect that to be documented on the 24 Hour Report. He stated if there were changes to the Resident #37's left thigh this should have been reported to the nurse and the nurse should have assessed the area. The DNS stated the 24 Hour Report was a communication tool for shift to shift reporting; anyone could document on the report. When asked about the documented condition change noted in the 11/05/12 progress note and related interviews, the DNS stated if there was a change in the condition of the area it would have been appropriate for staff to put on the 24 Hour Report to alert nursing staff to assess the site. She stated there should have been follow-up documentation of the area. The DNS also stated the MD should have been notified and the facility was ultimately responsible for the resident. Further interview, on 12/14/12 at 7:15 PM, with the QA Nurse revealed when any change in a resident was observed staff could complete the Stop and Watch form, the 24 Hour Report, and give verbal communication as well. He stated when the SRNAs observed changes to the resident on 11/05/12, 11/07/12 on the evening shift and 11/08/12 day shift, they should have completed a Stop and Watch form to notify the nurse of the changes. According to the QA Nurse, SRNAs had the ability to document on the 24 Hour Report; however it would have been more effective to take the nurse to the resident's room and point out the condition change. The QA Nurse indicated because these changes were not communicated to the nurse there was no monitoring of the area, and the Physician was not made notified of the changes in Resident #37's condition. Further interview revealed the facility nurse should have documented on the "skin sheet", the bruising identified on the 11/08/12 9:00 PM Nurse's Progress Note. In addition, he stated the care plan should have been updated accordingly with the nurse's findings on 11/05/12 and 11/08/12 at 9:00 PM. Continued interview, on 12/11/12 at 12:20 PM, with the DNS revealed staff did not monitor and assess the resident's changes in condition according to her expectation because for whatever reason staff did not utilize the communication tools available to alert other staff of the changes. She stated the documented changes identified on 11/05/12 should have been recorded on the 24 Hour Report to alert staff of the pain and puffiness. She indicated the bruising and pain to Resident #37's left hip/leg, reported by the aides on 11/07/12 and 11/08/12, should have been documented on the 24 Hour Report by the SRNAs. The DNS stated the SRNAs could also have utilized the Stop and Watch form, which had been in place for several months, that was another communication tool available to all staff to report changes. She stated the SRNAs should have completed the Stop and Watch form to communicate to the nurse the swelling and pain identified on 11/05/12, and the bruising and pain observed on 11/07/12 and 11/08/12. According to the DNS, the nurses should have conferred with Hospice about the changes in condition documented on 11/05/12 and 11/08/12 and then notified the Physician of the changes. She stated the care plan should have been revised with interventions related to the 11/05/12 and 11/08/12 assessment findings of bruising and the resident's left leg appearing to be shorter than the right. She stated the nurse should have documented her assessment findings on a "skin sheet" for a baseline and completed an event report so the area would have been assessed and charted on for seventy-two (72) hours. Interview, on 12/14/12 at 7:15 PM, with the facility's Executive Director (ED) revealed there was a misunderstanding by the nurse related to Physician notification and documentation of Resident #37's change of condition identified on 11/05/12. She stated the nurse did not follow the facility's process she had been educated on. The ED stated the nurse didn't put the change in condition on the alert charting or 24 Hour Report or notify the Physician of the change. According to the ED, staff were supposed to put changes on the 24 Hour Report for follow-up. She stated no one monitored the area as it had not been placed on the 24 Hour Report. The ED stated that on 11/08/12 at 9:00 PM, the nurse notified Hospice of the change in Resident #37's condition, however should have also notified the Physician. In addition, she stated the nurse should have documented her assessment findings on the "skin sheet". The facility provided an acceptable credible Allegation of Compliance (AOC) on 12/11/12 that alleged removal of the IJ effective 12/11/12. Review of the AOC revealed the facility implemented the following: 1) Head-to-toe skin assessments were performed on all residents from 12/05/12 through 12/06/12 by licensed nurses to identify any others with indication of any change of condition/puffiness, swelling or redness. Any notable findings were communicated to the attending Physician and responsible party. Notable findings included, but were not limited to, Pressure Ulcers, Arterial Ulcers, Diabetic Neuropathic Ulcers, [MEDICAL CONDITION] Ulcers, Surgical Wounds, Skin Tears, Lacerations, Abrasions, Bruises, Burns, Rashes, or a Lesion associated with bleeding, itching, burning, puffiness or swelling, discoloration and/or raised skin areas. The findings were documented by the licensed nurse, and communicated to the Physician and family for further follow-up. The licensed nurse was responsible to document findings in the residents' medical record and the 24 hour report. 2) On 12/05/12 and 12/06/12 facility licensed nurses conducted an audit that reviewed all current residents' progress notes and the 24 hour reports for the previous thirty (30) days (11/05/12 to current) to validate changes in resident condition were identified and addressed with the Physician and responsible party notification. This audit also included validating any changes in resident condition including updating the care plan. 3) The Administrator (Executive Director) communicated the change in the process for Physician notification by the facility to Hospice on 11/30/12 and again on 12/03/12. 4) Physician orders, condition change forms, alert charting lists, stop and watch forms, and 24 hour sift reports would be audited daily starting on 12/06/12 and ongoing by the Director of Nursing Services (DNS), Assistant Director of Nursing Services (ADNS), or Quality Assurance (QA) Registered Nurse (RN), Monday through Friday; and by the Weekend Supervisor RN on Saturdays and Sundays for any residents with a change in condition to validate appropriate identification of changes in resident condition, notification of the Physician and responsible party, and care plan revision. 5) Shift to shift report was observed daily on each unit beginning 12/10/12 and ongoing by the DNS, ADNS, QA Nurse, Unit Managers (UM), three (3) to eleven (11) Supervisor, Weekend Supervisor, RN Case Manager, District Clinical RN Consultant to validate proper use of the 24 hour report and follow-up to resident change in condition. 6) The Guidelines for Physician Notification of Change of Condition/Clinical Problems in Center Residents was placed on the Treatment Administration Record (TAR) on all units 12/06/12 for quick reference for the nurses. 7) On 12/04/12 the Staff Development Coordinator (SDC) initiated education with all facility licensed nursing staff related to change in condition of resident status. Inservice dates were 12/04/12, 12/05/12, 12/06/12 and ongoing until all facility clinical staff had received the education. Education was provided by the SDC, ADNS', three (3) to eleven (11) RN Supervisor, Weekend RN, DNS, or QA RN. No nursing staff would be allowed to work until they had received the education. The inservices included: Situation Background Assessment Recommendation/Request (SBAR) form, 24 hour report form, alert charting system, notification of the Physician and responsible party, assessing for a possible [MEDICAL CONDITION], State Registered Nursing Staff (SRNA) utilizing the Stop and Watch forms, Licensed Nurse notification to Hospice for recommendations for a resident with a change in condition, then notify Physician of the change in condition and notify family. 8) A Performance Improvement Committee (PIC) meeting was held on 12/05/12 and again on 12/06/12. The Medical Director was notified of the Immediate Jeopardy via telephone and approved the plan developed by the PIC on 12/05/12. The PIC reviewed and approved the Allegation of Compliance (AOC). The PIC was to ensure validation of the AOC by: beginning 12/06/12, initial and daily audits of the Physician orders, condition change forms, alert charting lists, Stop and Watch forms, and shift to shift observations were being reviewed by the DNS, ADNS', QA RN, and/or Weekend Supervisor RN on Saturday and Sunday to identify issues, trends or patterns and take corrective action as necessary. The QA RN would be responsible to report trends from the audits to the weekly PIC committee for review and further recommendations. The PIC would create corrective action plans for any areas of concern identified on the audits. The PIC committee would meet weekly or mor

Based on observation, interview, record review and review of the facility's policy it was determined the facility failed to have an effective system in place to ensure the Physician was notified of a change in condition for one (1) of nineteen (19) sampled residents (Residents #37). Facility staff observed changes of condition to Resident #37's left leg/hip on 11/05/12, 11/07/12, and 11/08/12 but failed to notify the resident's Physician. On 11/05/12 documentation revealed Resident #37 had swelling/puffiness, redness to the left hip and pain with movement; however, there was no evidence the facility notified the resident's physician. On 11/07/12, Resident #37 was exhibiting pain when repositioned and bruising was noted to the inner left thigh per staff interviews. Review of the Resident Progress Notes, dated 11/08/12, revealed Resident #37 had complained of pain and discomfort in left leg/, and the left foot turned inward and appeared shorter then the right leg. Record review and interview revealed no evidence the Physician was notified of the resident's change in condition until 11/09/12. An x-ray was obtained on 11/09/12 which revealed the resident had a left [MEDICAL CONDITION]. The facility's failure to ensure an effective system was in place to ensure Physician notification of a change in condition was likely to cause risk for serious injury, harm, or impairment or death. The Immediate Jeopardy was identified on 12/05/12, and determined to exist on 11/05/12. The facility was notified of the Immediate Jeopardy on 12/05/12. The facility provided an acceptable credible Allegation of Compliance (AOC) on 12/11/12 with the facility alleging removal of the Immediate Jeopardy on 12/11/12. The Immediate Jeopardy was verified to be removed on 12/11/12, prior to exiting the facility on 12/14/12, with remaining non-compliance at 42 CFR 483.10, Resident Rights, F-157 Notification of Changes with a Scope and Severity of "D", while the facility develops and implements a Plan of Correction, and the facility's Quality Assurance continues to monitor to ensure Physicians are notified of changes in residents' conditions. The findings include: Review of the facility's policy titled, "Condition Change of a Resident", revised date 10/31/06, revealed the Physician was to be informed of resident events and/or change in resident's condition". Continued review of the policy revealed the Physician should be informed at the time the event occurs either directly or by pager. Further review revealed the nurse should notify the Physician of clinical problems; if the attending Physician was unavailable the nurse was to notify the alternate Physician or the Medical Director. Review of Resident #37's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Significant Change Minimum Data Set (MDS) Assessment, dated 09/25/12, revealed the facility assessed the resident as severely cognitively impaired. Continued review of the MDS revealed the facility assessed the resident as requiring limited to extensive assist with his/her Activities of Daily Living (ADLs). Interview, on 11/28/12 at 5:10 PM, with State Registered Nursing Assistant (SRNA) #20 revealed when she worked 11/05/12, on the 3:00 PM to 11:00 PM shift, Resident #37 started "hollering" when the bed was raised while she and SRNA #23 were repositioning the resident. She indicated when she undid the resident's brief she noticed the resident's left hip was red, swollen and inflamed. Additional interview, on 12/10/12 at 3:30 PM revealed she told a nurse (Licensed Practical Nurse (LPN) #26) of Resident #37's change of condition on 11/05/12. Record review of a Nursing Progress Note, dated 11/05/12 at 9:00 PM, revealed the resident complained of pain to the left hip/leg. Continued review revealed the left hip area was puffy, with no redness, no discoloration, and the lower extremities were equal in length. Further review revealed the nurse documented she called the Hospice Nurse. However, there was no documented evidence the nurse notified the Physician of the change in the resident's condition. Interview, on 11/29/12 at 8:30 PM, with LPN #26, revealed on 11/05/12 the SRNAs (SRNA #20 and SRNA #23) told her Resident #37 was complaining of pain while they were providing care. LPN #26 stated Resident #37 moaned while she assessed the resident and pain was noted in both legs; however, more in the left leg. She indicated there was no redness or warmth to the site. She stated she called Hospice regarding the changes; however, she did not call the Physician. LPN #26 stated she thought the process was to call Hospice and Hospice notified the Physician. Interview, on 12/05/12 at 10:23 AM, with the Advanced Practice Registered Nurse (APRN) related to the resident's change of condition on 11/05/12, revealed she would want to be notified if there was puffiness or swelling to the resident's left hip. However, record review revealed no documented evidence the Physician or the APRN were notified of the puffiness in Resident #37's left hip area or the pain in the resident's legs on 11/05/12. Interview, on 11/30/12 at 5:05 PM, with SRNA #20 revealed during the beginning of her 3:00 PM to 7:00 PM shift on 11/07/12 ( two days after Resident #37 was noted to have red, swollen and inflamed hip) she and SRNA #29 noticed green/purple bruising approximately six (6) inches in length and a couple of inches wide to Resident #37's inner part of the resident's thigh and vaginal area while providing care. SRNA #20 stated the resident would "holler" when they repositioned him/her. She indicated she assumed the bruising had already been reported to the nurses because she was told it was found by day shift. SRNA #20 stated she did not tell the nurse the resident was in pain; however, she stated should have. Interview, on 11/30/12 at 5:40 PM, with SRNA #29 revealed when she and SRNA #20 went into the resident's room on 11/07/12 to change Resident #37, he/she was in pain if moved. She stated Resident #37 would grab at his/her hips to protect them. She stated she checked the resident's hip and observed discoloration, dark enough that it stood out. She indicated she reported to the nurse (LPN #26) that the resident was in a lot of pain; however, was not sure if she told the nurse about the discoloration. Interview, on 12/04/12 at 4:00 AM, with SRNA #30 revealed she worked 11:00 PM to 7:00 AM shift on 11/07/12 and 11/08/12. SRNA #30 stated on 11/07/12, Resident #37 seemed to be in more pain in the leg/hip area. She indicated the resident moaned more than usual and she could tell something was unusual Resident #37. The SRNA stated she reported this to LPN #26. However, record review revealed no documented evidence the Physician was notified of this change in the resident's condition on 11/07/12. Interview, on 12/01/12 at 5:44 PM, with LPN #26 revealed she worked on 11/07/12 from 3:00 PM until 7:00 AM and did not observe Resident #37's hip area during the shift. The LPN stated the resident did not complain of pain and she did not recall the SRNAs reporting Resident #37 had any bruising or pain to the hip area during her shift. Interview, on 12/03/12 at 3:10 PM, with SRNA #26 revealed when she did a check and change on 11/08/12 on day shift she noticed the discolored area, which she had observed on 11/07/12, looked larger and darker. She stated it was more purplish and had doubled in size from about a nickel size to about the size of a silver dollar and the resident seemed to be in pain whenever he/she was moved. SRNA #26 stated SRNA #28 reported this information to the nurse. Interview, on 12/02/12 at 12:45 PM, with SRNA #28 revealed when working with SRNA #26 during the day shift 11/08/12 they noticed the resident had bruising to the inside thigh area of her left leg near the groin area and was unaware of any discoloration to the area before this time. She stated this was reported to the nurse, who she thought was LPN #9. Interview, on 11/29/12 at 3:15 PM, with LPN #9 revealed she did not assess Resident #37's left hip area on 11/08/12 and no one reported the discoloration to the left thigh area or that the resident was having pain. She indicated if the SRNAs had thought there had been a change in the resident's condition, or he/she was having pain it should have been reported to her. Interview, on 11/29/12 at 2:00 PM, with SRNA #19 revealed while she and another SRNA were turning Resident #37 during the evening shift on 11/08/12 the resident yelled so they informed LPN #35. Interview, on 11/30/12 at 3:05 PM and on 12/06/12 at 2:30 PM, with LPN #35 revealed she assessed Resident #37's hip/thigh area on 11/08/12 related to a report of pain to the resident's left side. She stated there was bruising to the resident's vaginal area and left side and she observed one leg was shorter than the other. She contacted Hospice about the pain and bruising, but did not contact the Physician because calling the Physician was a judgement call. She was told in training if a resident was in Hospice she was supposed to call Hospice, but if Hospice did not called back she was to call the Physician. She stated if the Physician was contacted by Hospice she did not think she would have to notify the Physician also. Record review revealed no documented evidence the facility notified the Physician of the resident's change in condition on 11/08/12. Interview, on 12/05/12 at 10:23 AM, with the APRN, related to the resident's change of condition on 11/08/12, revealed she would expect to be notified if there was bruising on the hips/buttocks of any sort if it was significant whether a resident had Hospice or not. She stated that just because a resident had Hospice didn't mean "we don't treat them". Review of Resident #37's Nursing Progress Note, dated 11/08/12 at 9:00 PM, revealed the resident complained of pain and discomfort in the left leg/hip area, Hospice was called and a new order for [MEDICATION NAME] (a pain reliever) 400 milligrams (mg) every six (6) hours as needed was obtained. Continued review revealed Resident #37's outer left hip, back of left upper leg, and the front of the labia and left leg had discoloration noted and the resident's left foot was turned inward and appeared shorter than the right leg. However, there was no documented evidence the Physician was notified of the change in condition. Interview, on 12/06/12 at 11:05 AM, with LPN #37 revealed on the morning of 11/09/12 she assessed Resident #37 because of reported bruising and pain to the area. She stated during her assessment she observed bruising which was dark purple to the resident's left hip, groin, and "private" area. She stated the resident would cry out in pain anytime she was touched in that area. She stated she called the APRN and Hospice and got an order for [REDACTED]. Review of the x-ray report, dated 11/09/12, revealed Resident #37 had a left [MEDICAL CONDITION]. Interview, on 11/30/12 at 3:30 PM, with Unit Manager, regarding the Progress Note on 11/08/12 at 9:00 PM, revealed even if a resident was in Hospice, nurses were supposed to notify the Physician. She stated the facility was ultimately responsible for the resident. Interview, on 12/04/12 at 2:05 PM, with the Director of Nursing Services (DNS) revealed the Physician should have been notified if there was a change in a resident's condition. Continued interview, on 12/11/12 at 12:20 PM, with the DNS revealed nurses should have conferred with Hospice regarding the changes in Resident #37's condition documented on 11/05/12 and 11/08/12 and then called the resident's Physician. Interview, on 12/14/12 at 7:15 PM, with the facility's Executive Director revealed there was a misunderstanding by the nurse, on Resident #37's change of condition identified on 11/05/12, related to Physician notification. She stated the nurse did not follow the facility's process she had been educated on when she didn't notify the Physician. She stated, in regards to the documented change of Resident #37's condition on 11/08/12 at 9:00 PM, the nurse notified Hospice; however, she should have also notified the Physician. The facility provided an acceptable credible Allegation of Compliance (AOC) on 12/11/12 that alleged removal of the IJ effective 12/11/12. Review of the AOC revealed the facility implemented the following: 1) Head-to-toe skin assessments were performed on all residents from 12/05/12 through 12/06/12 by licensed nurses to identify any others with indication of any change of condition/puffiness, swelling or redness. Any notable findings were communicated to the attending Physician and responsible party. Notable findings included, but were not limited to, Pressure Ulcers, Arterial Ulcers, Diabetic Neuropathic Ulcers, [MEDICAL CONDITION] Ulcers, Surgical Wounds, Skin Tears, Lacerations, Abrasions, Bruises, Burns, Rashes, or a Lesion associated with bleeding, itching, burning, puffiness or swelling, discoloration and/or raised skin areas. The findings were documented by the licensed nurse, and communicated to the Physician and family for further follow-up. The licensed nurse was responsible to document findings in the residents' medical record and the 24 hour report. 2) On 12/05/12 and 12/06/12 facility licensed nurses conducted an audit that reviewed all current residents' progress notes and the 24 hour reports for the previous thirty (30) days (11/05/12 to current) to validate changes in resident condition were identified and addressed with the Physician and responsible party notification. This audit also included validating any changes in resident condition including updating the care plan. 3) The Administrator (Executive Director) communicated the change in the process for Physician notification by the facility to Hospice on 11/30/12 and again on 12/03/12. 4) Physician orders, condition change forms, alert charting lists, stop and watch forms, and 24 hour sift reports would be audited daily starting on 12/06/12 and ongoing by the Director of Nursing Services (DNS), Assistant Director of Nursing Services (ADNS), or Quality Assurance (QA) Registered Nurse (RN), Monday through Friday; and by the Weekend Supervisor RN on Saturdays and Sundays for any residents with a change in condition to validate appropriate identification of changes in resident condition, notification of the Physician and responsible party, and care plan revision. 5) Shift to shift report was observed daily on each unit beginning 12/10/12 and ongoing by the DNS, ADNS, QA Nurse, Unit Managers (UM), three (3) to eleven (11) Supervisor, Weekend Supervisor, RN Case Manager, District Clinical RN Consultant to validate proper use of the 24 hour report and follow-up to resident change in condition. 6) The Guidelines for Physician Notification of Change of Condition/Clinical Problems in Center Residents was placed on the Treatment Administration Record (TAR) on all units 12/06/12 for quick reference for the nurses. 7) On 12/04/12 the Staff Development Coordinator (SDC) initiated education with all facility licensed nursing staff related to change in condition of resident status. Inservice dates were 12/04/12, 12/05/12, 12/06/12 and ongoing until all facility clinical staff had received the education. Education was provided by the SDC, ADNS', three (3) to eleven (11) RN Supervisor, Weekend RN, DNS, or QA RN. No nursing staff would be allowed to work until they had received the education. The inservices included: Situation Background Assessment Recommendation/Request (SBAR) form, 24 hour report form, alert charting system, notification of the Physician and responsible party, assessing for a possible [MEDICAL CONDITION], State Registered Nursing Staff (SRNA) utilizing the Stop and Watch forms, Licensed Nurse notification to Hospice for recommendations for a resident with a change in condition, then notify Physician of the change in condition and notify family. 8) A Performance Improvement Committee (PIC) meeting was held on 12/05/12 and again on 12/06/12. The Medical Director was notified of the Immediate Jeopardy via telephone and approved the plan developed by the PIC on 12/05/12. The PIC reviewed and approved the Allegation of Compliance (AOC). The PIC was to ensure validation of the AOC by: beginning 12/06/12, initial and daily audits of the Physician orders, condition change forms, alert charting lists, Stop and Watch forms, and shift to shift observations were being reviewed by the DNS, ADNS', QA RN, and/or Weekend Supervisor RN on Saturday and Sunday to identify issues, trends or patterns and take corrective action as necessary. The QA RN would be responsible to report trends from the audits to the weekly PIC committee for review and further recommendations. The PIC would create corrective action plans for any areas of concern identified on the audits. The PIC committee would meet weekly or more often as necessary until the facility had removed the Immediate Jeopardy. Once the Immediate Jeopardy was removed the facility would return to routine monthly PIC committee meetings. The State Survey Agency validated the implementation of the facility's AOC as follows: Review of the skin assessment forms revealed all facility residents had skin assessments performed from 12/05/12 through 12/06/12 by licensed nurses, except three (3) who refused and one (1) that was end of life. Audit review revealed newly identified areas were reported to the physician and responsible party. Record review revealed the facility performed the audits as identified on the facility's AOC: An audit of resident progress notes and the 24 hour reports for the last 30 days was performed on 12/05/12 - 12/06/12. Daily audits of Physician orders, condition change forms, alert charting lists, stop and watch forms, and 24 hour shift reports started on 12/06/12. Problems identified were given to the Unit Managers for follow-up. The Shift to Shift audits were initiated by the facility on 12/10/12. Observation of the Treatment Administration Record (TAR) on each unit revealed they had Guidelines for Physician Notification of Change of Condition/Clinical Problems in the front. Interview, on 12/13/12 at 11:05 AM, with the Staff Development Coordinator (SDC) revealed she had completed education with facility staff related to the SBAR form, 24 hour report form, alert charting system, notification of the Physician and responsible party, assessing for a possible [MEDICAL CONDITION], State Registered Nursing Staff (SRNA) utilizing the Stop and Watch forms, Licensed Nurse notification to Hospice for recommendations for a resident with a change in condition, then notify Physician of the change in condition and notify family. Interviews with licensed nursing staff on 12/12/12 at 11:50 AM with Licensed Practical Nurse (LPN) #40, at 3:00 PM with Registered Nurse (RN) #11, at 3:15 PM with LPN #13; on 12/14/12 (7:00 AM to 3:00 PM shift) at 9:50 AM with LPN #3, at 2:00 PM with LPN #9, at 2:17 PM with LPN #16, at 2:45 PM with LPN #32, at 2:53 PM with LPN #15; on 12/14/12 (3:00 PM to 11:00 PM shift) at 5:35 PM with LPN #2, at 6:00 PM with LPN #31; and, on 12/14/12 (11:00 PM to 7:00 AM shift) at 3:42 PM with LPN #19 and at 4:32 PM with LPN #38 revealed they were all aware the "Guidelines for Physician Notification of Change of Condition/Clinical Problems in Center Residents" was on the Treatment Administration Record (TAR); they had received education on the Situation Background Assessment Recommendation/Request (SBAR) form; the 24 hour report form; the alert charting system; notification of the Physician and responsible party; assessing residents for a possible [MEDICAL CONDITION]; the State Registered Nursing Staff (SRNA) utilizing the Stop and Watch forms; and after notification to Hospice for recommendations for a resident with a change in condition, that they were to then notify the Physician of the change in condition and obtain orders, then notify the family. All licensed nurses interviewed confirmed that the shift to shift reports were being audited by Unit Managers, Assistant Director of Nursing Services (ADNS), 3:00 PM to 11:00 PM Supervisor, Quality Assurance Registered Nurse, and Weekend Supervisor. Interview, on 12/12/12 at 10:05 AM with State Registered Nursing Assistants (SRNAs) #8 and #9; on 12/14/12 at 9:15 AM with SRNA #37, at 9:15 AM with SRNA #38, at 2:33 PM with SRNA #27, at 3:00 PM with SRNA #32, at 3:40 PM with SRNA #39, at 4:00 PM with SRNA #13, at 4:19 PM with SRNA #34, at 4:28 PM with SRNA #35, and at 5:15 PM with SRNAs #33 and #36 revealed they had all received education on the Stop and Watch form for communicating changes in residents' condition to the nurses. Interview, on 12/14/12 at 9:25 AM with LPN #39 and at 9:30 AM with LPN #16 revealed the SRNAs had received training on the Stop and Watch form. Interview, on 12/11/12 at 12:20 PM, with the Director of Nursing Services (DNS) revealed education had been performed with facility staff in regards to the "skin sheet", Stop and Watch form, 24 hour report form, and proper notification of the Physician and family. She stated nurses had been re-educated to confer with Hospice, and also notify the Physician and responsible party. An additional interview, on 12/14/12 at 5:00 PM, with the DNS revealed in the facility's daily clinical review they were monitoring: the notification of change to the Physician and family, care plan updates, 24 hour report forms, alert charting forms, condition change forms, and Stop and Watch forms. She stated any concerns were followed up on by the Unit Managers (UM). The DNS stated she ensured the UMs completed the follow up via another meeting at the end of the day. According to the DNS, shift reports were being audited every day. She stated the audits were to ensure nurses were utilizing the 24 hour report form, alert charting, and any Stop and Watch forms to ensure the following shift was updated on residents' condition changes. Interview, on 12/14/12 at 11:40 AM, with RN #10/Assistant Director of Nursing Services (ADNS) for A and B units, revealed she audited progress notes, SBAR forms, Physician orders, condition change forms, alert charting lists, stop and watch forms, and 24 hour shift reports for the past thirty (30) days, and also ensured the care plan was updated. In an additional interview with RN #10/ADNS at 5:20 PM revealed she had monitored the shift to shift reports to ensure nurses were utilizing the 24 hour report form, the alert charting form, and any Stop and Watch forms to ensure the oncoming shift was aware of any changes in residents' condition. Interview, on 12/14/12 at 2:00 PM, with RN #2/ADNS (for C and D units) revealed he had performed audits of progress notes, SBAR forms, Physician orders, condition change forms, alert charting lists, stop and watch forms, and 24 hour shift reports for the past thirty (30) days. Interview, on 12/14/12 at 6:15 PM with the Weekend Supervisor RN revealed he had audited shift to shift reports to ensure the 24 hour report form, the alert charting and any Stop and Watch forms were being utilized to pass on residents' condition changes to the oncoming shift. He stated he had performed audits of the Physician orders, SBAR forms, condition change forms, alert charting lists, stop and watch forms, and 24 hour shift reports. Interview, on 12/14/12 at 6:10 PM, with the Medical Director revealed she had been notified of the Immediate Jeopardy by telephone and had approved the Allegation of Compliance (AOC) after discussion with the facility. She stated the Performance Improvement Committee (PIC) had been meeting weekly since the Immediate Jeopardy was identified and she was involved with these meetings. Interview, on 12/14/12 at 7:15 PM, with the ED and Quality Assurance (QA) RN revealed the Executive Director communicated the change in the process for Physician notification by the facility to Hospice. She stated Hospice had been educated that the facility's nurses would contact the Physician. The QA RN verified that audits were being performed as per the AOC, such as shift to shift report audits to ensure the 24 hour report form and alert charting information was being utilized. The QA RN indicated if audits were performed at shift change then the 24 hour report, alert charting, SBAR forms, and Stop and Watch forms were being audited to ensure a change in a resident's condition is being passed along. According to the QA RN, the results of all the audits on the 24 hour report form, SBAR form, alert charting form, condition change form, care plan updates, Physician orders, Physician and family notification, and Stop and Watch forms were taken to the morning clinical meeting and discussed. The QA RN stated if a problem was identified then staff were educated by the person doing the audit. The QA RN stated he reported the results of the audits and any trends to the weekly PIC meeting. The ED stated education was performed as per the AOC. She stated through the use of the new three (3) part SBAR form and Stop and Watch form that communication was now "shored" up. She stated staff had been educated to ensure a Stop and Watch form was filled out with any change in a resident's condition. An additional interview, on 12/14/12 at 8:00 PM, with the ED revealed the PIC had been meeting weekly. According to the ED, the PIC was performing what was indicated in the AOC (i.e.-validating the AOC by: reviewing initial and daily audits of the Physician orders, condition change forms, alert charting lists, Stop and Watch forms; and shift to shift observations were being reviewed to identify issues, trends or patterns and to take the corrective action as necessary). Corrective action plans for any areas of concern identified on the audits would be implemented.

Based on observation, interview, record review, and review of facility policy and the facility's plan of correction for the 10/03/12 standard survey it was determined the facility failed to maintain a Quality Assessment and Assurance Program that developed and implemented appropriate plans of action to correct quality deficiencies. This was evidenced by repeated deficiencies related to the facility's failure to provide necessary care and services, and failure to ensure Physician notification. This failure resulted in continued noncompliance at 42 CFR 483.5 Resident Rights, F-157; 42 CFR 483.25 Quality of Care, F-309, and 42 CFR 483.75 Administration, F-514 at a scope and severity of a "D" and F-520 at a scope and severity of a "J". The facility failed to ensure Resident #37 received the necessary care and services as evidenced by failure to assess and recognize a change in the resident's condition. Interviews revealed the resident had puffiness and pain in the left hip area on 11/05/12. The facility failed to notify the Physician of the puffiness and pain in the left hip area. The facility failed to ensure continued assessment and monitoring of this area. Interviews with staff revealed the left hip area continued to be painful to the resident, and the resident was observed by staff to have bruising in the area which changed in color and became larger. According to interview with a Hospice Registered Nurse (RN) when she observed the left hip area on the morning of 11/08/12 the bruising extended from the left hip to the pubic area. There was no documented evidence by the facility that the Physician was notified of Resident #37's condition change until 11/09/12 at 10:00 AM. An x-ray was ordered and obtained on 11/09/12, which revealed Resident #37 had a fractured left hip. In addition, the facility failed to maintain the residents' medical record so that the facility knew the status of each resident. Interview revealed Resident #2 had a wound infection that required antibiotic treatment. The facility made the decision to place the resident in contact precaution. However, record review revealed no documentation denoting that change. The facility's failure to ensure each resident received the necessary care and services related to assessing, monitoring and identifying changes in residents' condition; the facility's failure to notify the physician of changes in residents' condition; and failure of the facility's Quality Assurance Program to effectively re-educate and monitor staff on communicating and notifying the Physician on resident changes of condition was likely to cause risk for serious injury, harm, or impairment or death. The facility was notified, on 12/05/12, of the Immediate Jeopardy at 42 CFR 483.10 Resident Rights (F157); 42 CFR 483.25 Quality of Care (F309); 42 CFR 483.75 Administration (F490) and (F520) with Substandard Quality of Care in the area of 42 CFR 483.25 Quality of Care (F309). The Immediate Jeopardy was determined to exist on 11/05/12. The facility provided an acceptable credible Allegation of Compliance (AOC) on 12/11/12 prior to exiting the facility on 12/14/12, with the facility alleging removal of the Immediate Jeopardy on 12/11/12. The Immediate Jeopardy was verified to be removed on 12/14/12, prior to exiting the facility, with remaining non-compliance at 42 CFR 483.75, Administration, F-520 Quality Assurance, with a Scope and Severity of "D", while the facility develops and implements a Plan of Correction, and the facility's Quality Assurance continues to monitor to ensure the effectiveness of staff education, monitoring developed, and revisions to policies and procedures. The findings include: The facility's Quality Assurance Program failed to ensure the systemic changes noted on the acceptable Plan of Correction, for the 10/03/12 standard survey, were effective in ensuring compliance with F157 and F309 in regards to State Registered Nursing Assistants (SRNAs) communicating resident changes of condition, and licensed nurses notifying Physicians of changes in condition of a resident and related audits to monitor and assess changes in condition. In addition, the facility's QA program failed to ensure the systemic changes noted on the acceptable Plan of Correction, for the 10/03/12 standard survey, were effective in ensuring compliance with F 514 in regards to maintaining the residents' medical record. The facility failed to ensure implementation of the "Condition Change of a Resident" policy; failed to ensure the Physician was notified of changes in residents' condition; and, facility failed to ensure each resident received the necessary care and services to attain or maintain the highest practicable physical well-being. (Refer to F157, and F309). 1. Based on observation, interview, and record review, it was determined the facility failed to ensure the Physician was notified of a change in Resident #37's condition. This was a repeat deficiency which was cited during a Standard and Abbreviated Survey conducted 09/17/12 through 10/03/12 related to failure to notify the Physician when a resident had an area/nodule in the vaginal area that changed in color and appearance. Review of the facility's Plan of Correction (POC), with a compliance date of 10/30/12, revealed the licensed nurses were re-educated related to performing head to toe skin assessments, with emphasis on notable findings that required Physician and family notification. State Registered Nursing Assistants (SRNAs) were educated to report changes resident conditions. In addition, notices were posted at each nursing station for SRNAs to immediately report any change in a resident's skin condition. Additionally, according to the POC, the progress notes were to be reviewed Monday through Friday for appropriate notification. The results of the audits were to be reported to Performance Improvement Committee (PIC) for four (4) weeks, then monthly thereafter. Record review and interview revealed facility staff had observed changes of condition in Resident #37's left leg and hip area from 11/05/12 through 11/08/12, however failed to effectively communicate these changes to other staff and failed to notify the Physician of the changes in the resident's condition. The Physician was notified on 11/09/12 and orders were received for an x-ray of the area. Review of the Radiology Report revealed the resident had a left [MEDICAL CONDITION]. (Refer to F-157) 2. Based on observation, interview, record review and review of the facility policy the facility failed to have an effective system in place to ensure residents' received necessary care and services in regards to assessment and monitoring for one (1) resident (Resident #37) resulting in a repeat deficiency. Review of the facility's Plan of Correction (PoC), with a compliance date of 10/30/12, revealed five (5) SRNAs per week per unit for three (3) months were to be interviewed to validate new and/or unusual findings had been reported to the nurse, and that the nurse had appropriately assessed, documented, and made notification to the Physician and family. In addition, the Director of Nursing (DNS), Assistant Director of Nursing Services (ADNS), Staff Development Coordinator, would conduct an audit of three (3) skin assessments per unit per week for three months to validate skin assessment accuracy and one licensed nurse skin assessment would be observed weekly and documentation reviewed to determine accuracy and proper notification when appropriate. All weekly skin assessment documentation would be reviewed for one month to validate appropriate physician/family notification. Record review and interview revealed facility staff had observed changes of condition in Resident #37's left leg and hip from 11/05/12 through 11/08/12, however failed to assess and monitor these changes. Record review revealed an x-ray was obtained on 11/09/12 which indicated the resident had a [MEDICAL CONDITION]. (Refer to F-309). 3. Based on observation, interview, record review and review of the facility policy the facility failed to ensure the systemic changes noted on the acceptable Plan of Correction, for the 10/03/12 standard survey were effective in ensuring compliance with F 514 in regards to maintaining the residents' medical record so that the facility knew the status of each resident resulting in a repeat deficiency. (Refer to F 514) Interview, on 12/14/12 at 7:15 PM, with the Executive Director and the Quality Assurance Nurse revealed the when the nurses identified a change of condition, to Resident #37, they did not follow the facility's notification process to contact the Physician. They re-educated the nurses, when a change of condition was identified, to contact Hospice for recommendations and then contact the Physician. They have also informed Hospice of the change. The Executive Director further stated there was miscommunication. The nurse on 11/05/12 did not put the information regarding the resident's change of condition on the alert charting or the 24 hour report to communicate to other staff to follow-up. The Quality Assurance Nurse reported when the aides noted changes to Resident #37, left leg/hip area and increased pain, on 11/07/12 and 11/08/12 they should have completed the Stop and Watch form, written the findings on the 24 hour report, or they should have brought the nurse to the resident and pointed it out. Because this was not done, the site was not monitored (assessed) by the nurses and the Physician was not made aware. Further interview with the Quality Assurance Nurse revealed to prevent re-occurrence the facility put in place a shift to shift report audit to ensure nurses used the 24 hour report and alert charting for any resident condition change. In addition, the shift audit looked at alert charting documentation and if the SBAR form and Stop and Watch forms were utilized. At the morning clinical meetings they continued the audit process, by review of the 24 hour report sheet, alert charting, condition change forms, any care plan revisions, Physician Orders, the SBAR and Stop and Watch forms, and was proper notification completed if changes were identified. If problems were identified the person who performed the audit would re-educate staff and the expectation was it was corrected that day. The Unit Managers follow-up and report back at the PM meeting. The audit data was reviewed to identify problems/problematic trends and the results reported at the weekly Performance Improvement meeting and the monthly Quality Assurance Meeting. The facility provided an acceptable credible Allegation of Compliance (AOC) on 12/11/12 that alleged removal of the IJ effective 12/11/12. Review of the AOC revealed the facility implemented the following: 1) Head-to-toe skin assessments were performed on all residents from 12/05/12 through 12/06/12 by licensed nurses to identify any others with indication of any change of condition/puffiness, swelling or redness. Any notable findings were communicated to the attending Physician and responsible party. Notable findings included, but were not limited to, Pressure Ulcers, Arterial Ulcers, Diabetic Neuropathic Ulcers, [MEDICAL CONDITION] Ulcers, Surgical Wounds, Skin Tears, Lacerations, Abrasions, Bruises, Burns, Rashes, or a Lesion associated with bleeding, itching, burning, puffiness or swelling, discoloration and/or raised skin areas. The findings were documented by the licensed nurse, and communicated to the Physician and family for further follow-up. The licensed nurse was responsible to document findings in the residents' medical record and the 24 hour report. 2) On 12/05/12 and 12/06/12 facility licensed nurses conducted an audit that reviewed all current residents' progress notes and the 24 hour reports for the previous thirty (30) days (11/05/12 to current) to validate changes in resident condition were identified and addressed with the Physician and responsible party notification. This audit also included validating any changes in resident condition including updating the care plan. 3) The Administrator (Executive Director) communicated the change in the process for Physician notification by the facility to Hospice on 11/30/12 and again on 12/03/12. 4) Physician orders, condition change forms, alert charting lists, stop and watch forms, and 24 hour sift reports would be audited daily starting on 12/06/12 and ongoing by the Director of Nursing Services (DNS), Assistant Director of Nursing Services (ADNS), or Quality Assurance (QA) Registered Nurse (RN), Monday through Friday; and by the Weekend Supervisor RN on Saturdays and Sundays for any residents with a change in condition to validate appropriate identification of changes in resident condition, notification of the Physician and responsible party, and care plan revision. 5) Shift to shift report was observed daily on each unit beginning 12/10/12 and ongoing by the DNS, ADNS, QA Nurse, Unit Managers (UM), three (3) to eleven (11) Supervisor, Weekend Supervisor, RN Case Manager, District Clinical RN Consultant to validate proper use of the 24 hour report and follow-up to resident change in condition. 6) The Guidelines for Physician Notification of Change of Condition/Clinical Problems in Center Residents was placed on the Treatment Administration Record (TAR) on all units 12/06/12 for quick reference for the nurses. 7) On 12/04/12 the Staff Development Coordinator (SDC) initiated education with all facility licensed nursing staff related to change in condition of resident status. Inservice dates were 12/04/12, 12/05/12, 12/06/12 and ongoing until all facility clinical staff had received the education. Education was provided by the SDC, ADNS', three (3) to eleven (11) RN Supervisor, Weekend RN, DNS, or QA RN. No nursing staff would be allowed to work until they had received the education. The inservices included: Situation Background Assessment Recommendation/Request (SBAR) form, 24 hour report form, alert charting system, notification of the Physician and responsible party, assessing for a possible [MEDICAL CONDITION], State Registered Nursing Staff (SRNA) utilizing the Stop and Watch forms, Licensed Nurse notification to Hospice for recommendations for a resident with a change in condition, then notify Physician of the change in condition and notify family. 8) A Performance Improvement Committee (PIC) meeting was held on 12/05/12 and again on 12/06/12. The Medical Director was notified of the Immediate Jeopardy via telephone and approved the plan developed by the PIC on 12/05/12. The PIC reviewed and approved the Allegation of Compliance (AOC). The PIC was to ensure validation of the AOC by: beginning 12/06/12, initial and daily audits of the Physician orders, condition change forms, alert charting lists, Stop and Watch forms, and shift to shift observations were being reviewed by the DNS, ADNS', QA RN, and/or Weekend Supervisor RN on Saturday and Sunday to identify issues, trends or patterns and take corrective action as necessary. The QA RN would be responsible to report trends from the audits to the weekly PIC committee for review and further recommendations. The PIC would create corrective action plans for any areas of concern identified on the audits. The PIC committee would meet weekly or more often as necessary until the facility had removed the Immediate Jeopardy. Once the Immediate Jeopardy was removed the facility would return to routine monthly PIC committee meetings. 9) The District and/or Regional team would provide RN clinical oversight a minimum of three (3) days per week beginning the week of 12/02/12. 10) The facility contracted an outside clinical consulting group on 11/20/12 to conduct onsite facility clinical oversight two (2) days per week beginning 12/02/12. The State Survey Agency validated the implementation of the facility's AOC as follows: Review of the skin assessment forms revealed all facility residents had skin assessments performed from 12/05/12 through 12/06/12 by licensed nurses, except three (3) who refused and one (1) that was end of life. Audit review revealed newly identified areas were reported to the physician and responsible party. Record review revealed the facility performed the audits as identified on the facility's AOC: An audit of resident progress notes and the 24 hour reports for the last 30 days was performed on 12/05/12 - 12/06/12. Daily audits of Physician orders, condition change forms, alert charting lists, stop and watch forms, and 24 hour shift reports started on 12/06/12. Problems identified were given to the Unit Managers for follow-up. The Shift to Shift audits were initiated by the facility on 12/10/12. Observation of the Treatment Administration Record (TAR) on each unit revealed they had Guidelines for Physician Notification of Change of Condition/Clinical Problems in the front. Interview, on 12/13/12 at 11:05 AM, with the Staff Development Coordinator (SDC) revealed she had completed education with facility staff related to the SBAR form, 24 hour report form, alert charting system, notification of the Physician and responsible party, assessing for a possible [MEDICAL CONDITION], State Registered Nursing Staff (SRNA) utilizing the Stop and Watch forms, Licensed Nurse notification to Hospice for recommendations for a resident with a change in condition, then notify Physician of the change in condition and notify family. Interview, on 12/13/12 at 11:00 AM, with the Executive Director (ED), Vice President of Clinical Operations, Director of District Operations, Director of Nursing Services (DNS), Quality Assurance (QA) RN, and contracted Nurse Consultant revealed the District and/or Regional team would provide RN clinical oversight a minimum of three (3) days per week beginning the week of 12/02/12. In addition, the facility had contracted with an outside clinical consulting group on to conduct onsite facility clinical oversight two (2) days per week. Interviews with licensed nursing staff on 12/12/12 at 11:50 AM with Licensed Practical Nurse (LPN) #40, at 3:00 PM with Registered Nurse (RN) #11, at 3:15 PM with LPN #13; on 12/14/12 (7:00 AM to 3:00 PM shift) at 9:50 AM with LPN #3, at 2:00 PM with LPN #9, at 2:17 PM with LPN #16, at 2:45 PM with LPN #32, at 2:53 PM with LPN #15; on 12/14/12 (3:00 PM to 11:00 PM shift) at 5:35 PM with LPN #2, at 6:00 PM with LPN #31; and, on 12/14/12 (11:00 PM to 7:00 AM shift) at 3:42 PM with LPN #19 and at 4:32 PM with LPN #38 revealed they were all aware the "Guidelines for Physician Notification of Change of Condition/Clinical Problems in Center Residents" was on the Treatment Administration Record (TAR); they had received education on the Situation Background Assessment Recommendation/Request (SBAR) form; the 24 hour report form; the alert charting system; notification of the Physician and responsible party; assessing residents for a possible [MEDICAL CONDITION]; the State Registered Nursing Staff (SRNA) utilizing the Stop and Watch forms; and after notification to Hospice for recommendations for a resident with a change in condition, that they were to then notify the Physician of the change in condition and obtain orders, then notify the family. All licensed nurses interviewed confirmed that the shift to shift reports were being audited by Unit Managers, Assistant Director of Nursing Services (ADNS), 3:00 PM to 11:00 PM Supervisor, Quality Assurance Registered Nurse, and Weekend Supervisor. Interview, on 12/12/12 at 10:05 AM with State Registered Nursing Assistants (SRNAs) #8 and #9; on 12/14/12 at 9:15 AM with SRNA #37, at 9:15 AM with SRNA #38, at 2:33 PM with SRNA #27, at 3:00 PM with SRNA #32, at 3:40 PM with SRNA #39, at 4:00 PM with SRNA #13, at 4:19 PM with SRNA #34, at 4:28 PM with SRNA #35, at 5:15 PM with SRNAs #33 and #36 revealed they had all received education on the Stop and Watch form for communicating changes in residents' condition to the nurses. Interview, on 12/14/12 at 9:25 AM with LPN #39 and at 9:30 AM with LPN #16 revealed the SRNAs had received training on the Stop and Watch form. Interview, on 12/11/12 at 12:20 PM, with the Director of Nursing Services (DNS) revealed education had been performed with facility staff in regards to the "skin sheet", Stop and Watch form, 24 hour report form, and proper notification of the Physician and family. She stated nurses had been re-educated to confer with Hospice, however they were to notify the Physician and responsible party. In an additional interview, on 12/14/12 at 5:00 PM, with the DNS revealed in the facility's daily clinical review they were monitoring: the notification of change to the Physician and family, care plan updates, 24 hour report forms, alert charting forms, condition change forms, and Stop and Watch forms. She stated any concerns are followed up on by the Unit Managers (UM). The DNS stated she ensures the UMs complete the follow up via another meeting at the end of the day. According to the DNS, shift reports were being audited every day. She stated the audits were to ensure nurses were utilizing the 24 hour report form, alert charting, and any Stop and Watch forms to ensure the following shift was updated on residents' condition changes. Interview, on 12/14/12 at 11:40 AM, with RN #10/Assistant Director of Nursing Services (ADNS) for A and B units, revealed she audited progress notes, SBAR forms, Physician orders, condition change forms, alert charting lists, stop and watch forms, and 24 hour shift reports for the past thirty (30) days, and also ensured the care plan was updated. In an additional interview with RN #10/ADNS at 5:20 PM revealed she had monitored the shift to shift reports to ensure nurses were utilizing the 24 hour report form, the alert charting form, and any Stop and Watch forms to ensure the oncoming shift was aware of any changes in residents' condition. Interview, on 12/14/12 at 2:00 PM, with RN #2/ADNS (for C and D units) revealed he had performed audits of progress notes, SBAR forms, Physician orders, condition change forms, alert charting lists, stop and watch forms, and 24 hour shift reports for the past thirty (30) days. Interview, on 12/14/12 at 6:15 PM with the Weekend Supervisor RN revealed he had audited shift to shift reports to ensure the 24 hour report form, the alert charting and any Stop and Watch forms were being utilized to pass on residents' condition changes to the oncoming shift. He stated he had performed audits of the Physician orders, SBAR forms, condition change forms, alert charting lists, stop and watch forms, and 24 hour shift reports. Interview, on 12/14/12 at 6:10 PM, with the Medical Director revealed she had been notified of the Immediate Jeopardy by telephone and had approved the Allegation of Compliance (AOC) after discussion with the facility. She stated the Performance Improvement Committee (PIC) had been meeting weekly since the Immediate Jeopardy was identified and she was involved with these meetings. Interview, on 12/14/12 at 7:15 PM, with the ED and Quality Assurance (QA) RN revealed the Executive Director communicated the change in the process for Physician notification by the facility to Hospice. She stated Hospice had been educated that the facility's nurses would contact the Physician. The QA RN verified that audits were being performed as per the AOC, such as shift to shift report audits to ensure the 24 hour report form and alert charting information was being utilized. The QA RN indicated if audits were performed at shift change then the 24 hour report, alert charting, SBAR forms, and Stop and Watch forms were being audited to ensure a change in a resident's condition is being passed along. According to the QA RN, the results of all the audits on the 24 hour report form, SBAR form, alert charting form, condition change form, care plan updates, Physician orders, Physician and family notification, and Stop and Watch forms were taken to the morning clinical meeting and discussed. The QA RN stated if a problem was identified then staff were educated by the person doing the audit. The QA RN stated he reported the results of the audits and any trends to the weekly PIC meeting. The ED stated education was performed as per the AOC. She stated through the use of the new three (3) part SBAR form and Stop and Watch form that communication was now "shored" up. She stated staff had been educated to ensure a Stop and Watch form was filled out with any change in a resident's condition. An additional interview, on 12/14/12 at 8:00 PM, with the ED revealed the PIC had been meeting weekly. According to the ED, the PIC was performing what was indicated in the AOC (i.e.-validating the AOC by: reviewing initial and daily audits of the Physician orders, condition change forms, alert charting lists, Stop and Watch forms; and shift to shift observations were being reviewed to identify issues, trends or patterns and to take the corrective action as necessary). Corrective action plans for any areas of concern identified on the audits would be implemented.

Based on observation, interview and record review, it was determined the facility failed to maintain a Quality Assessment and Assurance Program that developed and implemented appropriate plans of action to correct quality deficiencies. This was evidenced by repeated deficiencies related to the facility's failure to ensure accommodation of needs for residents, failure to ensure Comprehensive Plans of Care were reviewed and/or revised, and failure to ensure accurate maintenance of clinical records. This failure resulted in continued noncompliance at 42 CFR 483.15 Quality of Life, F-246; 42 CFR 483.20 Resident Assessment, F-281; and 42 CFR 483.75 Administration, F-514. The findings include: 1. The facility failed to ensure accommodation of residents' needs for one (1) resident, with left-sided weakness who required limited assistance with toileting, related to not having the necessary equipment (grab bars) provided in the resident's bathroom to assist the resident with transfers. This resulted in a repeat deficiency. Review of the facility's Plan of Correction (PoC), with a compliance date of 06/18/12, revealed interviews were conducted with interviewable residents, those with a Brief Interview for Mental Status (BIMS) score of twelve (12) to fifteen (15) and/or legal representatives of non-interviewable residents in relation to unresolved concerns involving accommodation of needs and preferences in terms of staff treatment of [REDACTED]. The Staff Development Coordinator (SDC) conducted an inservice with all staff related to accommodation of needs and preferences. All new hires were to receive this education also. Any identified accommodation of need or preference concern to be tracked and trended by the Social Services Director (SSD) on a monthly basis through the Performance Improvement Committee (PIC). Action plans were to be developed and implemented as indicated. The audits were to be reviewed in the monthly PIC for three (3) months and as needed thereafter. A review of the medical record for Resident #15 revealed the facility admitted the resident on 07/17/12, with [DIAGNOSES REDACTED]. During a group interview conducted on 09/18/12 at 9:30 AM, Resident #15 stated "there were no grab bars in his/her bath room and transferring to the toilet was difficult". Observation of Resident #15's bath room conducted on 09/20/12 at 3:45 PM, revealed no grab bars in the bath room available for resident use. An interview conducted with the Therapy Supervisor, on 09/20/12 at 4:00 PM, revealed the bar in Resident #15's bath room was a towel rack and not a grab bar. The Therapy Supervisor was not aware grab bars were not in the resident's bath room. According to the Therapy Supervisor the lack of grab bars should have been identified when the therapy evaluation was conducted for Resident #15. 2. The facility failed to ensure services provided met professional standards of quality according to accepted standards of practice for one (1) resident in regards to pain medication administration and documentation of pain medication which resulted in a repeat deficiency. This was a repeat deficiency for which the facility was cited for 05/11/12. Review of the facility's Plan of Correction (PoC), with a compliance date of 06/18/12, revealed Unit Managers were to conduct audits for accuracy and completion of care plans weekly times three (3) months. Inservices were held by the Staff Development Coordinator (SDC) on developing initial care plans, resident dignity and respect with an emphasis on addressing residents' receiving timely incontinence care, toileting, showers, and response to call lights. The audits were to be taken to the Performance Improvement Committee (PIC) every month for three (3) months, and as needed thereafter. Review of Resident #13's medical record revealed a pain medication was ordered PRN (as necessary) every four (4) hours. Review of the record revealed the pain medication was given on 09/02/12, at 6:00 AM and 8:00 AM, a two (2) hour time interval. Additional review of the medical record revealed no documented evidence of a follow-up post pain rating or response related to the pain medication administration at 8:00 AM when the second dose of pain medication was administered early. Interview with the Director of Nursing Services (DNS), who served on the PIC, on 09/25/12 at 4:35 PM, revealed the pain medication was not administered as ordered. Continued interview revealed staff should also have followed up for effectiveness after the 8:00 AM dose to see if the resident was relieved of pain and was doing okay. 3. Additionally, the facility failed to have an effective system in place to maintain clinical records for each resident in accordance with accepted professional standards and practice for completeness and accuracy for two (2) residents, resulting in a repeat deficiency. Review of the facility's Plan of Correction (PoC), with a compliance date of 06/18/12, revealed a review of all active medical records was completed on 06/16/12, to validate that only the correct medical record was "in the chart". The Staff Development Coordinator (SDC) inserviced all licensed staff on proper filing of the medical record, and the procedures to discontinue a medication in the medical record. The Medical Records Clerk was to audit three (3) residents' medical record per month for three (3) months to validate accuracy. The Medical Records Clerk was to report, track and trend audit findings to the PIC which included the Administrator, and DNS for three (3) months and thereafter as needed. Interview, on 10/03/12 at 7:25 PM, with the Administrator, and Director of Nursing Services (DNS), who served on the PIC on 06/18/12, the date of alleged compliance from the previous PoC, and the Quality Assurance (QA) Nurse revealed the PIC meets monthly and the Medical Director attends. The Administrator stated the PIC would meet more often if necessary. According to the Administrator, the PIC looked at "various things"; if issues were identified from rounds, through data collection, from the weekly forums with the residents. She stated issues or concerns were brought to the PIC, who discussed the issue or concern, and put a plan in place to try to resolve the issue or concern. The plan is then brought back to the PIC where results were reported and changes made as necessary. Further interview, on 10/03/12 at 7:25 PM, with the Administrator, and DNS, revealed the facility was not aware of the repeated identified deficiencies until the current survey was in progress. The Administrator stated grab bars have now been added to all the A unit bathrooms in regards to 483.15 Quality of Life, F-246, Accommodation of Needs. The DNS stated the facility was currently working on education on medication administration and documentation of pain medication in the appropriate areas of the medical record in regards to 42 CFR 483.20 Resident Assessment, F-281. The Administrator stated the Master Signature Log had been updated. The DNS stated staff had been educated on documentation in the medical record in regards to 42 CFR 483.75 Administration, F-514.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to have an effective system in place to ensure residents' clinical records were maintained in accordance with accepted professional standards and practices for completeness and accuracy for one (1) of nineteem (19) sampled residents (Resident #2). The facility failed to maintain the residents' medical record so that the facility knew the status of each resident. Interview revealed Resident #2 had a wound infection that required antibiotic treatment. The facility made the decision to place the resident in contact precaution. However, record review revealed no documentation denoting that change. The findings include: Review of the facility's policy titled, "Documentation of Resident's Health Status, Needs and Services" revealed the resident's medical record was a continuing account of the resident's health status and needs. Review of facility policy titled "Transmission-based Precautions", dated 09/19/12, revealed guidelines to document in resident's medical record that included the reason for isolation/precautions, type: contact,droplet, airborne, duration of isolation, notification of family, and discontinuation of isolation. Observation, on 12/11/12 at 4:30 PM, revealed LPN #14 was in Resident #2's room administering medications. The nurse wore gloves but no gown. Personal Protective Equipment (PPE), disposable gloves and gowns were available in a plastic container that was hung on the resident's door. A sign was posted that instructed you to see the nurse before entering the room. Interview with LPN #14, on 12/11/12 at 4:35 PM, revealed she was not aware the resident had been placed in contact isolation. She was aware the resident had an infected toe. Interview with the Assistant Director of Nursing (ADON), on 12/11/12 at 4:35 PM, revealed the resident had been placed in contact isolation yesterday, 12/10/12. She stated that decision had been made at the morning meeting. Although the resident's wound culture revealed [MEDICAL CONDITION] Susceptible Staph Aureus (MSSA), the facility decided to place the resident in contact precautions. However, that information was not documented in the clinical record. Review of the clinical record revealed no documentation regarding the decision to place Resident #2 in contact precautions with PPE. In addition, review of the 24 hour report for the dates of 12/11/12, 12/12/12, and 12/13/12 revealed the nurses did not communicate that change in the resident's status. Interview with the ADON, on 12/14/12 at 6:10 PM, revealed a physician's orders [REDACTED]. She stated when the lab came back, the nurse should have documented in the clinical record and the 24 hour report according to the Plan of Correction. The three (3) part form that included Physician telephone order, change in condition form, and care plan update was not completed because there was no new physician's orders [REDACTED].

Based on observation, interview, record review and review of the facility's policy it was determined the facility's Administration failed to ensure the facility was administered in a manner which enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychological well-being of each resident. The Administrator failed to ensure the facility had an effective Quality Assessment and Assurance Program that developed and implemented appropriate plans of action to correct quality deficiencies. This was evidenced by repeat deficiencies related to the facility's failure to ensure the physician was notified with a significant change in residents' physical condition physical status and failure to fully assess and monitor residents' physical change in condition. This failure resulted in repeat noncompliance at 42 CFR 483.10 Resident Rights F-157 and 42 CFR 483.25 Quality of Care F-309. In addition, the Administration failed to have an effective system to ensure the Comprehensive Plans of Care were revised to include effective interventions in regards to assessing and monitoring of residents who experienced a change in condition. (Refer to F-280) On 11/05/12 Resident #37 was noted to have swelling/puffiness and redness to the left hip and pain with movement. There was no documented evidence the Physician was notified of this change in condition or that the plan of care was revised to ensure further assessment and monitoring. Interviews with facility staff revealed, on 11/07/12, the resident had a bruise-like discolored area to the inner left thigh however, failed to communicate this change to a nurse. On the morning of 11/08/12, a Hospice Nurse and Aide both noted Resident #37 had bruising from the left hip to the pubic area, however, review of facility documentation revealed no assessment or monitoring of the resident's change in condition by facility staff until 11/08/12 at 9:00 PM when Resident #37 was noted to have pain/discomfort to the left leg/hip, the left foot was noted to be turned inward and appeared shorter then the right leg and there was discoloration to the outer left hip, back of left leg, front of labia, and inside the left leg. The facility's administration failed to ensure that on 11/05/12 and 11/08/12 when facility staff noted changes of condition to Resident #37's left leg/hip that the resident's Physician was notified. The Physician was not notified until 11/09/12, when an x-ray revealed the resident had a left [MEDICAL CONDITION]. Based on the above findings it was determined the facility's failure to have an effective system in place to ensure the facility was administered in a manner that enabled it to use its resources effectively and efficiently was likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy (IJ) was identified on 12/05/12 and determined to exist on 11/05/12. An acceptable credible Allegation of Compliance (AOC), related to the Immediate Jeopardy, was received on 12/11/12. On 12/14/12, the State Agency verified the Immediate Jeopardy was removed on 12/11/12 as alleged, prior to exit, with remaining non-compliance at 42 CFR 483.75 Administration, F-490 at a Scope and Severity (S/S) of a "D" while the facility develops and implements the Plan of Correction (POC) and the facility's Quality Assurance monitors the effectiveness of the systemic changes. The findings include: (Refer to F-157) The facility failed to ensure the physician was notified of a significant change in a residents physical status. This was a repeat deficiency which was cited during a Standard Survey conducted 10/03/12 for deficiencies related to failure to notify the physician when a resident was noted to have a nodule in the vaginal area. During this survey, it was identified the facility failed to notify the physician changes of condition to Resident #37's left leg/hip beginning 11/05/12 through 11/08/12, until 11/09/12 when an x-ray revealed the resident had a left [MEDICAL CONDITION]. (Refer to F-280) The facility failed to ensure comprehensive plans of care were reviewed and revised when a change in condition was noted for Residents #37, Resident #41 and Resident #2. The facility failed to update the care plan for Resident #37 after the resident was assessed on 11/05/12 for having pain and puffiness in the left hip area for interventions to include continued monitoring and assessment of the area to prevent further pain and ensure the resident received the appropriate care and services. Three days later, on 11/08/12, Resident #37 was assessed by the nurse with pain/discomfort in the left hip/leg area and discoloration to the left hip, back of the left leg, front of the labia, and inside of the left leg, and the left foot was turned inward and the left leg was noted being shorter than the right leg. Review of the Comprehensive Care Plan revealed no documented evidence the care plan was revised related to the resident's change in condition other than an order to administer 400 milligrams [MEDICATION NAME] every six hours as needed. On the morning of 11/09/12 Resident #37 was noted to have bruising which was dark purple to the resident's left hip, groin, and "private" area and the resident cried out in pain. The APRN was contacted and an order obtained for an x-ray which revealed Resident #37 had a left [MEDICAL CONDITION]. In addition, the facility failed to revise Resident #41's care plan after the resident was readmitted to the facility and had oxygen in use. Also, the facility failed to revise Resident #2's care plan when he/she was placed in contact precautions after being diagnosed with [REDACTED]. (Refer to F-309) The facility failed to ensure each resident received the necessary care and services to attain or maintain the highest practicable physical well-being for two (2) of forty-one (41) sampled residents (Residents #37) as evidenced by Resident #37 had a left [MEDICAL CONDITION] of unknown origin. This was a repeat deficiency for the facility which was cited during a Standard Survey conducted 10/03/12 for deficiencies related to failure to assess and monitor a resident after a nodule in the vaginal area was identified. Interview, on 12/14/12 at 3:00 PM, with the Administrator revealed the facility had been conducting audits of three skin assessments per unit per week to validate accuracy of skin assessments and documentation of these skin assessments to include appropriate physician and family notification. Further interview revealed these audits were turned into her, she reviewed them and problems had been identified and changes had been made since the compliance date of 10/30/12 from the survey ending 10/03/12. She stated the changes she had implemented included contracting with a consulting group on 11/20/12, to come to the facility two (2) days per week to help with problem solving. Continued interview revealed she implemented another new process in which she conducted walking rounds and had monitors go to each unit for thirty minutes. Further interview revealed these walking rounds would be used as teachable moments. According to the Administrator, she lead the PIC and it was continuously reviewing the problems identified. The administrator indicated the nurse on 11/05/12 did not follow the process for the MD notification and documentation she had been educated on as far as putting her assessment on the alert charting, 24 hour report, and notifying the Physician. She indicated when the nurse's findings were not on the 24 Hour Report, no one was aware to monitor the site. The facility provided an acceptable credible Allegation of Compliance (AOC) on 12/11/12 that alleged removal of the IJ effective 12/11/12. Review of the AOC revealed the facility implemented the following: 1) Head-to-toe skin assessments were performed on all residents from 12/05/12 through 12/06/12 by licensed nurses to identify any others with indication of any change of condition/puffiness, swelling or redness. Any notable findings were communicated to the attending Physician and responsible party. Notable findings included, but were not limited to, Pressure Ulcers, Arterial Ulcers, Diabetic Neuropathic Ulcers, [MEDICAL CONDITION] Ulcers, Surgical Wounds, Skin Tears, Lacerations, Abrasions, Bruises, Burns, Rashes, or a Lesion associated with bleeding, itching, burning, puffiness or swelling, discoloration and/or raised skin areas. The findings were documented by the licensed nurse, and communicated to the Physician and family for further follow-up. The licensed nurse was responsible to document findings in the residents' medical record and the 24 hour report. 2) On 12/05/12 and 12/06/12 facility licensed nurses conducted an audit that reviewed all current residents' progress notes and the 24 hour reports for the previous thirty (30) days (11/05/12 to current) to validate changes in resident condition were identified and addressed with the Physician and responsible party notification. This audit also included validating any changes in resident condition including updating the care plan. 3) The Administrator (Executive Director) communicated the change in the process for Physician notification by the facility to Hospice on 11/30/12 and again on 12/03/12. 4) Physician orders, condition change forms, alert charting lists, stop and watch forms, and 24 hour sift reports would be audited daily starting on 12/06/12 and ongoing by the Director of Nursing Services (DNS), Assistant Director of Nursing Services (ADNS), or Quality Assurance (QA) Registered Nurse (RN), Monday through Friday; and by the Weekend Supervisor RN on Saturdays and Sundays for any residents with a change in condition to validate appropriate identification of changes in resident condition, notification of the Physician and responsible party, and care plan revision. 5) Shift to shift report was observed daily on each unit beginning 12/10/12 and ongoing by the DNS, ADNS, QA Nurse, Unit Managers (UM), three (3) to eleven (11) Supervisor, Weekend Supervisor, RN Case Manager, District Clinical RN Consultant to validate proper use of the 24 hour report and follow-up to resident change in condition. 6) The Guidelines for Physician Notification of Change of Condition/Clinical Problems in Center Residents was placed on the Treatment Administration Record (TAR) on all units 12/06/12 for quick reference for the nurses. 7) On 12/04/12 the Staff Development Coordinator (SDC) initiated education with all facility licensed nursing staff related to change in condition of resident status. Inservice dates were 12/04/12, 12/05/12, 12/06/12 and ongoing until all facility clinical staff had received the education. Education was provided by the SDC, ADNS', three (3) to eleven (11) RN Supervisor, Weekend RN, DNS, or QA RN. No nursing staff would be allowed to work until they had received the education. The inservices included: Situation Background Assessment Recommendation/Request (SBAR) form, 24 hour report form, alert charting system, notification of the Physician and responsible party, assessing for a possible [MEDICAL CONDITION], State Registered Nursing Staff (SRNA) utilizing the Stop and Watch forms, Licensed Nurse notification to Hospice for recommendations for a resident with a change in condition, then notify Physician of the change in condition and notify family. 8) A Performance Improvement Committee (PIC) meeting was held on 12/05/12 and again on 12/06/12. The Medical Director was notified of the Immediate Jeopardy via telephone and approved the plan developed by the PIC on 12/05/12. The PIC reviewed and approved the Allegation of Compliance (AOC). The PIC was to ensure validation of the AOC by: beginning 12/06/12, initial and daily audits of the Physician orders, condition change forms, alert charting lists, Stop and Watch forms, and shift to shift observations were being reviewed by the DNS, ADNS', QA RN, and/or Weekend Supervisor RN on Saturday and Sunday to identify issues, trends or patterns and take corrective action as necessary. The QA RN would be responsible to report trends from the audits to the weekly PIC committee for review and further recommendations. The PIC would create corrective action plans for any areas of concern identified on the audits. The PIC committee would meet weekly or more often as necessary until the facility had removed the Immediate Jeopardy. Once the Immediate Jeopardy was removed the facility would return to routine monthly PIC committee meetings. 9) The District and/or Regional team would provide RN clinical oversight a minimum of three (3) days per week beginning the week of 12/02/12. 10) The facility contracted an outside clinical consulting group on 11/20/12 to conduct onsite facility clinical oversight two (2) days per week beginning 12/02/12. The State Survey Agency validated the implementation of the facility's AOC as follows: Review of the skin assessment forms revealed all facility residents had skin assessments performed from 12/05/12 through 12/06/12 by licensed nurses, except three (3) who refused and one (1) that was end of life. Audit review revealed newly identified areas were reported to the physician and responsible party. Record review revealed the facility performed the audits as identified on the facility's AOC: An audit of resident progress notes and the 24 hour reports for the last 30 days was performed on 12/05/12 - 12/06/12. Daily audits of Physician orders, condition change forms, alert charting lists, stop and watch forms, and 24 hour shift reports started on 12/06/12. Problems identified were given to the Unit Managers for follow-up. The Shift to Shift audits were initiated by the facility on 12/10/12. Observation of the Treatment Administration Record (TAR) on each unit revealed they had Guidelines for Physician Notification of Change of Condition/Clinical Problems in the front. Interview, on 12/13/12 at 11:05 AM, with the Staff Development Coordinator (SDC) revealed she had completed education with facility staff related to the SBAR form, 24 hour report form, alert charting system, notification of the Physician and responsible party, assessing for a possible [MEDICAL CONDITION], State Registered Nursing Staff (SRNA) utilizing the Stop and Watch forms, Licensed Nurse notification to Hospice for recommendations for a resident with a change in condition, then notify Physician of the change in condition and notify family. Interview, on 12/13/12 at 11:00 AM, with the Executive Director (ED), Vice President of Clinical Operations, Director of District Operations, Director of Nursing Services (DNS), Quality Assurance (QA) RN, and contracted Nurse Consultant revealed the District and/or Regional team would provide RN clinical oversight a minimum of three (3) days per week beginning the week of 12/02/12. In addition, the facility had contracted with an outside clinical consulting group on to conduct onsite facility clinical oversight two (2) days per week. Interviews with licensed nursing staff on 12/12/12 at 11:50 AM with Licensed Practical Nurse (LPN) #40, at 3:00 PM with Registered Nurse (RN) #11, at 3:15 PM with LPN #13; on 12/14/12 (7:00 AM to 3:00 PM shift) at 9:50 AM with LPN #3, at 2:00 PM with LPN #9, at 2:17 PM with LPN #16, at 2:45 PM with LPN #32, at 2:53 PM with LPN #15; on 12/14/12 (3:00 PM to 11:00 PM shift) at 5:35 PM with LPN #2, at 6:00 PM with LPN #31; and, on 12/14/12 (11:00 PM to 7:00 AM shift) at 3:42 PM with LPN #19 and at 4:32 PM with LPN #38 revealed they were all aware the "Guidelines for Physician Notification of Change of Condition/Clinical Problems in Center Residents" was on the Treatment Administration Record (TAR); they had received education on the Situation Background Assessment Recommendation/Request (SBAR) form; the 24 hour report form; the alert charting system; notification of the Physician and responsible party; assessing residents for a possible [MEDICAL CONDITION]; the State Registered Nursing Staff (SRNA) utilizing the Stop and Watch forms; and after notification to Hospice for recommendations for a resident with a change in condition, that they were to then notify the Physician of the change in condition and obtain orders, then notify the family. All licensed nurses interviewed confirmed that the shift to shift reports were being audited by Unit Managers, Assistant Director of Nursing Services (ADNS), 3:00 PM to 11:00 PM Supervisor, Quality Assurance Registered Nurse, and Weekend Supervisor. Interview, on 12/12/12 at 10:05 AM with State Registered Nursing Assistants (SRNAs) #8 and #9; on 12/14/12 at 9:15 AM with SRNA #37, at 9:15 AM with SRNA #38, at 2:33 PM with SRNA #27, at 3:00 PM with SRNA #32, at 3:40 PM with SRNA #39, at 4:00 PM with SRNA #13, at 4:19 PM with SRNA #34, at 4:28 PM with SRNA #35, at 5:15 PM with SRNAs #33 and #36 revealed they had all received education on the Stop and Watch form for communicating changes in residents' condition to the nurses. Interview, on 12/14/12 at 9:25 AM with LPN #39 and at 9:30 AM with LPN #16 revealed the SRNAs had received training on the Stop and Watch form. Interview, on 12/11/12 at 12:20 PM, with the Director of Nursing Services (DNS) revealed education had been performed with facility staff in regards to the "skin sheet", Stop and Watch form, 24 hour report form, and proper notification of the Physician and family. She stated nurses had been re-educated to confer with Hospice, however they were to notify the Physician and responsible party. In an additional interview, on 12/14/12 at 5:00 PM, with the DNS revealed in the facility's daily clinical review they were monitoring: the notification of change to the Physician and family, care plan updates, 24 hour report forms, alert charting forms, condition change forms, and Stop and Watch forms. She stated any concerns are followed up on by the Unit Managers (UM). The DNS stated she ensures the UMs complete the follow up via another meeting at the end of the day. According to the DNS, shift reports were being audited every day. She stated the audits were to ensure nurses were utilizing the 24 hour report form, alert charting, and any Stop and Watch forms to ensure the following shift was updated on residents' condition changes. Interview, on 12/14/12 at 11:40 AM, with RN #10/Assistant Director of Nursing Services (ADNS) for A and B units, revealed she audited progress notes, SBAR forms, Physician orders, condition change forms, alert charting lists, stop and watch forms, and 24 hour shift reports for the past thirty (30) days, and also ensured the care plan was updated. In an additional interview with RN #10/ADNS at 5:20 PM revealed she had monitored the shift to shift reports to ensure nurses were utilizing the 24 hour report form, the alert charting form, and any Stop and Watch forms to ensure the oncoming shift was aware of any changes in residents' condition. Interview, on 12/14/12 at 2:00 PM, with RN #2/ADNS (for C and D units) revealed he had performed audits of progress notes, SBAR forms, Physician orders, condition change forms, alert charting lists, stop and watch forms, and 24 hour shift reports for the past thirty (30) days. Interview, on 12/14/12 at 6:15 PM with the Weekend Supervisor RN revealed he had audited shift to shift reports to ensure the 24 hour report form, the alert charting and any Stop and Watch forms were being utilized to pass on residents' condition changes to the oncoming shift. He stated he had performed audits of the Physician orders, SBAR forms, condition change forms, alert charting lists, stop and watch forms, and 24 hour shift reports. Interview, on 12/14/12 at 6:10 PM, with the Medical Director revealed she had been notified of the Immediate Jeopardy by telephone and had approved the Allegation of Compliance (AOC) after discussion with the facility. She stated the Performance Improvement Committee (PIC) had been meeting weekly since the Immediate Jeopardy was identified and she was involved with these meetings. Interview, on 12/14/12 at 7:15 PM, with the ED and Quality Assurance (QA) RN revealed the Executive Director communicated the change in the process for Physician notification by the facility to Hospice. She stated Hospice had been educated that the facility's nurses would contact the Physician. The QA RN verified that audits were being performed as per the AOC, such as shift to shift report audits to ensure the 24 hour report form and alert charting information was being utilized. The QA RN indicated if audits were performed at shift change then the 24 hour report, alert charting, SBAR forms, and Stop and Watch forms were being audited to ensure a change in a resident's condition is being passed along. According to the QA RN, the results of all the audits on the 24 hour report form, SBAR form, alert charting form, condition change form, care plan updates, Physician orders, Physician and family notification, and Stop and Watch forms were taken to the morning clinical meeting and discussed. The QA RN stated if a problem was identified then staff were educated by the person doing the audit. The QA RN stated he reported the results of the audits and any trends to the weekly PIC meeting. The ED stated education was performed as per the AOC. She stated through the use of the new three (3) part SBAR form and Stop and Watch form that communication was now "shored" up. She stated staff had been educated to ensure a Stop and Watch form was filled out with any change in a resident's condition. An additional interview, on 12/14/12 at 8:00 PM, with the ED revealed the PIC had been meeting weekly. According to the ED, the PIC was performing what was indicated in the AOC (i.e.-validating the AOC by: reviewing initial and daily audits of the Physician orders, condition change forms, alert charting lists, Stop and Watch forms; and shift to shift observations were being reviewed to identify issues, trends or patterns and to take the corrective action as necessary). Corrective action plans for any areas of concern identified on the audits would be implemented.

Based on observation, interview, record review, review of the facility standards of practice manual "Delmar's Fundamental and Advanced Nursing Skills", and review of the facility's policies, it was determined the facility failed to ensure each resident received the necessary care and services to attain or maintain the highest practicable physical well-being for one (1) of thirty-six (36) sampled residents (Resident #2). The facility failed to have an effective system to assess residents' skin in order to establish a baseline from which to identify skin changes needing further evaluation and/or treatment. The facility failed to assess and establish a baseline assessment of an area on Resident #2's vagina. This failure resulted in the inability of staff to determine when the area developed, how long the area had been present, and when changes in the area began. Interviews with facility staff revealed inconsistent and varying accounts of when the area was identified and when the area began to change. On 09/04/12, the area was noted to be bleeding. The Physician was contacted; however, interview and record review revealed the Physician was not given an accurate assessment of the area. Orders were received for an oral antibiotic and a topical antibiotic. On 09/06/12, the resident's Physician assessed Resident #2 and ordered the resident as a direct admitted to the hospital where he/she was diagnosed with [REDACTED]. The facility's failure to ensure each resident received the necessary care and services related to assessing and identifying changes in residents' skin condition was likely to cause risk for serious injury, harm, or impairment or death. The Immediate Jeopardy was identified on 09/21/12, and determined to exist on 08/31/12. The facility was notified of the Immediate Jeopardy on 09/21/12. The facility provided an acceptable credible Allegation of Compliance (AOC) on 09/27/12 prior to exiting the facility on 10/03/12, with the facility alleging removal of the Immediate Jeopardy on 09/27/12. The Immediate Jeopardy was verified to be removed on 09/27/12, prior to exiting the facility on 10/03/12, with remaining non-compliance at 42 CFR 483.25, Quality of Care, F-309 Necessary Care and Services, with a Scope and Severity of "D", while the facility develops and implements a Plan of Correction, and the facility's Quality Assurance continues to monitor to ensure assessments and recognition of changes in residents' conditions. The findings include: Review of the facility's policy titled, "Incontinence/Perineal Care" revealed nursing staff was to report and document any abnormalities observed. Review of the facility's policy titled, "Condition Change of a Resident" revealed the rationale was "resident change of condition is identified for proper treatment implementation". Review of the facility standards of practice manual "Delmar's Fundamental and Advanced Nursing Skills", identified by the Director of Nursing Services (DNS) as being utilized by the facility, revealed when performing a physical assessment the nurse should inspect the skin for [MEDICAL CONDITION] and ulcers and should assess environment, resources, and medical condition to determine a complete and systematic examination by reducing the possibility of overlooking important findings. Further review revealed the nurse should take a moment to assess initially and inspect for color, vascularity, [MEDICAL CONDITION], ulcers, etc when performing a physical assessment. Additionally, it indicated nurses should measure, describe, draw, and/or stage abnormalities with the rationale to detect normal variations and abnormalities and establish a baseline for future comparisons. The rationale further indicated skin abnormalities were often indicators of systemic abnormalities. Review of the Nurse's Notes, dated 09/04/12 at timed 1:50 PM, revealed the Primary Care Physician (PCP) had been notified of "bleeding from nodule to vaginal area...". Review of a fax sent to the PCP on 09/04/12, revealed the resident had been running a low grade temperature "since over the weekend...but today the CNA (Certified Nursing Assistant) came and got me", she (SRNA/CNA) said Resident #2 was bleeding. Further review of the fax revealed the resident had an area that looked like a "cyst" near the vaginal area that was bleeding. Review of the physician's orders [REDACTED]. Interview, on 09/21/12 at 2:45 PM and on 09/30/12 with State Registered Nursing Assistant (SRNA) #15 revealed she had first noticed the area/nodule on Resident #2 approximately nine (9) months ago. She stated the area/nodule started out real small and had "gotten bigger" and "kept growing" since she first noticed it. Per interview, SRNA #15 was providing care to Resident #2 on 09/04/12 and noticed a small amount of fresh-looking red blood on the brief and while cleaning the resident a stream of blood came from the the area/nodule. She stated she went and got the nurse. Interview with with Licensed Practical Nurse (LPN) #3, on 09/19/12 at 10:45 AM, on 09/21/12 at 2:05 PM, and on 09/30/12 at 8:50 PM, revealed she did not recall hearing about the area/nodule until 09/04/12 when the SRNA reported to her that the area/nodule was bleeding. Per interview, when she saw the area/nodule on 09/04/12 it was not bleeding very much, "just a little bit on the brief, bright red". She stated the area/nodule was approximately four (4) to five (5) centimeters in length; approximately two (2) centimeters wide; and, was tumor-like and pink with little white areas on it. She stated she notified the PCP by fax. When the PCP called her back she told the PCP it was a "cyst-like" area and was bleeding and he ordered "labs" and [MEDICATION NAME] (antibiotic ointment). According to the LPN, the PCP came in a "day or two (2) later" and looked at the area/nodule and ordered Resident #2 direct admitted to the hospital. Interview with LPN #14, on 09/20/12 at 7:25 PM, on 09/30/12 at 3:28 PM, and on 10/02/12 at 5:40 PM revealed the area/nodule had been present since she started work at the facility in 2010. She stated at that time the area/nodule was about the size of a pencil eraser, normal skin color, "looked kind of like a mole". According to the LPN, when she saw the area/nodule on 09/04/12 she felt a sense of urgency. The area was a very large mass, with abnormal edges, "un-uniform", it had an elongated shape and was darker than Resident #2's normal skin in that area and . She stated it was "pinkish brown with a tint of red". The LPN indicated she took the orders from the Physician on 09/04/12; however, she did not describe the area/nodule to the Physician on 09/04/12. Interview, on 09/20/12 at 4:20 PM with Resident #2's Primary Care Physician (PCP) revealed he had become aware of the area/nodule on 09/04/12. He stated he had received a fax that indicated the resident had a cyst that was bleeding in the vaginal area. He stated he was not aware of the area/nodule prior to 09/04/12. Per interview, when the PCP saw the area/nodule on 09/06/12 he thought it [MEDICAL CONDITION]. The PCP stated the area/nodule was large with irregular borders. According to the PCP, had he saw the area/nodule he would have ordered a Gynecological consult to examine the area/nodule. On 09/06/12, the PCP gave a verbal order for Resident #2 to be sent to the hospital for further evaluation. Review of the hospital History and Physical (H&P), dated 09/06/12, revealed the reason for admission as a large vaginal tumor, suspected [MEDICAL CONDITION], which is actively bleeding and in need of immediate attention. Under the Impression section of the H&P the Physician (Resident #2's PCP) documented the area was friable (brittle or fragile; easily damaged (Mosbys Medical Dictionary)), actively bleeding, and appears most likely to be a vaginal [MEDICAL CONDITION]. Review of the hospital Consultation report dictated by the Consultant Gynecologist, revealed he evaluated what appeared to be a fungating (to grow rapidly like a fungus) [MEDICAL CONDITION] emanating from the right labia. Review of the hospital Discharge Summary revealed the Primary Care Physician had examined the resident on 09/06/12 related to nursing's request to examine a "cystic lesion" on the vagina. The PCP documented Resident #2 had a large five (5) centimeter fungating friable lesion that had some active bleeding. He documented he had arranged for immediate hospitalization for purposes of obtaining an urgent gynecological consultation. The PCP documented Resident #2 was seen by the Gynecologist with the [DIAGNOSES REDACTED]. Interview, on 09/20/12 at 4:00 PM with the Gynecologist (GYN) who saw Resident #2 when he/she was admitted to the hospital on [DATE], revealed he felt the area/nodule was a Vulvar [MEDICAL CONDITION]. He stated he couldn't tell how long the area/nodule had been present on Resident #2's vagina. The GYN stated in his opinion it was there longer than a month, that the area/nodule had not developed overnight. He stated the Primary Care Physician was "significantly concerned" about the area/nodule and had Resident #2 admitted to the hospital. According to the GYN, he did not think the PCP had been made aware of the area/nodule prior to 09/06/12. The GYN stated he "suggested" getting Resident #2 to a GYN Oncologist. Interview, on 09/20/12 at 4:43 PM with the GYN Oncologist revealed the area/nodule was a [MEDICAL CONDITION]. He stated he did not biopsy the area/nodule, so he couldn't say with any accuracy how long it had been there. The GYN Oncologist stated the area was treatable with surgery, however he questioned whether to operate related to the resident's co-morbidities. Review of [MEDICAL CONDITION] information from the Mayo Clinic (http://www.mayoclinic.com/health/vulvar-cancer) revealed [MEDICAL CONDITION] forms as a "lump or sore on the vulva" (area of skin that surrounds the urethra and vagina). According to this information, symptoms include itching that doesn't go away, skin changes, such as color changes or thickening, "a lump, wart-like bumps or an open sore (ulcer)". The information indicated to see a doctor if the patient experienced vulvar symptoms, such as: ...itching. Record review revealed the facility admitted Resident #2 on 07/21/98, with [DIAGNOSES REDACTED]. Review of the most recent Quarterly Minimum Data Set (MDS) Assessment, dated 07/02/12, revealed the facility assessed the resident to be severely impaired with daily decision making, and to have long term and short term memory problems. Observation, on 09/19/12 at 10:09 AM, of Resident #2's skin assessment revealed the resident had a glove and splint on his/her right hand. When the glove and splint were removed during the skin assessment, Resident #2 attempted to scratch at the vaginal area. Further observation revealed the resident had an area/nodule on the vagina. Interview during the skin assessment with Licensed Practical Nurse (LPN) #4 revealed the area/nodule was approximately six (6) centimeters and was a Squamous Cell [MEDICAL CONDITION]. Interview, on 09/30/12 at 1:08 PM with SRNA #17 revealed she worked on Resident #2's unit and had been there for one (1) year. She stated at the time she started the area/nodule on the resident's vagina was three (3) times smaller than it was now, was pink, and stood out. She stated she was told the area/nodule had always been there, that it was "no big deal". Per interview SRNA #17 stated the area/nodule had started to changed in the last month to two (2) months and had gotten bigger, darker in color, bumpy, and hard. She stated she told the nurse, however was unable to remember who the nurse was. SRNA #17 stated staff had to watch the resident when giving him/her a shower as he/she would "grab" at the area/nodule and scratch it making it bleed. Interview, on 09/19/12 at 10:35 AM with SRNA #9 revealed she had started working for the facility approximately one (1) year ago. She stated the area/nodule was present at that time and was approximately the size of a nickel, the same color as the resident's skin, and almost perfectly round. The SRNA stated she did not tell the nurses as she assumed they already knew about the area/nodule. Interview, on 09/26/12 at 1:14 PM, with SRNA #12 revealed she had worked on the resident's unit for approximately two (2) to three (3) months. She stated she was aware of the area/nodule on the resident's vagina. SRNA #12 stated it was about the size of a nickel, raised, and pink-looking then. The SRNA stated toward the end of August the area/nodule "got bigger". She stated she reported it to a nurse, however was unable to recall who the nurse was. Interview with SRNA #15 on 09/21/12 at 2:45 PM and on 09/30/12 at 2:12 PM revealed when she first noticed the area/nodule approximately nine months ago, she reported it to LPN #20. She stated the area/nodule became larger, was red with a few white dots and was rougher. The SRNA stated she could not recall if she had reported this change to the nurses. Interview, on 09/19/12 at 4:22 PM, with LPN #20, who had performed Resident #2's skin assessments, revealed she had been employed for approximately three (3) years and the area/nodule on the resident's vagina had been there "as far as" she could think back. She stated the area/nodule looked like an "external hemorrhoid" in the vaginal area. An interview, on 09/27/12 with LPN #20 revealed the area/nodule was pinkish, veinish, purple, very vascular, raised and rounded. Further interview, on 09/29/12 with LPN #20 revealed nodules should be documented on an admission skin assessment. She stated to check for a baseline for Resident #2's area/nodule she would check the "old" part of the chart. The LPN stated for a baseline she would check the Treatment Administration Record (TAR), and the Pressure/Non-Pressure Monitoring sheets. According to LPN #20, the area/nodule on Resident #2's vagina should also be documented in the Physician's Notes or History and Physical. She stated she had never documented this area because they only chart changes. She stated the area/nodule had not changed and it could always be seen. She stated the labia did not have to be parted to see the area/nodule. Interview, on 09/21/12 at 2:20 PM, with SRNA #14 revealed the area/nodule had been present since she had started work at the facility three (3) years ago. She stated the area/nodule had started to change approximately six (6) months before. The SRNA stated the area/nodule had "gotten bigger". Interview, on 09/26/12 at 1:03 PM with SRNA #13 revealed she had worked on Resident #2's unit for approximately six (6) months to a year. She stated the area/nodule on the resident's vagina was a "small place, like a dime" when she saw it then. SRNA #13 stated the area/nodule started to get "bigger" the last of August. According to the SRNA, she notified the nurse (LPN #19) of this information. An additional interview with SRNA #13, on 09/30/12 at 10:55 AM, revealed at the end of August the area/nodule was "wedge-shaped" and about the size of a fifty (50) cent piece if "you smashed it" (area/nodule) out. She stated it was pink, thicker, and "bumpier" looking. She stated at the last of August, 2012 the area/nodule bled a little and she would have to clean around it. The SRNA stated she told LPN #19 this information. SRNA #13 stated a glove was kept on Resident #2's right hand because he/she wanted to "dig" at his/herself. Interview, on 09/30/12 at 11:00 AM, with SRNA #16 revealed she had cared for Resident #2. She stated the resident had an area/nodule on the vagina that looked like a mole or wart. The SRNA stated that in the last two (2) to three (3) months the area/nodule had "started growing". The SRNA indicated she brought this to LPN #19's attention. She stated Resident #2 always put his/her hand "down there and scratched at the area/nodule. SRNA #16 stated when perineal-care was provided to the resident he/she would try to scratch the area/nodule. Interview, on 09/25/12 at 11:51 PM, with LPN #19 revealed she was uncertain how long the area/nodule had been on Resident #2's vagina. She stated it was kind of like a nodule, not markedly raised, marble size prior to 09/04/12. Per interview, the LPN could tell if the area/nodule had changed, by looking at past skin assessments. She stated she would expect an area/nodule like that to be documented on initially, then if any changes occurred thereafter. Additional interview with LPN #19, on 09/30/12 at 11:16 PM, revealed the area/nodule had not stood out like a marble, was just round in circumference like one. She indicated the area/nodule had been "pretty smooth" and "pinkish-whitish" in color, not markedly different from the skin in that area prior to 09/04/12. According to LPN #19, the area changed, became about the "size of a quarter", pinker, rougher. The LPN stated she was not aware of the area/nodule bleeding until 09/04/12. She stated she thought she had passed this information along in report, however did not remember to which nurse. Interview, on 09/25/12 at 7:48 PM, with Registered Nurse (RN) #4 revealed she cared for Resident #2, and was unaware of the area/nodule until a month to a month and a half ago. She stated SRNA #16 had commented to her that the area/nodule had been there quite a while and was getting bigger. She stated she had talked to LPN #14 about the area/nodule and LPN #14 told her the SRNAs had reported the area/nodule was getting bigger, that it had been there for a long time. The RN stated when she observed the area/nodule in mid-August it was not bleeding. The RN indicated the area/nodule was dark pink, oblong, about the size of a quarter in diameter when she saw it. Per interview, if the area/nodule was getting bigger, or getting worse in anyway, it should have been documented. The RN stated she would know if the area had changed by looking at past skin assessments. According to the RN, that was where changes should be documented. Interview with LPN #3 on on 09/19/12 at 10:45 AM, on 09/21/12 at 2:05 PM, and on 09/30/12 at 8:50 PM revealed to obtain a baseline for the area/nodule she would refer to the resident's skin assessments. However, she was unable to find any documentation of the area on the skin assessments. Review of the Admission Nursing Assessment, dated 07/21/98, revealed no documented evidence of an area/nodule to the resident's vagina. Review of the Admission History and Physical (H&P), dated 07/21/98, revealed no documented evidence of the area/nodule. Review of the Readmission Nursing Assessment, dated 12/13/01, revealed no documented evidence of an area/nodule to Resident #2's vagina. Review of an H&P dated 03/21/07, revealed no documented evidence of an area/nodule to Resident #2's vagina. Review of weekly skin assessments from 01/01/09 to 09/01/12 revealed no documented evidence of an area/nodule to the resident's vagina. Review of Nurse's Notes and Weekly Pressure and Non-Pressure Skin Condition Reports for the same time frame revealed no documented evidence of the area/nodule on Resident #2's vaginal area. Further interview with RN #4, on 09/28/12 at 4:25 PM, revealed she could not remember if she had reported what she had observed in mid-August. She stated she probably didn't report it to the other nurses because the others were aware of the area/nodule. Per interview, the area/nodule should have been put on the twenty-four (24) hour report (facility's communication book between shifts) when it started getting bigger, started to change. However, she could not remember if she had documented the area/nodule on the twenty-four (24) report. Review of the facility's twenty-four (24) hour report revealed no documented evidence related to the area/nodule on Resident #2's vagina during the month of August. Interview, on 09/21/12 at 4:58 PM with the Director of Nursing Services (DNS) revealed she became aware of the area/nodule on Resident #2's vaginal are on 09/06/12. The DNS stated staff had reported to her that the area/nodule had "gotten bigger", and that it had done this suddenly. According to the DNS, when the area/nodule was first identified it should have been documented on a skin assessment sheet and the Physician should have been made aware of the area/nodule when it was first discovered. She stated she had looked in Resident #2's medical record; however, there was nothing documented related to the area/nodule prior to 09/04/12. She stated her nursing staff utilized "Delmar's Fundamental and Advanced Nursing Skills" for a standard of practice manual. However, an interview, on 09/26/12 at 3:13 PM with the DNS revealed the Delmar manual was a "point of reference", and she expected her nurses to utilize the "great eight (8)" policy and procedure manuals. Review of the "great eight (8)" manuals with the DNS revealed no documented evidence of how to perform a head-to-toe skin assessment. Further interview with the DNS, on 09/27/12 at 4:30 PM, revealed a head-to-toe skin assessment was performed to check the skin from head-to-toe, looking at all visible parts of the body. Nurses would be looking for any signs/symptoms of breakdown and redness. This head-to-toe assessment should include the perineal area according to the DNS. She stated if a lesion was present nurses should measure and describe it. Interview, on 09/30/12 with the Staff Development Coordinator (SDC) revealed she was unable to locate a policy on head-to-toe assessments. When asked where she would document [MEDICAL CONDITION] (such as Resident #2's area/nodule) she stated she would "probably put it on the skin assessment sheet". She stated she had not been made aware of any need for education related to skin assessments and documentation. Interview, on 09/30/12 at 5:03 PM, with the DNS and the Executive Director (ED) revealed an inservice education on skin assessments was performed by the Staff Development Coordinator (SDC) in June, 2012. The DNS stated the SDC went over the steps to performing a skin assessment. Per interview, she would expect the nurse to look at all visible areas of the skin, everywhere there was visible skin when conducting a head-to-toe skin assessment. Any abnormalities should be documented on the weekly pressure/non-pressure sheets. The ED stated when they interviewed the nurse responsible for Resident #2's skin assessments she had told them there had been no change. According to the ED, staff could look back at the weekly non-pressure forms for changes. Per the DNS, the admission sheet went into more detail for "things" that wouldn't be documented on every week and would establish a baseline for abnormalities of the skin. Interview, on 09/21/12 at 3:07 PM, with the Medical Director revealed areas/nodules like the one on Resident #2's vagina could be present for years. She stated that sometimes itching could be a part of diagnosing [MEDICAL CONDITION]. Per interview, the resident's PCP should have been notified of the area. The facility provided an acceptable credible Allegation of Compliance (AOC) on 09/27/12 that alleged removal of the IJ effective 09/27/12. Review of the AOC revealed the facility implemented the following: 1) On 09/25/12, a Nurse Practitioner conducted education with facility licensed nurses on performing skin assessments, with emphasis on notable findings that require Physician and family notification. Education included, but was not limited to, notification guidelines and documentation of objective findings. Notable findings included, but were not limited to, Pressure Ulcers, Arterial Ulcers, Diabetic Neuropathic Ulcers, [MEDICAL CONDITION] Ulcers, Surgical Wounds, Skin Tears, Lacerations, Abrasions, Bruises, Burns, Rashes, or a Lesion associated with bleeding, itching, burning, discoloration and/or raised. On 09/25/12 through 09/26/12, after receiving education from the Nurse Practitioner on 09/25/12, the Assistant Director of Nursing Services (ADNS), Staff Development Coordinator (SDC), and/or Shift Supervisor conducted this education with licensed nurses. The Weekend Supervisor received education from the ADNS on 09/26/12. 2) Head-to-toe skin assessments were performed on all but two (2) residents from 09/25/12 through 09/26/12 by licensed nurses. Two (2) residents refused the skin assessments. Notable findings were communicated to the Physician and family on 09/26/12. Notable findings included, but were not limited to, Pressure Ulcers, Arterial Ulcers, Diabetic Neuropathic Ulcers, [MEDICAL CONDITION] Ulcers, Surgical Wounds, Skin Tears, Lacerations, Abrasions, Bruises, Burns, Rashes, or a Lesion associated with bleeding, itching, burning, discoloration and/or raised. The findings were documented by the licensed nurse, and communicated to the Physician and family for further follow-up. The licensed nurse was responsible to communicate findings and document findings in the residents' medical record. No licensed nurse would be allowed to work after 09/26/12, without having received the education from the ADNS, SDC, Shift Supervisor, and/or Weekend Supervisor. The procedure for conducting a skin assessment will be included in the orientation of new hires for licensed nurses. The facility does not employ contract employees. If the facility were to employ contract employees, the licensed nurses would receive the education before being allowed to work in the facility. 3) Notices were posted at each nursing station on 09/26/12 for all State Registered Nursing Assistants (SRNAs) to immediately report any change in a resident's skin condition to the nurse. SRNAs were to report new and/or unusual findings to the licensed nurse at the time of visualization. 4) A Performance Improvement Committee (PIC) meeting was held on 09/21/12 to review the Immediate Jeopardy. The Medical Director was notified of the Immediate Jeopardy on 09/21/12. Another PIC was held on 09/26/12, the Medical Director was notified and approved the action plan. The PIC reviewed and approved the Allegation of Compliance (AOC). The PIC was to ensure validation of the AOC by: discussing areas of concern identified through audits; creating corrective action plans for any areas of concern identified, this will be assigned by the Executive Director (ED) as concerns are identified; and meeting weekly or more often as necessary until the facility had demonstrated substantial compliance with the corrective actions described in the AOC. Additionally, a corrective action plan will be developed by members of the PIC for any areas identified as not in compliance with the AOC. The facility will then return to routine monthly meetings. On 10/03/12 the State Survey Agency verified the Immediate Jeopardy was removed on 09/27/12 and the facility implemented corrective actions as alleged in the AOC, effective 09/27/12 based on the following: Review of the facility's inservice on skin assessment revealed nursing staff were educated on the performance of skin assessments and on the identification of skin abnormalities to include [MEDICAL CONDITION]. Review of the Attendance Rosters revealed the Director of Nursing Services (DNS), both Assistant Directors of Nursing Services (ADNS), the Quality Assurance (QA)Nurse, all the Unit Managers, Staff Development Coordinator (SDC), Shift Supervisors and Weekend Supervisor received education on 09/25/12 on performing skin assessments and Physician Notification; then performed inservice training of other licensed staff, forty-six (46) RNs and LPNs, on 09/25/12 and 09/26/12 related to skin assessments and Physician Notification. Review of the skin assessment forms revealed all facility residents had skin assessments performed from 09/25/12 through 09/26/12 by licensed nurses, except two (2) who refused. Review of the Physician notifications revealed the Physician was notified of the findings of the skin assessments and new orders were obtained as necessary. Review of the family notifications revealed families were notified of the findings of the skin assessments by the licensed nurses. Review of the residents' Care Plan Update forms revealed residents' care plans were updated with the findings of the skin assessments and any new physician's orders [REDACTED]. Interview, on 10/03/12 at 7:45 PM, with the Evening Supervisor revealed she had been trained on skin assessments, documentation of these, and Physician notification on 09/25/12. She stated she then inserviced 3:00 PM to 11:00 PM and 11:00 PM to 7:00 AM shift staff prior to starting their shift. Telephone interview on, 10/03/12 at 7:30 PM, with the Weekend Supervisor revealed he had received training on skin assessments, documentation related to these, and Physician notification. Interview, on 10/03/12 at 7:35 PM, with the Assistant Director of Nursing Services (ADNS) for the A and B units, revealed she had received inservice training on 09/25/12 from a Nurse Practitioner related to performing skin assessments, documentation, and Physician notification. She stated she was trained on inservicing other licensed staff, and had done so. Interview, on 10/03/12 at 8:00 PM, with the Staff Development Coordinator (SDC) revealed an Advanced Practice Registered Nurse (APRN) had educated her, the Unit Managers, Director of Nursing Services (DNS), and both ADNS' on skin assessments, documentation, and Physician Notification. She stated the other licensed staff were then trained by herself, or one of the others who had received the APRN's training. Interviews with licensed nursing staff on 10/02/12, on the 3:00 PM to 11:00 PM shift, on the A unit at 7:20 PM (LPN #31), at 7:45 PM (LPN #22), on the B unit at 7:20 PM (LPN #28), 7:25 PM (LPN #14); the C unit at 7:20 PM (LPN #2), revealed they had received inservice training on the performance of skin assessments, documentation of these, and Physician notification. Interview with licensed nursing staff on 10/02/12 on the D unit, at 7:15 PM (LPN #29) revealed she was an as needed (PRN) staff person and had just received the inservice training on skin assessments, documentation of these, and Physician notification prior to starting her shift that day. Telephone interviews with licensed nursing staff, on 10/03/12 on the 11:00 PM to 7:00 AM shift, on the A unit at 1:32 AM (RN #6); on the C unit at 1:43 AM (RN #7); and on the D unit at 1:50 AM (LPN #26), revealed they had received inservice training on how to perform skin assessments, document these, and on Physician notification. Interviews with licensed nursing staff on 10/03/12, on the 7:00 AM to 3:00 PM shift, on the A unit at 2:48 PM (LPN #15), at 2:55 PM (LPN #32); on the B unit at 11:45 AM (LPN #3), at 11:30 AM (LPN #13); on the C unit at 10:35 AM (LPN #1), at 12:05 PM (RN #8); on the D unit at 10:05 AM (LPN #7) revealed they had all had training on skin assessments, documentation of these, and Physician notification. Observation, on 10/02/12 and 10/03/12, revealed a sign at each nurse's station that stated, "ALL NEW SKIN CONDITIONS AS WELL AS CHANGES IN EXISTING AREAS NEED TO BE REPORTED TO THE NURSE IMMEDIATELY!!!!!!!!". Review of the facilities Performance Improvement Committee (PIC) meeting minutes revealed meetings were held on 09/21/12 to discuss the Immediate Jeopardy and on 09/26/12 to discuss and approve the Allegation of Compliance (AOC) to implement plans of correction to remove the IJ. Interview, on 10/03/12 at 8:40 PM with the Executive Director (ED) revealed she had participated in formulating and writing of the AOC, along with the DNS, Nurse Consultant, Quality Assurance (QA) Nurse, and Medical Director. She stated they had reviewed the cited deficiencies and developed the abatement plan. She ensured the skin assessments were performed as per the AOC, the Physician and family notifications were performed, and all licensed staff received the inservice training. The facility remained out of compliance at a lower scope and severity of a "D", an isolated deficiency with potential for more than minimal harm in order for the facility to develop and implement the Plan of Correction (POC).

Based on observation, interview, record review, review of the facility's policies and review of the facility's Plan of Correction (POC) with a compliance date of 06/18/12, it was determined the facility failed to be administered in a manner that enabled it to use it's resources effectively and efficiently as evidenced by failure to provide documented evidence that a reportable offense was reported to the Kentucky Board of Nursing (KBN). A licensed staff member was convicted of driving under the influence and there was no documented evidence it was reported to KBN within the ninety (90) day time frame. Additionally, the facility's Administration failed to have an effective system in place to ensure programs, policies, and procedures, and the facility's Plan of Correction (POC) were implemented to correct deficiencies cited during the former Recertification Survey. This failure resulted in continued noncompliance at 42 CFR 483.15 Quality of Life, F-246; 42 CFR 483.20 Resident Assessment, F-281; and 42 CFR 483.75 Administration, F-514. The findings include: 1. Review of Kentucky Revised Statute (KRS) 314.109 revealed that state law required a licensed/credentialed individual to report criminal convictions to the Kentucky Board of Nursing (KBN), within ninety (90) days of the conviction. Review of the facility's employee handbook "Standards of Care" section, item #27 revealed criminal convictions are to be reported to Executive Director/CEO or Human Resources in writing within five (5) days of the conviction. Review of County District Court records, dated 05/07/12, revealed Licensed Practical Nurse (LPN) #4 was charged with Driving Under the Influence (DUI) on 04/13/12 and convicted of the (DUI) charge on 05/07/12. Review of LPN #4's employee file revealed no evidence the facility had ensured LPN #4's DUI charge had been reported to the KBN within the 90 day time frame. Interview with a KBN investigator, on 09/25/12 at 10:50 AM via telephone, verified licensed personnel or a facility had 90 days to report criminal convictions to KBN. Further interview revealed the Board had not received notification of LPN #4's DUI conviction by the date of this interview, one hundred forty one (141) days post conviction. Interview with the Payroll Benefits Coordinator, on 09/25/12 at 11:10 AM, revealed she assumed a DUI conviction would be reportable to the KBN; however, she had not personally reported LPN #4's conviction or any other conviction by any employee. She further stated it would be the staff members' supervisor, in this case the Director of Nursing (DON), to make sure the incident was reported correctly. Interview with the current Executive Director, on 09/25/12 at 11:25 AM, revealed it was the Assistant Executive Director's responsibility to follow up on reportable incidents. She further stated the incident happened before she was hired and she assumed the incident had been resolved. Interview, on 09/25/12 at 11:40 AM, with LPN #4 revealed she could not remember the exact date she reported the conviction to the KBN but that "it was sometime during the first week of August, 2012"; however, she had no documented evidence she had reported the conviction. Interviews, on 09/26/12 at 4:05 PM with the DON; on 09/27/12 at 10:45 AM with the Assistant Executive Director and on 09/27/12 at 4:30 PM with the former Executive Director revealed they felt as long as the alleged perpetrator self reported the incident they had no obligation to follow up to make sure it had been reported. 2. (a)The facility failed to ensure accommodation of residents' needs for one (1) resident with left-sided weakness who requiring limited assistance with toileting and did not have the necessary equipment (grab bars) provided in the resident's bathroom to assist the resident with transfers which resulted in a repeat deficiency at 42 CFR 483.15 Quality of Life, F-246. (b) The facility failed to ensure services provided met professional standards of quality according to accepted standards of practice for one (1) resident in regards to pain medication administration and documentation of pain medication which resulted in a repeat deficiency at 42 CFR 483.20 Resident Assessment, F-281. (c) Additionally, the facility failed to have an effective system in place to maintain clinical records for each resident in accordance with accepted professional standards and practice for completeness and accuracy for two (2) residents, resulting in a repeat deficiency at 42 CFR 483.75 Administration, F-514. Interview, on 10/03/12 at 7:25 PM, with the Administrator, and Director of Nursing Services (DNS), who served on the PIC on 06/18/12, the date of alleged compliance from the previous PoC, revealed the PIC meets monthly and the Medical Director attends. The Administrator stated the PIC would meet more often if necessary. According to the Administrator, the PIC looked at "various things"; if issues were identified from rounds, through data collection and from the weekly forums with the residents. She stated issues or concerns were brought to the PIC, who discussed the issue or concern, and put a plan in place to try to resolve the issue or concern. The plan is then brought back to the PIC where results were reported. Further interview, on 10/03/12 at 7:25 PM, with the Administrator and DNS, revealed the facility was not aware of the repeated identified deficiencies until the current survey was in progress. The Administrator stated grab bars have now been added to all the A unit bathrooms in regards to 42 CFR 483.15 Quality of Life, F-246, Accommodation of Needs. The DNS stated the facility was currently working on education on medication administration and documentation of pain medication in the appropriate areas of the medical record in regards to 42 CFR 483.20 Resident Assessment, F-281. The Administrator stated the Master Signature Log had been updated. The DNS stated staff had been educated on documentation in the medical record in regards to 42 CFR 483.75 Administration, F-514.

Based on observation, interview, record review, and review of the facility's policy and standard of practice manual, it was determined the facility failed to have an effective system in place to ensure residents' clinical records were maintained in accordance with accepted professional standards and practices for completeness and accuracy for two (2) of thirty-six (36) sampled residents (Resident #2 and #13). The facility failed to maintain the residents' medical record so that the facility knew the status of each resident. Interviews revealed Resident #2 had an area/nodule on the vaginal area. However, record review revealed no documented evidence of the area/nodule to establish a baseline for Resident #2's skin condition or documented evidence of the changes in the area/nodule as evidenced per the staff interviews. On 09/04/12, record review revealed the area/nodule was bleeding. The Physician examined the area on 09/06/12, and ordered the resident's direct admission to the hospital where he/she was diagnosed with [REDACTED]. The facility failed to document accurately and completely the administration of [MEDICATION NAME] (a pain medication) for Resident #13. Review of the resident's record revealed staff failed to document the pain medication administration on the Narcotics Record, Medication Administration Record (MAR), and the Pain Monitoring Flow Sheet as according to the facility's documentation process for the review period of 08/31/12 through 09/16/12. In addition, the facility failed to ensure the Master Signature Log was updated in a timely manner. Review of the Log revealed it had not been updated since July, 2012. Record review revealed initials of nurses who were not on the Log. The facility's failure to ensure an effective system was in place to ensure residents' clinical records were maintained in accordance with accepted professional standards and practices for completeness and accuracy was likely to cause risk for serious injury, harm, or impairment or death. The Immediate Jeopardy was identified on 09/21/12, and determined to exist on 08/31/12. The facility was notified of the Immediate Jeopardy on 09/21/12. The facility provided an acceptable credible Allegation of Compliance (AOC) on 09/27/12 prior to exiting the facility on 10/03/12, with the facility alleging removal of the Immediate Jeopardy on 09/27/12. The Immediate Jeopardy was verified to be removed on 09/27/12, prior to exiting the facility on 10/03/12, with remaining non-compliance at 42 CFR 483.75, F-514 Clinical Records Maintained with Professional Standards, with a Scope and Severity of "D", while the facility develops and implements a Plan of Correction, and the facility's Quality Assurance continues to monitor to ensure assessments and recognition of changes in residents' conditions. The findings include: 1. Review of the facility's policy titled, "Documentation of Resident's Health Status, Needs and Services" revealed "The resident's medical record is a continuing account of the resident's health status and needs,...The Interdisciplinary Team involved in the care of the resident is responsible for recording assessments of a resident's condition, changes in a resident's condition...". Further review of the policy revealed staff was to record pertinent resident data that included, but was not limited to, a change of condition and ongoing monitoring, and notification of the Physician. Review of the facility's nursing staff standard of practice manual provided by the Director of Nursing Services (DNS) titled, "Delmar's Fundamental and Advanced Nursing Skills" revealed nurses should measure, describe, draw, and/or stage abnormalities to detect normal variations and abnormalities and establish a baseline for future comparisons. Review of the Nurse's Notes, dated 09/04/12 and timed 1:50 PM, revealed the Primary Care Physician (PCP) had been notified of "bleeding from nodule to vaginal area...". Review of a fax sent to the PCP on 09/04/12, revealed the resident had an area that looked like a "cyst" near the vaginal area that was bleeding. Review of the physician's orders [REDACTED]. Interview, on 09/20/12 at 7:25 PM, with LPN #14 revealed the area/nodule had been present since she started work at the facility in 2010. She stated at that time the area/nodule was about the size of a pencil eraser, normal skin color, "looked kind of like a mole"; however, record review revealed no documented evidence of the area/nodule. LPN #14 she stated she did not document on the area/nodule because it was not out of his/her "norm". She stated the area had always been there, had not changed in size or color, and was not bleeding. Further interview, on 09/30/12 at 3:28 PM with LPN #14 revealed when she saw the area on 09/04/12, she felt a sense of urgency. According to the LPN, the area/nodule on 09/04/12 was a very large mass, with abnormal edges, "un-uniform", had an elongated shape and was darker than Resident #2's normal skin in that area. She stated it was "pinkish brown with a tint of red". Interview, on 09/19/12 at 4:22 PM, with LPN #20, who had performed Resident #2's skin assessments, revealed she had been employed for approximately three (3) years and the area/nodule on the resident's vagina had been there "as far as" she could remember. She stated the area/nodule looked like an "external hemorrhoid" in the vaginal area. An interview, on 09/27/12 with LPN #20 revealed the area/nodule was pinkish, veinish, purple, very vascular, raised and rounded. Further interview, on 09/29/12 with LPN #20 revealed nodules should be documented on an admission skin assessment. She stated to check for a baseline for Resident #2's area/nodule she would check the "old" part of the chart and review the Treatment Administration Record (TAR) and the Pressure/Non-Pressure Monitoring sheets. According to LPN #20, the area/nodule on Resident #2's vagina should also be documented in the Physician's Notes or History and Physical. However, she stated she had never documented this area because she only charts changes. Interview, on 09/26/12 at 1:03 PM with SRNA #13 revealed she had worked on Resident #2's unit for approximately six (6) months to a year. She stated the area/nodule on the resident's vagina was a "small place, like a dime" when she first saw it but it started to get "bigger" the last of August. An additional interview with SRNA #13, on 09/30/12 at 10:55 AM, revealed at the end of August the area/nodule was "wedge-shaped" and about the size of a fifty (50) cent piece if "you smashed it" (area/nodule) out. She stated it was pink, thicker, and "bumpier" looking. The SRNA stated she told LPN #19 this information. However, record review revealed no documented evidence of the area/nodule. Interview, on 09/30/12 at 11:00 AM, with SRNA #16 revealed she had cared for Resident #2. She stated the resident had an area/nodule on the vagina that looked like a mole or wart. The SRNA stated that in the last two (2) to three (3) months the area/nodule had "started growing". The SRNA indicated she brought this to LPN #19's attention. Interview, on 09/25/12 at 11:51 PM, with LPN #19 revealed she was uncertain how long the area/nodule had been on Resident #2's vagina. She stated it was kind of like a nodule, not markedly raised, marble size prior to 09/04/12. When asked how she could tell if the area/nodule had changed, the LPN stated she could look at past skin assessments. She stated she would expect an area/nodule like that to be documented on initially, then if any changes occurred. Additional interview with LPN #19, on 09/30/12 at 11:16 PM, revealed the area/nodule became about the "size of a quarter", pinker, rougher. Per interview, she did not document the changes in this area in Resident #2's medical record. In an interview, 09/21/12 at 2:05 PM with LPN #3 revealed the area/nodule should have been documented on the skin assessment sheets prior to 09/04/12 to establish a baseline for Resident #2's skin. Interview, on 09/21/12 at 4:58 PM with the Director of Nursing Services (DNS) revealed she became aware of the area/nodule on Resident #2's vaginal area on 09/06/12. According to the DNS, when the area/nodule was first identified it should have been documented on a skin assessment sheet. She stated she had looked in Resident #2's medical record, however there was nothing documented related to the area/nodule prior to 09/04/12. Interview, on 09/30/12 at 5:03 PM, with the DNS and the Executive Director (ED) revealed nurses should document any abnormalities on the weekly pressure/non-pressure sheets. Observation, on 09/19/12 at 10:09 AM, of Resident #2's skin assessment revealed the resident had an area/nodule on the vagina. Interview during the skin assessment with Licensed Practical Nurse (LPN) #4 revealed the area/nodule was approximately six (6) centimeters and was a Squamous Cell [MEDICAL CONDITION]. Record review revealed the facility admitted Resident #2 on 07/21/98, with [DIAGNOSES REDACTED]. Review of the Admission Nursing Assessment, dated 07/21/98, revealed no documented evidence of an area/nodule to the resident's vagina. Review of the Admission History and Physical (H&P), dated 07/21/98, revealed no documented evidence of the area/nodule. Review of the Readmission Nursing Assessment, dated 12/13/01, revealed no documented evidence of an area/nodule to Resident #2's vagina. Review of Nurse's Notes, Weekly Pressure and Non-Pressure Skin Condition Reports, and weekly skin assessments from 01/01/09 to 09/01/12 revealed no documented evidence of an area/nodule to the resident's vagina. 2. Review of the facility's policy: "Medication Administration", revised 08/31/12, revealed medication administration should be documented on the Medication Administration Record (MAR) and the controlled drug record for a Schedule II drug should be updated, if applicable. Documentation on the patient's MAR should be completed by the person administering the medication. If PRN (as needed) medication was administered, initial the space provided and on the back of the MAR (Nurse's Medication Notes) document date, time of administration, dose, route, complaints or symptoms for which the medication was given, and results achieved. Review of the facility's policy: "Pain Management", revised date 04/28/09, revealed the pain assessment, interventions and evaluation of effectiveness were to be documented in a clear and concise manner. Interview, on 09/25/12 at 4:30 PM, with the Assistant Director of Nursing (ADNS) for Wings C & D, revealed the documentation process for administration of a PRN narcotic pain medication was to document on the Narcotic sheet the date, time, and the nurse who gave the medication. Document on the front of the MAR, for the medication administered, their initials and time. Document on the back of the MAR under the Nurse's Medication Notes the date, time, medication and dose, route, reason for giving, the initials of who gave it, and the effectiveness. Document on the Pain Monitoring Flow Sheet the results of the pain assessment tool. They would document the date, time, type of pain scale used, where the pain was located, the medication dose, any alternate treatments, document the post pain rating, and their initials. Review of the medical record for Resident #13 revealed the resident was readmitted by the facility on 04/20/12 with [DIAGNOSES REDACTED]. In addition the resident suffered a right [MEDICAL CONDITION], at the facility, which required surgical repair, and returned to the facility on [DATE]. Review of the physician's orders [REDACTED]. Review of the September 2012 MAR revealed [MEDICATION NAME] 5/500 mg, by mouth, every four hours as needed for pain. Review of the documentation for the September 2012 administration of [MEDICATION NAME] 5/500 mg PRN revealed the following documentation inconsistencies on the MAR and Pain Monitoring Flowsheet by staff: On 09/02/12 the narcotic book revealed documentation [MEDICATION NAME] was administered at: 2400; 0600; 0800; 1330; and at 1830. Review of the MAR's Nurse's Medication notes revealed only the doses administered at 2400; 0600; and 1830 were documented. On the Pain Monitoring Flowsheet all doses administered were documented; however, there was no follow-up of a post pain rating at the 0800 and 1330 doses. On 09/03/12 the narcotic book revealed documentation [MEDICATION NAME] was administered at: 2400; 0500: 10:00; 1600; and at 2300. Review of the MAR's Nurse's Medication Notes revealed only the doses administered at 0600, 10:00, and 1600 were documented and the 1600 documentation did not include results. On the Pain Monitoring Flowsheet there was no documentation of the 2300 administration and the post pain rating for the dose administered at 1600. On 09/04/12 the narcotic book revealed [MEDICATION NAME] was administered at: 0400 by LPN #26 and 0900 and 1430 by LPN #27. Review of the MAR and the Pain Monitoring Flowsheet revealed no documentation about the 0400 and 1430 doses being administered other than the documentation in the narcotic book. On 09/05/12 the narcotic book revealed [MEDICATION NAME] was administered at: 0300 by LPN #26 and at 0900. Review of the MAR and the Pain Monitoring Flowsheet revealed no documentation about the 0300 dose. The dose administered at 0900 had no documentation on the MAR Nurse's Medication Notes of the response to the medication and no documentation on the Pain Monitoring Flowsheet. On 09/06/12 the narcotic book revealed [MEDICATION NAME] was administered at: 0300, 0900 and at 2130. Review of the MAR's Nurse's Medication Notes revealed only the 2130 dose administration was documented but did not include documentation of the response. On the Pain Monitoring Flowsheet only the 2130 dose was documented. On 09/07/12 the narcotic book revealed [MEDICATION NAME] was administered at: 0300, 0800 and 1600. Review of the MARs Nurse's Medication Notes revealed no documentation of administration for any of the doses given and review of the Pain Monitoring Flowsheet revealed only the 0300 dose was documented. On 09/08/12 the narcotic book revealed [MEDICATION NAME] was administered at: 0300, 0800 and 1300 by LPN #25 and at 1800. Review of the MAR and Pain Monitoring Flowsheet revealed no documentation of the 1300 administration. In addition, there was no documentation on the MAR's Nurse's Medication Notes about any of the doses administered. On 09/09/12 the narcotic book revealed [MEDICATION NAME] was administered at: 0300, 0800, 1400 and 1900 by LPN #25). Review of the MAR and Pain Monitoring Flowsheet revealed no documentation of the 1900 administration. There was no documentation on the MAR's Nurse's Medication Notes of the dose administered at 0300. On 09/13/12 the narcotic book revealed [MEDICATION NAME] administered at: 0310 and at 0800 by LPN #27. Review of the MAR and Pain Monitoring Flowsheet revealed no documentation of the 0800 dose. Interview, on 09/26/12 at 9:25 AM, with LPN #26 revealed if she signed out the [MEDICATION NAME] in the Narcotic book for the doses given on 09/04/12 at 0400 and 09/05/12 at 0300 she would have given the medicine. The resident was in pain and needed the pain medications. It was a mistake on her part for not following the facility's documentation process when she gave the medicine. LPN #26 stated sometimes events may happen that needed to be taken care of and she may have forgotten to document. Further interview revealed when signing the MAR everyone did it differently. Some nurses only initial when giving medications and some would initial and put the time. She was never told to put the time on the front of the MAR when administering PRN medication. The LPN also revealed she did not use the MAR's Nurse's Medication Notes on the back of the MAR, but put the information on the Pain Monitoring Flowsheet because it had a place to assess the pain. She was taught to use the Pain Monitoring Flowsheet. A lot of the nurses document on both the Nurse's Medication Notes and the Pain Monitoring Flowsheet on her unit. The LPN did not know why it was not done the same. In addition, LPN #26 stated it was important to follow-up and know if the pain medication was effective after administration of the pain medication so they could notify the Physician if it was not effective. Interview, on 09/25/12 at 2:00 PM, with LPN #27 revealed if she signed out the medication in the narcotic book on 09/04/12 at 1430 she would have given the medication. The LPN stated when giving medication she was supposed to initial the front of the MAR and put the time given. In addition, she would document on the back of the MAR on the Nurse's Medication Notes and also document the Pain Monitoring Flowsheet. She needed to be more accurate when giving medication and follow the facility's process. Interview, on 09/26/12 at 12:40 PM, with LPN #25 revealed she gave the [MEDICATION NAME] signed out in the narcotic book for the doses administered on 09/08/12 at 1300 and on 09/09/12 at 1900. LPN #25 revealed she failed to follow the facility's documentation process when she administered the medication on those dates. She may have been pulled away to do something else and forgot to document. Further interview revealed they had a Pain Monitoring Flowsheet and a Medication Nurse Notes on the back of the MAR for PRN pain medication documentation, but she had received inconsistent training on where to document. Some Unit Managers want you to document on the Medication Nurse's Notes only and others want you to document on the Pain Flowsheet. Sometimes she had noticed nurses had not documented on either sheet. The facility should have a standardized process. It was important to have standard documentation to ensure medicines were given at the appropriate times and were effective. Interview after review of the [MEDICATION NAME] administration documentation, on 09/20/12 at 1:15 PM, with the LPN #8 Unit Manger of "D" wing revealed there appeared to be a disconnect between the MAR and the Pain Monitor Flowsheet. It was important to monitor the pain medication administered to see if the resident was comfortable or if further measures were needed. It appeared staff failed to follow-up to see if the pain medication was effective. Further interview with LPN #8 Unit Manger of "D" wing, on 09/26/12 at 2:40 PM, after review of the documentation of the [MEDICATION NAME] administration revealed on 09/04/12; 09/05/12; 09/08/12; 09/09/12; and 09/13/12, staff failed to follow the process for documenting the administration of the medication on these dates. The facility should ensure narcotics were given when signed out. In addition, there were inconsistencies in the documentation. Staff should be documenting consistently. The medication administration policy stated they were supposed to document on the back of the MAR (Nurse's Medication Notes) the date, time of administration, dose, route, and results achieved. However, they had a meeting with the Staff Development Coordinator a few years ago and they were told to use the pain flowsheet to document the information and not the back of the MAR. Staff did not have to document in both places. Continued interview with the ADNS of "C" and "D" wings, on 09/25/12 at 4:30 PM, after review of the [MEDICATION NAME] medication administration documentation revealed it appeared there were multiple events where the facility's medication administration processes were not followed. In regard to the doses signed out on the narcotic book, but not documented on the MAR or Pain Monitor Flowsheet there was no documentation according to their processes the medication was given. It was important to ensure narcotics were being administered to residents. Interview with the Director of Nursing Services (DNS), on 09/26/12 at 4:35 PM, revealed the expected process for documentation of a narcotic pain medications, given PRN, would be to document on the narcotic count sheet, to document on the front and back of the MAR, and to document on the pain flowsheet. After review of the documentation of [MEDICATION NAME] administration for Resident #13, the DNS stated there were inconsistencies in documentation by staff related to administration of the medication. Staff failed to follow the documentation process. Staff needed to follow-up on the effectiveness of the pain medication to determine if the medication was controlling the pain. They were not currently doing any audits of documentation of pain medication administration. After review of some dates where only documentation of the medication being administered was in the narcotic book, the DNS stated it was a concern because it was a narcotic and they needed to follow-up on the effectiveness of the pain medication. When auditing for possible narcotic theft they would look for patterns. In this case there was not really a pattern. 3. Review of the facility's Patient Medical Records policy, dated 04/01/11, revealed "The Payroll Benefits Coordinator (PBC) maintains a Master Signature Log for the center to authenticate the authors of documentation contained in the patient's medical record". A list of disciplines included were listed. And also, " The PBC obtains new employees' printed name, credentials handwritten signature and initials upon hire". Observations during the investigation of the allegation of diversion of narcotics revealed there were initials on the Mediations Administration Records and the Narcotic Signout Sheets without signatures to match the nurse who had administered the medications on the Master Signature Log. Interview with the Director of Nursing Services (DNS) on 09/19/12 at 10:40, revealed the Payroll Clerk was responsible for maintaining the Master Signature Log. The DNS stated she would have the Staff Development staff member start getting the signatures on the list as soon as possible. Interview with the Payroll Clerk, on 09/19/12 at 10:55 AM, revealed she had received a e-mail in June that the Master Signature Log needed to be updated. She stated prior to anyone picking up their check during one of the pay periods that month, all employees had to sign the Log. Review of list of new employees from July 2012 until September, 19 2012, revealed the facility had hired RN's, LPN's and SRNA's who's names where not on the Master Signature Log and those staff members worked through out the facility. The facility provided an acceptable credible Allegation of Compliance (AOC) on 09/27/12 that alleged removal of the IJ effective 09/27/12. Review of the AOC revealed the facility implemented the following: 1) On 09/25/12, a Nurse Practitioner conducted education with facility licensed nurses on performing skin assessments, with emphasis on notable findings that require Physician and family notification. Education included, but was not limited to, notification guidelines and documentation of objective findings. Notable findings included, but were not limited to, Pressure Ulcers, Arterial Ulcers, Diabetic Neuropathic Ulcers, [MEDICAL CONDITION] Ulcers, Surgical Wounds, Skin Tears, Lacerations, Abrasions, Bruises, Burns, Rashes, or a Lesion associated with bleeding, itching, burning, discoloration and/or raised. On 09/25/12 through 09/26/12, after receiving education from the Nurse Practitioner on 09/25/12, the Assistant Director of Nursing Services (ADNS), Staff Development Coordinator (SDC), and/or Shift Supervisor conducted this education with licensed nurses. The Weekend Supervisor received education from the ADNS on 09/26/12. 2) Head-to-toe skin assessments were performed on all but two (2) residents from 09/25/12 through 09/26/12 by licensed nurses. Two (2) residents refused the skin assessments. Notable findings were communicated to the Physician and family on 09/26/12. Notable findings included, but were not limited to, Pressure Ulcers, Arterial Ulcers, Diabetic Neuropathic Ulcers, [MEDICAL CONDITION] Ulcers, Surgical Wounds, Skin Tears, Lacerations, Abrasions, Bruises, Burns, Rashes, or a Lesion associated with bleeding, itching, burning, discoloration and/or raised. The findings were documented by the licensed nurse, and communicated to the Physician and family for further follow-up. The licensed nurse was responsible to communicate findings and document findings in the residents' medical record. No licensed nurse would be allowed to work after 09/26/12, without having received the education from the ADNS, SDC, Shift Supervisor, and/or Weekend Supervisor. The procedure for conducting a skin assessment will be included in the orientation of new hires for licensed nurses. The facility does not employ contract employees. If the facility were to employ contract employees, the licensed nurses would receive the education before being allowed to work in the facility. 3) Notices were posted at each nursing station on 09/26/12 for all State Registered Nursing Assistants (SRNAs) to immediately report any change in a resident's skin condition to the nurse. SRNAs were to report new and/or unusual findings to the licensed nurse at the time of visualization. 4) A Performance Improvement Committee (PIC) meeting was held on 09/21/12 to review the Immediate Jeopardy. The Medical Director was notified of the Immediate Jeopardy on 09/21/12. Another PIC was held on 09/26/12, the Medical Director was notified and approved the action plan. The PIC reviewed and approved the Allegation of Compliance (AOC). The PIC was to ensure validation of the AOC by: discussing areas of concern identified through audits; creating corrective action plans for any areas of concern identified, this will be assigned by the Executive Director (ED) as concerns are identified; and meeting weekly or more often as necessary until the facility had demonstrated substantial compliance with the corrective actions described in the AOC. Additionally, a corrective action plan will be developed by members of the PIC for any areas identified as not in compliance with the AOC. The facility will then return to routine monthly meetings. On 10/03/12 the State Survey Agency verified the Immediate Jeopardy was removed on 09/27/12 and the facility implemented corrective actions as alleged in the AOC, effective 09/27/12 based on the following: Review of the facility's inservice on skin assessment revealed nursing staff were educated on the performance of skin assessments and on the identification of skin abnormalities to include [MEDICAL CONDITION]. Review of the Attendance Rosters revealed the Director of Nursing Services (DNS), both Assistant Directors of Nursing Services (ADNS), the Quality Assurance (QA)Nurse, all the Unit Managers, Staff Development Coordinator (SDC), Shift Supervisors and Weekend Supervisor received education on 09/25/12 on performing skin assessments and Physician Notification; then performed inservice training of other licensed staff, forty-six (46) RNs and LPNs, on 09/25/12 and 09/26/12 related to skin assessments and Physician Notification. Review of the skin assessment forms revealed all facility residents had skin assessments performed from 09/25/12 through 09/26/12 by licensed nurses, except two (2) who refused. Further review revealed the results of the skin assessments, which had notable findings, were documented in the residents' progress notes. Review of the Physician notifications revealed the Physician was notified of the findings of the skin assessments and new orders were obtained as necessary. Review of the family notifications revealed families were notified of the findings of the skin assessments by the licensed nurses. Review of the residents' Care Plan Update forms revealed residents' care plans were updated with the findings of the skin assessments and any new physician's orders [REDACTED]. Interview, on 10/03/12 at 7:45 PM, with the Evening Supervisor revealed she had been trained on skin assessments, documentation of these, and Physician notification on 09/25/12. She stated she then inserviced 3:00 PM to 11:00 PM and 11:00 PM to 7:00 AM shift staff prior to starting their shift. Telephone interview on, 10/03/12 at 7:30 PM, with the Weekend Supervisor revealed he had received training on skin assessments, documentation related to these, and Physician notification. Interview, on 10/03/12 at 7:35 PM, with the Assistant Director of Nursing Services (ADNS) for the A and B units, revealed she had received inservice training on 09/25/12 from a Nurse Practitioner related to performing skin assessments, documentation, and Physician notification. She stated she was trained on inservicing other licensed staff, and had done so. Interview, on 10/03/12 at 8:00 PM, with the Staff Development Coordinator (SDC) revealed an Advanced Practice Registered Nurse (APRN) had educated her, the Unit Managers, Director of Nursing Services (DNS), and both ADNS' on skin assessments, documentation, and Physician Notification. She stated the other licensed staff were then trained by herself, or one of the others who had received the APRN's training. Interviews with licensed nursing staff on 10/02/12, on the 3:00 PM to 11:00 PM shift, on the A unit at 7:20 PM (LPN #31), at 7:45 PM (LPN #22), on the B unit at 7:20 PM (LPN #28), 7:25 PM (LPN #14); the C unit at 7:20 PM (LPN #2), revealed they had received inservice training on the performance of skin assessments, documentation of these, and Physician notification. Interview with licensed nursing staff on 10/02/12 on the D unit, at 7:15 PM (LPN #29) revealed she was an as needed (PRN) staff person and had just received the inservice training on skin assessments, documentation of these, and Physician notification prior to starting her shift that day. Telephone interviews with licensed nursing staff, on 10/03/12 on the 11:00 PM to 7:00 AM shift, on the A unit at 1:32 AM (RN #6); on the C unit at 1:43 AM (RN #7); and on the D unit at 1:50 AM (LPN #26), revealed they had received inservice training on how to perform skin assessments, document these, and on Physician notification. Interviews with licensed nursing staff on 10/03/12, on the 7:00 AM to 3:00 PM shift, on the A unit at 2:48 PM (LPN #15), at 2:55 PM (LPN #32); on the B unit at 11:45 AM (LPN #3), at 11:30 AM (LPN #13); on the C unit at 10:35 AM (LPN #1), at 12:05 PM (RN #8); on the D unit at 10:05 AM (LPN #7) revealed they had all had training on skin assessments, documentation of these, and Physician notification. Observation, on 10/02/12 and 10/03/12, revealed a sign at each nurse's station that stated, "ALL NEW SKIN CONDITIONS AS WELL AS CHANGES IN EXISTING AREAS NEED TO BE REPORTED TO THE NURSE IMMEDIATELY!!!!!!!!". Review of the facilities Performance Improvement Committee (PIC) meeting minutes revealed meetings were held on 09/21/12 to discuss the Immediate Jeopardy and on 09/26/12 to discuss and approve the Allegation of Compliance (AOC) to implement plans of correction to remove the IJ. Interview, on 10/03/12 at 8:40 PM with the Executive Director (ED) revealed she had participated in formulating and writing of the AOC, along with the DNS, Nurse Consultant, Quality Assurance (QA) Nurse, and Medical Director. She stated they had reviewed the cited deficiencies and developed the abatement plan. She ensured the skin assessments were performed as per the AOC, the Physician and family notifications were performed, and all licensed staff received the inservice training. The facility remained out of compliance at a lower scope and severity of a "D", an isolated deficiency with potential for more than minimal harm in order for the facility to develop and implement the Plan of Correction (POC).

Based on observation, interview, and record review, and review of the facility's policy, it was determined the facility failed to ensure residents were free from neglect and misappropriation of property two (2) of thirty-six (36) sampled residents (Resident #2 and #23) and one (1) unsampled residents (Residents C). The facility failed to provide the necessary care and services for Resident #2. The facility failed to have an effective system in place to accurately assess and monitor changes in residents' skin for Resident #2. Numerous interviews revealed Resident #2 had an area/nodule on the vaginal area which grew and was noted to bleed on 09/04/12. The facility failed to assess the area, recognize the change in the area/nodule, and obtain appropriate treatment for [REDACTED]. would now take. (Refer to F-157 and F-309) Additionally, the facility failed to secure residents' property as evidenced by the misappropriation of five (5) vials of Resident #23's [MEDICATION NAME] (medication indicated for the management of anxiety disorders or for the short-term relief of the symptoms of anxiety or anxiety associated with depressive symptoms) after the medication room key was found missing. Resident C's [MEDICATION NAME] (a topical pain reliever) medication was misappropriated as evidenced by the medication found at an employee's residence. The facility's failure to ensure each resident was free from neglect was likely to cause risk for serious injury, harm, or impairment or death. The Immediate Jeopardy was identified on 09/21/12, and determined to exist on 08/31/12. The facility was notified of the Immediate Jeopardy on 09/21/12. The facility provided an acceptable credible Allegation of Compliance (AOC) on 09/27/12 prior to exiting the facility on 10/03/12, with the facility alleging removal of the Immediate Jeopardy on 09/27/12. The Immediate Jeopardy was verified to be removed on 09/27/12, prior to exiting the facility on 10/03/12, with remaining non-compliance at 42 CFR 483.13, Resident Behavior and Facility Practice, F-224 Staff treatment of [REDACTED]. Assurance continues to monitor to ensure assessments and recognition of changes in residents' conditions. The findings include: 1. Review of the facility policy titled, "Abuse Prevention" revealed the rationale was to identify, correct, and intervene in situations in which abuse, neglect, and/or misappropriation of resident property are more likely to occur through analysis of...the assessment, care planning, and monitoring of residents with needs and behaviors which might lead to conflict or neglect. Review of the facility policy entitled, "Abuse" revealed staff should identify residents at risk for neglect such as residents who are bedfast and totally dependent on staff for care. Review of the facility policy entitled, "Condition Change of a Resident" revealed the rationale was "resident change of condition is identified for proper treatment implementation". Review of Resident #2's record revealed an admission date of [DATE], and [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE], revealed the facility assessed the resident to be severely impaired with daily decision making, and to have long term and short term memory problems. Further review of the MDS revealed the facility assessed the resident to be totally dependent on staff for all Activities of Daily Living (ADLs). Observation from 09/19/12 to 10/03/12 revealed Resident #2 to be bedbound. Observation, during a skin assessment performed on 09/19/12, at 10:09 AM of Resident #2 revealed a glove and splint were present on the resident's right hand. Observation of Resident #2's left arm and hand revealed them to be flaccid (having defective or absent muscular tone). During the assessment the glove and splint were removed from the right hand and the resident immediately attempted to scratch at the vaginal area. Further observation revealed the resident had an large area/nodule on the vagina. Interview with Licensed Practical Nurse (LPN) #4 during the skin assessment, revealed the area/nodule was approximately six (6) centimeters in length and was a Squamous Cell [MEDICAL CONDITION]. Review of an Admission Nursing Assessment, dated 07/21/98, and a Readmission Nursing assessment dated [DATE], revealed no documented evidence of an area/nodule to Resident #2's vagina. Review of weekly skin assessments, Nurse's Notes and Weekly Pressure and Non-Pressure Skin Condition Reports from 01/01/09 to 09/01/12 revealed no documented evidence of an area/nodule to the resident's vagina. Review of the Physician's Admission History and Physical (H&P) dated 07/21/98 and an H&P dated 03/21/07, revealed no documented evidence of an area/nodule to Resident #2's vagina. Review of the Nurse's Notes, dated 09/04/12 at 1:50 PM, revealed documentation that indicated the Primary Care Physician (PCP) had been notified that there was an area/nodule that was bleeding on Resident #2's vaginal area. Review of a fax sent to the PCP on 09/04/12, revealed a State Registered Nursing Assistant (SRNA) had informed the nurse, who sent the fax, that Resident #2 was bleeding. Continued review of the fax revealed there was an area/nodule that looked like a "cyst" near Resident #2's vaginal area that was bleeding. Review of the Physician's Orders dated 09/04/12 revealed orders for laboratory work, a Urinalysis with Culture and Sensitivity (C&S), [MEDICATION NAME] (an oral antibiotic), and [MEDICATION NAME] (an antibiotic ointment) twice a day for ten (10) days "to vaginal cyst". Interview, on 09/20/12 at 4:20 PM with Resident #2's Primary Care Physician (PCP) revealed he had received a fax on 09/04/12 that indicated Resident #2 had a cyst that was bleeding on the vaginal area. He stated he was not aware of the area/nodule prior to 09/04/12. The PCP stated he saw the area/nodule on 09/06/12 when it was large with irregular borders and he thought it [MEDICAL CONDITION]. The resident was transferred to the hospital for further evaluation. Review of the hospital History and Physical (H&P), dated 09/06/12, revealed Resident #2 was admitted related to having a large area/nodule that was bleeding. The admitting Physician (also the resident's Primary Care Physician at the facility) documented the area/nodule appeared to most likely be Vaginal [MEDICAL CONDITION]. The hospital Consultant Gynecologist documented the area/nodule appeared to be a [MEDICAL CONDITION] emanating from the right labia. Review of the hospital Discharge Summary revealed Resident #2 had a large five (5) centimeter lesion on the vaginal area and the Consultant Gynecologist recommended further evaluation by an Gynecological Oncologist. Interview, on 09/20/12 at 4:00 PM with the Gynecologist (GYN) who saw Resident #2, revealed he had evaluated the resident's condition and felt the area/nodule was a Vulvar [MEDICAL CONDITION]. According to the GYN he was unable to evaluate how long the area/nodule had been present on the resident's vagina. The GYN stated in his opinion the area/nodule had not developed overnight and had been there longer than a month. The GYN stated he referred Resident #2 to a GYN Oncologist at another facility. Interview, on 09/20/12 at 4:43 PM with the GYN Oncologist revealed he examined the area/nodule on Resident #2's vaginal area. He stated the area/nodule was a [MEDICAL CONDITION]. According to the GYN Oncologist, a biopsy was not performed on the area/nodule, so he couldn't say with any accuracy how long it had been there. He stated the area was treatable with surgery; however, he questioned whether to operate related to the resident's co-morbidities. Interview, on 09/20/12 at 7:25 PM, with LPN #14 revealed she had been employed by the facility since 2010 and the area/nodule was present on Resident #2's vaginal area at that time. LPN #14 indicated the area/nodule was molelike in appearance then, and was approximately the size of a pencil eraser. She stated the area had not changed when she observed it in July, 2012. Further interview, on 09/30/12 at 3:28 PM with LPN #14 revealed she was not aware of changes in the area/nodule, and when she observed it on 09/04/12, she felt a sense of urgency. She stated her observation of the area/nodule on 09/04/12 revealed it to be a very large mass, with abnormal edges, and an elongated shape. She stated it was darker than the resident's normal vaginal skin color, it was"pinkish brown with a tint of red". In an interview, on 10/02/12 at 5:40 PM with LPN #14 she stated the area/nodule had always been on the resident's vagina, and it had not changed in size, or color, and had not bled prior to that day. She indicated the area was not out of the resident's "norm", so she did not document on it. Interview, on 09/19/12 at 10:45 AM and on 09/30/12 at 8:50 PM with Licensed Practical Nurse (LPN) #3 revealed she was not aware of the area/nodule on Resident #2's vaginal area until 09/04/12. She stated the State Registered Nursing Assistants showed it to her on that date and she assessed the area, documented her findings in the resident's medical record, and notified the PCP. She visualized the area/nodule and it was bleeding a small amount of bright red blood which was on the resident's brief. The LPN indicated the area/nodule was approximately four (4) to five (5) centimeters in length and approximately two (2) centimeters wide. The LPN stated the area/nodule was tumor-like, and pink with little white areas on it. According to the LPN, she told the PCP it was a "cyst-like" area and was bleeding. She stated she tried to look back through previous skin assessments to locate documentation of the area/nodule, however there were none. According to the LPN this area/nodule should have been documented on the skin assessment sheets. She stated she had asked SRNA #15 about the area/nodule, and she had told her it had started growing in the last six (6) months. Interview, on 09/21/12 at 2:45 PM, with SRNA #15 revealed she had first noticed the area/nodule approximately nine (9) months ago. The SRNA indicated then it was small and she had reported it LPN #20 she thought. According to the SRNA, the area/nodule had grown larger since she first noticed it. Additional interview, on 09/30/12 at 2:12 PM with SRNA #15 revealed the area/nodule had became larger, and was red with a few white dots on it. She indicated she was unable to recall if she had notified the nurses of the change in the area/nodule. She stated on 09/04/12, she noted a small amount of fresh-looking blood on Resident #2's brief. The SRNA stated she got the nurse. SRNA #15 stated when she was cleaning the resident after that the bleeding from the area/nodule became a stream. Interview, on 09/19/12 at 4:22 PM, with LPN #20, revealed she had been at the facility for approximately three (3) years. LPN #20 stated she performed Resident #2's skin assessments, and the area/nodule on the resident's vagina had been there "as far as" she could think back. According to the LPN, the area/nodule looked like an "external hemorrhoid" in the vaginal area. An interview, on 09/27/12 with LPN #20 revealed the area/nodule was pinkish, veinish, purple, very vascular, raised and rounded. Further interview, on 09/29/12 with LPN #20 revealed areas/nodules, such as Resident #2's, should be documented on an admission skin assessment. She indicated she would look through the medical record to check for a baseline for Resident #2's area/nodule. The LPN stated she would determine if there was a baseline by checking the Pressure/Non-Pressure Monitoring sheets, or Treatment Administration Records (TARs). The LPN indicated she had not documented on the area/nodule, she would only document changes. According to LPN #20, there were no changes to the area/nodule. She stated it could always be visualized, the labia did not have to be parted to see it. Interview, on 09/21/12 at 2:20 PM, with SRNA #14 revealed she had been employed by the facility for three (3) years and the area/nodule had been present then. The SRNA stated the area/nodule had become bigger and this started approximately six (6) months ago. Interview, on 09/30/12 at 1:08 PM, with SRNA #17 revealed she had been on Resident #2's unit for one (1) year. According to the SRNA, initially when she saw it, the area/nodule was three (3) times smaller than it was now, was pink, and stood out. She stated she was told the area/nodule had always been there, that it was "no big deal". The SRNA indicated the area/nodule had changed in a month to two (2) months. She stated the area/nodule had gotten bigger, darker in color, bumpy, and hard. Interview, on 09/26/12 at 1:14 PM, with SRNA #12 revealed approximately two (2) to three (3) months previously she was aware of the area/nodule on the resident's vagina. She stated it was about nickel-sized, raised, and pink-looking then. According to the SRNA, towards the end of August the area/nodule grew larger. She indicated she reported it to a nurse, however was unable to recall who the nurse was. Interview, on 09/26/12 at 1:03 PM, with SRNA #13 revealed she had worked on Resident #2's unit for approximately six (6) months to a year. According to the SRNA, the area/nodule on the resident's vagina then was small, like a dime when she saw it. She stated at the last of August, the area/nodule had gotten "bigger". She stated that at the end of August the area/nodule was "wedge-shaped" and about the size of a fifty (50) cent piece if you "smashed it" (area/nodule) out. She stated it was pink, thicker, and "bumpier" looking, and bled a little. SRNA #13 stated she informed LPN #19 of these changes. Interview, on 09/30/12 with SRNA #16 revealed that in the last two (2) to three (3) months the area/nodule on Resident #2's vaginal area had grown. SRNA #16 stated the area/nodule looked like a mole or wart. She stated she brought this to LPN #19's attention. Interview, on 09/25/12 at 11:51 PM, with LPN #19 revealed she did not know how long Resident #2 had the area/nodule in the vaginal area. The LPN indicated it was kind of like a nodule, not markedly raised, and marble size prior to 09/04/12. The LPN stated she would look at previous skin assessments to tell if the area/nodule had changed. According to the LPN, she would expect an area/nodule like that to be documented on initially, then thereafter if any changes occurred. However, record review revealed the area had never been assessed. According to LPN #19, the area changed, and became about the "size of a quarter", pinker, rougher. The LPN stated she thought she had reported this information, however did not remember to which nurse. She stated she was not aware of the area/nodule bleeding until 09/04/12. Interview, on 09/25/12 at 7:48 PM, with Registered Nurse (RN) #4 revealed she cared for Resident #2, and was unaware of the area/nodule until a month to a month and a half ago. She stated one (1) of the SRNAs (SRNA #16) had commented to her that the area/nodule had been there quite a while and was getting bigger. She stated she had talked to LPN #14 about the area/nodule and LPN #14 told her the SRNAs had reported the area/nodule was getting bigger, that it had been there for a long time. The RN stated when she observed the area/nodule in mid-August it was not bleeding. The RN indicated the area/nodule was dark pink, oblong, about the size of a quarter in diameter when she saw it. Per interview, the nodule should have been documented on past skin assessments and the changes noted on the skin assessment. Further interview, on 09/28/12 at 4:25 PM, with RN #4 she revealed she was unable to recall if she had reported her observations in mid-August. She stated she probably didn't report it to the other nurses because the others were aware of the area/nodule. Per interview the changes should have been noted on the twenty-four (24) hour report (facility's communication book between shifts). However, she could not remember if she had documented the area/nodule on the twenty-four (24) report. Review of the facility's twenty-four (24) hour report revealed no documented evidence related to the area/nodule during the month of August. Interview, on 09/21/12 at 4:58 PM, with the Director of Nursing Services (DNS) revealed she became aware of the area/nodule on Resident #2's vaginal are on 09/06/12. The DNS stated staff had reported to her that the area/nodule had "gotten bigger", and that it had done this suddenly. According to the DNS, when the area/nodule was first identified it should have been documented on a skin assessment sheet. She stated she had looked in Resident #2's medical record; however, there was nothing documented related to the area/nodule prior to 09/04/12. Interview, on 09/30/12 at 5:03 PM, with the DNS and the Executive Director (ED) revealed nurses were to document any abnormalities on the weekly pressure/non-pressure sheets. The ED stated when they interviewed the nurse responsible for Resident #2's skin assessments she had told them there had been no change in this area/nodule. According to the ED, staff could look back at the weekly non-pressure forms for changes. However, record review revealed no evidence this area had been assessed on the non-pressure forms for Resident #2. 2. Review of the facility's policy titled, "Responding and Investigating an Abuse Allegation", dated 07/22/10, revealed for all abuse allegations, to begin an internal investigation, immediately report to the Director of Operations, DDCO, Regional Vice President, Human Resources and legal counsel, call the police, report the alleged abuse to the appropriate state agencies, determine root cause and plan and implement corrective action. Further review of the policy revealed if there was alleged theft of an item, staff should contact the Executive Director and the DNS immediately. Review of the facility's policy titled, "Abuse", dated 10/26/11, revealed all alleged violations of misappropriation of resident property should be reported immediately to the Administrator of the facility and to other officials in accordance with state law through established procedures (including to the State Survey and Certification Agency). Review of the facility's policy, "Controlled Medications", dated 03/12/12, revealed the staff must maintain possession of the key to controlled medication storage areas. Conduct an inventory at each shift change or when keys are rendered, of all controlled medications. Review of Resident #23's record revealed the facility admitted the resident on of 12/01/11 with [DIAGNOSES REDACTED]. Review of Resident #23's Plan of Care dated 03/16/12 revealed Problem #6: "I have the potential to be verbally and/or be physically abusive related to poor impulse control and [DIAGNOSES REDACTED]. Review of the Physicians orders for the month of June 2012, revealed an order for [REDACTED]. Interview with the Director of Nursing Services (DNS), on 09/20/12 at 1:15 PM, revealed the facility had a nurse who was no longer employed by the facility, who gave her ring of keys to a State Registered Nursing Assist (SRNA) to get razors from a locked area. There were keys on the ring to the medication cart and medication room. The DNS stated the ring of keys ended up missing, and the facility had pharmacy change the lock on the two (2) medication carts. On a second interview with the DNS, on 09/20/12 at 2:35 PM, she stated she could not find the investigation related to the missing [MEDICATION NAME], and she did not think it was necessary to report it to the State Agency because the medication was replaced and billed to the facility. Interview with the Assistant Director of Nursing (ADON) for C and D Wings, on 09/25/12 at 11:20 AM, revealed he had been on-call the day the keys were found to be missing. He stated two (2) medication carts were re-keyed, but the DNS did not think to have the medication room locks changed. The ADON stated a week later, when the night shift nurse counted the narcotics with the day shift nurse, it was discovered five (5) vials of [MEDICATION NAME] were missing. The night shift had stated she had failed to count with the evening shift nurse. He stated they called the DNS, the Director of District Operations, and the Deputy. He stated maintenance change the lock on the medication room door. The ADON stated the [MEDICATION NAME] was replaced the day it was found to be missing. He stated Resident #23 had an [MEDICAL CONDITION], and also had Versed ordered as needed for agitation, he stated Resident #23 did not go without a dose of [MEDICATION NAME]. Interview with the Administrator, on 09/25/12 at 5:00 PM, revealed she did not think the missing [MEDICATION NAME] was Misappropriation of Resident Property because the resident did not go without the [MEDICATION NAME] and because the facility replaced the medication with no charge to Resident #23. Interview with the ADON for the A and B Wings, on 09/26/12 at 2:15 PM, revealed an inservice was given on the C Wing only, related to not giving keys to unauthorized personal, because that was where the incident had occurred. 3. Review of Unsampled Resident #C's record revealed the facility admitted the resident on of 03/13/12 with [DIAGNOSES REDACTED]. Review of the Physician's orders revealed Unsampled Resident #C had [MEDICATION NAME] for mouth pain; apply with Q-tip two (2) times a day ordered on [DATE]. According to the Physician's order dated 07/25/12 the [MEDICATION NAME] was discontinued. Review of the Plan of Care, dated 07/16/12, revealed Problem #5: "I have the potential for alteration in my oral mucosa related to episodes of sore mouth complaints with intervention in place". Interview with the ADON of the A & B Wings, on 09/20/12 at 6:50 PM, revealed LPN #34 was terminated on Friday (09/14/12). She stated the police had searched LPN #34's house and found the [MEDICATION NAME] with Unsampled Resident #C's name on it and had returned it to the nursing facility. She stated LPN #34 was terminated. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Interview with the Administrator, on 09/25/12 at 5:00 PM, revealed they did not think this incident was reportable. She stated the facility was a special focus facility so they report everything. Interview with LPN #34, on 09/25/12 at 6:40 PM, revealed she had been terminated for misappropriation of resident's property. She stated she had put the gel on Unsampled Resident C's gums, then on her way to put the medication back in the medication cart, she had been called to another resident's room and put the medication in her lab jacket pocket. LPN #34 stated the medication was in her pocket when she got home and she had put it in a cabinet over a sink. She stated the medication had been there for about six (6) months. She stated she was not been trying to steal the medication. The facility provided an acceptable credible Allegation of Compliance (AOC) on 09/27/12 that alleged removal of the IJ effective 09/27/12. Review of the AOC revealed the facility implemented the following: 1) On 09/25/12, a Nurse Practitioner conducted education with facility licensed nurses on performing skin assessments, with emphasis on notable findings that require Physician and family notification. Education included, but was not limited to, notification guidelines and documentation of objective findings. Notable findings included, but were not limited to, Pressure Ulcers, Arterial Ulcers, Diabetic Neuropathic Ulcers, [MEDICAL CONDITION] Ulcers, Surgical Wounds, Skin Tears, Lacerations, Abrasions, Bruises, Burns, Rashes, or a Lesion associated with bleeding, itching, burning, discoloration and/or raised. On 09/25/12 through 09/26/12, after receiving education from the Nurse Practitioner on 09/25/12, the Assistant Director of Nursing Services (ADNS), Staff Development Coordinator (SDC), and/or Shift Supervisor conducted this education with licensed nurses. The Weekend Supervisor received education from the ADNS on 09/26/12. 2) Head-to-toe skin assessments were performed on all but two (2) residents from 09/25/12 through 09/26/12 by licensed nurses. Two (2) residents refused the skin assessments. Notable findings were communicated to the Physician and family on 09/26/12. Notable findings included, but were not limited to, Pressure Ulcers, Arterial Ulcers, Diabetic Neuropathic Ulcers, [MEDICAL CONDITION] Ulcers, Surgical Wounds, Skin Tears, Lacerations, Abrasions, Bruises, Burns, Rashes, or a Lesion associated with bleeding, itching, burning, discoloration and/or raised. The findings were documented by the licensed nurse, and communicated to the Physician and family for further follow-up. The licensed nurse was responsible to communicate findings and document findings in the residents' medical record. No licensed nurse would be allowed to work after 09/26/12, without having received the education from the ADNS, SDC, Shift Supervisor, and/or Weekend Supervisor. The procedure for conducting a skin assessment will be included in the orientation of new hires for licensed nurses. The facility does not employ contract employees. If the facility were to employ contract employees, the licensed nurses would receive the education before being allowed to work in the facility. 3) Notices were posted at each nursing station on 09/26/12 for all State Registered Nursing Assistants (SRNAs) to immediately report any change in a resident's skin condition to the nurse. SRNAs were to report new and/or unusual findings to the licensed nurse at the time of visualization. 4) A Performance Improvement Committee (PIC) meeting was held on 09/21/12 to review the Immediate Jeopardy. The Medical Director was notified of the Immediate Jeopardy on 09/21/12. Another PIC was held on 09/26/12, the Medical Director was notified and approved the action plan. The PIC reviewed and approved the Allegation of Compliance (AOC). The PIC was to ensure validation of the AOC by: discussing areas of concern identified through audits; creating corrective action plans for any areas of concern identified, this will be assigned by the Executive Director (ED) as concerns are identified; and meeting weekly or more often as necessary until the facility had demonstrated substantial compliance with the corrective actions described in the AOC. Additionally, a corrective action plan will be developed by members of the PIC for any areas identified as not in compliance with the AOC. The facility will then return to routine monthly meetings. On 10/03/12 the State Survey Agency verified the Immediate Jeopardy was removed on 09/27/12 and the facility implemented corrective actions as alleged in the AOC, effective 09/27/12 based on the following: Review of the facility's inservice on skin assessment revealed nursing staff were educated on the performance of skin assessments and on the identification of skin abnormalities to include [MEDICAL CONDITION]. Review of the Attendance Rosters revealed the Director of Nursing Services (DNS), both Assistant Directors of Nursing Services (ADNS), the Quality Assurance (QA)Nurse, all the Unit Managers, Staff Development Coordinator (SDC), Shift Supervisors and Weekend Supervisor received education on 09/25/12 on performing skin assessments and Physician Notification; then performed inservice training of other licensed staff, forty-six (46) RNs and LPNs, on 09/25/12 and 09/26/12 related to skin assessments and Physician Notification. Review of the skin assessment forms revealed all facility residents had skin assessments performed from 09/25/12 through 09/26/12 by licensed nurses, except two (2) who refused. Review of the Physician notifications revealed the Physician was notified of the findings of the skin assessments and new orders were obtained as necessary. Review of the family notifications revealed families were notified of the findings of the skin assessments by the licensed nurses. Review of the residents' Care Plan Update forms revealed residents' care plans were updated with the findings of the skin assessments and any new Physician's Orders. Interview, on 10/03/12 at 7:45 PM, with the Evening Supervisor revealed she had been trained on skin assessments, documentation of these, and Physician notification on 09/25/12. She stated she then inserviced 3:00 PM to 11:00 PM and 11:00 PM to 7:00 AM shift staff prior to starting their shift. Telephone interview on, 10/03/12 at 7:30 PM, with the Weekend Supervisor revealed he had received training on skin assessments, documentation related to these, and Physician notification. Interview, on 10/03/12 at 7:35 PM, with the Assistant Director of Nursing Services (ADNS) for the A and B units, revealed she had received inservice training on 09/25/12 from a Nurse Practitioner related to performing skin assessments, documentation, and Physician notification. She stated she was trained on inservicing other licensed staff, and had done so. Interview, on 10/03/12 at 8:00 PM, with the Staff Development Coordinator (SDC) revealed an Advanced Practice Registered Nurse (APRN) had educated her, the Unit Managers, Director of Nursing Services (DNS), and both ADNS' on skin assessments, documentation, and Physician Notification. She stated the other licensed staff were then trained by herself, or one of the others who had received the APRN's training. Interviews with licensed nursing staff on 10/02/12, on the 3:00 PM to 11:00 PM shift, on the A unit at 7:20 PM (LPN #31), at 7:45 PM (LPN #22), on the B unit at 7:20 PM (LPN #28), 7:25 PM (LPN #14); the C unit at 7:20 PM (LPN #2), revealed they had received inservice training on the performance of skin assessments, documentation of these, and Physician notification. Interview with licensed nursing staff on 10/02/12 on the D unit, at 7:15 PM (LPN #29) revealed she was an as needed (PRN) staff person and had just received the inservice training on skin assessments, documentation of these, and Physician notification prior to starting her shift that day. Telephone interviews with licensed nursing staff, on 10/03/12 on the 11:00 PM to 7:00 AM shift, on the A unit at 1:32 AM (RN #6); on the C unit at 1:43 AM (RN #7); and on the D unit at 1:50 AM (LPN #26), revealed they had received inservice training on how to perform skin assessments, document these, and on Physician notification. Interviews with licensed nursing staff on 10/03/12, on the 7:00 AM to 3:00 PM shift, on the A unit at 2:48 PM (LPN #15), at 2:55 PM (LPN #32); on the B unit at 11:45 AM (LPN #3), at 11:30 AM (LPN #13); on the C unit at 10:35 AM (LPN #1), at 12:05 PM (RN #8); on the D unit at 10:05 AM (LPN #7) revealed they had all had training on skin assessments, documentation of these, and Physician notification. Observation, on 10/02/12 and 10/03/12, revealed a sign at each nurse's station that stated, "ALL NEW SKIN CONDITIONS AS WELL AS CHANGES IN EXISTING AREAS NEED TO BE REPORTED TO THE NURSE IMMEDIATELY!!!!!!!!". Review of the facilities Performance Improvement Committee (PIC) meeting minutes revealed meetings were held on 09/21/12 to discuss the Immediate Jeopardy and on 09/26/12 to discuss and approve the Allegation of Compliance (AOC) to implement plans of correction to remove the IJ. Interview, on 10/03/12 at 8:40 PM with the Executive Director (ED) revealed she had participated in formulating and writing of the AOC, along with the DNS, Nurse Consultant, Quality Assurance (QA) Nurse, and Medical Director. She stated they had reviewed the cited deficiencies and developed the abatement plan. She ensured the skin assessments were performed as per th

RBased on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to have an effective system in place to ensure the Physician was notified of a change in condition for one (1) of thirty-six (36) sampled residents (Resident #2). Facility staff identified an area/nodule on Resident #2's vagina; however, the facility failed to assess the area and notify the resident's Physician. Facility staff interviews revealed the area/nodule changed in size and color; however, there was no documented evidence the Physician was notified of the change. The area proceeded to grow and on 09/04/12 the area/nodule started bleeding. On 09/04/12, the Physician was notified of the bleeding; however, was not informed of any urgency related to the bleeding. On 09/06/12, the Physician examined the resident and ordered Resident #2 be a direct admit to the hospital. The resident was examined at the hospital by a Gynecologist and diagnosed with [REDACTED]. The facility's failure to ensure an effective system was in place to ensure Physician notification of a change in condition was likely to cause risk for serious injury, harm, or impairment or death. The Immediate Jeopardy was identified on 09/21/12, and determined to exist on 08/31/12. The facility was notified of the Immediate Jeopardy on 09/21/12. The facility provided an acceptable credible Allegation of Compliance (AOC) on 09/27/12 prior to exiting the facility on 10/03/12, with the facility alleging removal of the Immediate Jeopardy on 09/27/12. The Immediate Jeopardy was verified to be removed on 09/27/12, prior to exiting the facility on 10/03/12, with remaining non-compliance at 42 CFR 483.10, Resident Rights, F-157 Notify Physician, with a Scope and Severity of "D", while the facility develops and implements a Plan of Correction, and the facility's Quality Assurance continues to monitor to ensure assessments and recognition of changes in residents' conditions. The findings include: Review of the facility's policy titled, "Condition Change of a Resident", revealed the rationale was "Resident change of condition is identified for proper treatment implementation. The Physician is informed of resident events and/or change in resident's condition". Continued review of the policy revealed under the "Non-Immediate Notification" section the Physician should be informed of the problem or event during office hours and generally no later than the next regular office day. Review of the "Procedure" portion of the policy, revealed the nurse should notify the Physician of clinical problems; if the attending Physician was unavailable the nurse was to notify the alternate Physician or the Medical Director. The Physician would develop a working [DIAGNOSES REDACTED]. Review of the Nurse's Notes, dated 09/04/12 at 1:50 PM, revealed the Primary Care Physician (PCP) had been notified of "bleeding from nodule to vaginal area...". Review of a fax sent to the PCP on 09/04/12, revealed the resident had been running a low grade temperature "since over the weekend...but today the CNA (Certified Nursing Assistant) came and got me", she (SRNA/CNA) said Resident #2 was bleeding. Further review of the fax revealed the resident had an area that looked like a "cyst" near the vaginal area that was bleeding. Review of the physician's orders [REDACTED]. Interview, on 09/19/12 at 10:45 AM, with Licensed Practical Nurse (LPN) #3 revealed she did not recall hearing about the area/nodule until 09/04/12 when the SRNA showed it to her. She stated the area/nodule was approximately four (4) to five (5) centimeters in length and approximately two (2) centimeters wide. The LPN stated the area/nodule was tumor-like, and pink with little white areas on it. Per interview, she notified the Primary Care Physician (PCP) on 09/04/12 and he ordered "labs" and [MEDICATION NAME] (antibiotic ointment). According to the LPN, the PCP came in a "day or two (2) later" and looked at the area/nodule and ordered Resident #2 direct admitted to the hospital. Interview, on 09/20/12 at 4:20 PM and on 09/30/12 at 5:30 PM with Resident #2's Primary Care Physician (PCP), revealed he became aware of the area/nodule on 09/04/12. He stated he had received a fax that indicated the resident had a cyst that was bleeding in the vaginal area. He thought this area was "more in the order of a boil" and that was why he ordered the antibiotic ointment. He stated when he saw the area/nodule on 09/06/12 he thought it [MEDICAL CONDITION]. The PCP stated the area/nodule was large with irregular borders. According to the PCP, had he known about the area/nodule earlier he would have ordered a Gynecological consult. Interview, on 09/21/12 at 2:20 PM, with State Registered Nursing Assistant (SRNA) #14 revealed the area/nodule had been present since she had started work at the facility three (3) years ago. She stated the area/nodule had started to change approximately six (6) months before. The SRNA stated the area/nodule had "gotten bigger". Interview, on 09/30/12 at 1:08 PM with SRNA #17 revealed she worked on Resident #2's unit and had been there for one (1) year. She stated at the time she started the area/nodule on the resident's vagina was three (3) times smaller than it was now. The SRNA stated at that time it was pink, and stood out. She stated she was told the area/nodule had always been there, that it was "no big deal". Interview, on 09/21/12 at 2:45 PM, with SRNA #15 revealed she had first noticed the area/nodule approximately nine (9) months ago. She stated the area/nodule started out real small and she had reported it to the nurse. The SRNA stated the area/nodule had "gotten bigger" since she first noticed it. Additional interview, on 09/30/12 at 2:12 PM, with SRNA #15 revealed the area/nodule on Resident #2's vagina had "kept growing" since she had first observed it. She stated the area/nodule became larger, was red with a few white dots and rougher. Interview, on 09/26/12 at 1:14 PM, with SRNA #12 revealed she had worked on the resident's unit for approximately two (2) to three (3) months. She stated she was aware of the area/nodule on the resident's vagina. SRNA #12 stated it was about the size of a nickel, raised, and pink-looking then. The SRNA stated toward the end of August the area/nodule "got bigger". She stated she reported it to a nurse, however was unable to recall who the nurse was. Interview, on 09/26/12 at 1:03 PM with SRNA #13 revealed she had worked on Resident #2's unit for approximately six (6) months to a year. She stated the area/nodule on the resident's vagina was a "small place, like a dime" when she saw it then. SRNA #13 stated the area/nodule started to get "bigger" the last of August. According to the SRNA, she notified the nurse (LPN #19) of this information. Interview, on 09/30/12 at 11:00 AM, with SRNA #16 revealed she had cared for Resident #2. She stated the resident had an area/nodule on the vagina that looked like a mole or wart. The SRNA stated that in the last two (2) to three (3) months the area/nodule had "started growing". The SRNA indicated she brought this to LPN #19's attention. Interview, on 09/25/12 at 11:51 PM, with LPN #19 revealed she was uncertain how long the area/nodule had been on Resident #2's vagina. She stated it was kind of like a nodule, not markedly raised, and marble size initially. According to LPN #19, the area changed, became about the "size of a quarter", pinker, rougher. However, she did not notify the Physician of the changes to the area/nodule on Resident #2's vaginal area. Interview, on 09/20/12 at 7:25 PM, with LPN #14 revealed the area/nodule had been present since she started work at the facility in 2010. She stated at that time the area/nodule was about the size of a pencil eraser, normal skin color, "looked kind of like a mole". According to the LPN, when she saw the area/nodule on 09/04/12 it was a very large mass, with abnormal edges, "un-uniform", it had an elongated shape and was darker than Resident #2's normal skin in that area. She stated it was "pinkish brown with a tint of red". The LPN stated she did not notify the Physician about the area prior to the change on 09/04/12. Interview, on 09/25/12 at 7:48 PM and on 09/28/12 at 4:25 PM, with Registered Nurse (RN) #4 revealed she cared for Resident #2, and was unaware of the area/nodule until a month to a month and a half ago. She stated SRNA #16 had commented to her that the area/nodule had been there quite a while and was getting bigger. She stated she had talked to LPN #14 about the area/nodule and LPN #14 told her the SRNAs had reported the area/nodule was getting bigger, that it had been there for a long time. The RN indicated the area/nodule was dark pink, oblong, about the size of a quarter in diameter when she saw it. The RN stated she did not notify the Physician upon becoming aware of the area/nodule a month to a month and a half ago. Interview, on 09/19/12 at 4:22 PM, with LPN #20, who had performed Resident #2's skin assessments, revealed she had been employed for approximately three (3) years and the area/nodule on the resident's vagina had been there "as far as" she could think back. She stated the area/nodule looked like an "external hemorrhoid" in the vaginal area. An interview, on 09/27/12 with LPN #20 revealed the area/nodule was pinkish, veinish, purple, very vascular, raised and rounded. Per interview, the resident's Physician should have been notified. Interview, on 09/21/12 at 4:58 PM with the Director of Nursing Services (DNS) revealed she became aware of the area/nodule on Resident #2's vaginal are on 09/06/12. The DNS stated staff had reported to her that the area/nodule had "gotten bigger", and that it had done this suddenly. The DNS stated the resident's Physician should have been notified when the area/nodule was first discovered. Further interview, on 09/26/12 at 12:26 PM with the Primary Care Physician (PCP) revealed had the area/nodule been identified and recognized "early on" it could have been treated with less aggressive measures than the "significant" surgical procedure it would take now. According to the PCP he thought it was "something that fell through the cracks". Interview, on 09/21/12 at 3:07 PM, with the Medical Director revealed areas/nodules like the one on Resident #2's vagina could be present for years. When asked if she would expect nurses to notify her of such an area if she were a resident's Primary Care Physician (PCP), she stated "yes". Observation, on 09/19/12 at 10:09 AM, of Resident #2's skin assessment revealed the resident had an area/nodule on the vagina. Interview during the skin assessment with Licensed Practical Nurse (LPN) #4 revealed the area/nodule was approximately six (6) centimeters and was a Squamous Cell [MEDICAL CONDITION]. Record review revealed the facility admitted Resident #2 on 07/21/98, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 07/02/12, revealed the facility assessed the resident to be severely impaired with daily decision making, and to have long term and short term memory problems. Additionally, review of the record revealed no documented evidence of the area/nodule on the weekly skin assessments, Nurse's Notes, and Weekly Pressure and Weekly Non-Pressure Skin Condition Reports from 01/01/09 to 09/01/12 Review of the Admission History and Physical (H&P), dated 07/21/98, revealed no documented evidence of the area/nodule. Review of an H&P dated 03/21/07, revealed no documented evidence of an area/nodule to Resident #2's vagina. Further review of the record revealed no documented evidence the Physician was notified of the area/nodule to Resident #2's vagina until 09/04/12 when the area/nodule began to bleed. The facility provided an acceptable credible Allegation of Compliance (AOC) on 09/27/12 that alleged removal of the IJ effective 09/27/12. Review of the AOC revealed the facility implemented the following: 1) On 09/25/12, a Nurse Practitioner conducted education with facility licensed nurses on performing skin assessments, with emphasis on notable findings that require Physician and family notification. Education included, but was not limited to, notification guidelines and documentation of objective findings. Notable findings included, but were not limited to, Pressure Ulcers, Arterial Ulcers, Diabetic Neuropathic Ulcers, [MEDICAL CONDITION] Ulcers, Surgical Wounds, Skin Tears, Lacerations, Abrasions, Bruises, Burns, Rashes, or a Lesion associated with bleeding, itching, burning, discoloration and/or raised. On 09/25/12 through 09/26/12, after receiving education from the Nurse Practitioner on 09/25/12, the Assistant Director of Nursing Services (ADNS), Staff Development Coordinator (SDC), and/or Shift Supervisor conducted this education with licensed nurses. The Weekend Supervisor received education from the ADNS on 09/26/12. 2) Head-to-toe skin assessments were performed on all but two (2) residents from 09/25/12 through 09/26/12 by licensed nurses. Two (2) residents refused the skin assessments. Notable findings were communicated to the Physician and family on 09/26/12. Notable findings included, but were not limited to, Pressure Ulcers, Arterial Ulcers, Diabetic Neuropathic Ulcers, [MEDICAL CONDITION] Ulcers, Surgical Wounds, Skin Tears, Lacerations, Abrasions, Bruises, Burns, Rashes, or a Lesion associated with bleeding, itching, burning, discoloration and/or raised. The findings were documented by the licensed nurse, and communicated to the Physician and family for further follow-up. The licensed nurse was responsible to communicate findings and document findings in the residents' medical record. No licensed nurse would be allowed to work after 09/26/12, without having received the education from the ADNS, SDC, Shift Supervisor, and/or Weekend Supervisor. The procedure for conducting a skin assessment will be included in the orientation of new hires for licensed nurses. The facility does not employ contract employees. If the facility were to employ contract employees, the licensed nurses would receive the education before being allowed to work in the facility. 3) Notices were posted at each nursing station on 09/26/12 for all State Registered Nursing Assistants (SRNAs) to immediately report any change in a resident's skin condition to the nurse. SRNAs were to report new and/or unusual findings to the licensed nurse at the time of visualization. 4) A Performance Improvement Committee (PIC) meeting was held on 09/21/12 to review the Immediate Jeopardy. The Medical Director was notified of the Immediate Jeopardy on 09/21/12. Another PIC was held on 09/26/12, the Medical Director was notified and approved the action plan. The PIC reviewed and approved the Allegation of Compliance (AOC). The PIC was to ensure validation of the AOC by: discussing areas of concern identified through audits; creating corrective action plans for any areas of concern identified, this will be assigned by the Executive Director (ED) as concerns are identified; and meeting weekly or more often as necessary until the facility had demonstrated substantial compliance with the corrective actions described in the AOC. Additionally, a corrective action plan will be developed by members of the PIC for any areas identified as not in compliance with the AOC. The facility will then return to routine monthly meetings. On 10/03/12 the State Survey Agency verified the Immediate Jeopardy was removed on 09/27/12 and the facility implemented corrective actions as alleged in the AOC, effective 09/27/12 based on the following: Review of the facility's inservice on skin assessment revealed nursing staff were educated on the performance of skin assessments and on the identification of skin abnormalities to include [MEDICAL CONDITION]. Review of the Attendance Rosters revealed the Director of Nursing Services (DNS), both Assistant Directors of Nursing Services (ADNS), the Quality Assurance (QA)Nurse, all the Unit Managers, Staff Development Coordinator (SDC), Shift Supervisors and Weekend Supervisor received education on 09/25/12 on performing skin assessments and Physician Notification; then performed inservice training of other licensed staff, forty-six (46) RNs and LPNs, on 09/25/12 and 09/26/12 related to skin assessments and Physician Notification. Review of the skin assessment forms revealed all facility residents had skin assessments performed from 09/25/12 through 09/26/12 by licensed nurses, except two (2) who refused. Review of the Physician notifications revealed the Physician was notified of the findings of the skin assessments and new orders were obtained as necessary. Review of the family notifications revealed families were notified of the findings of the skin assessments by the licensed nurses. Review of the residents' Care Plan Update forms revealed residents' care plans were updated with the findings of the skin assessments and any new physician's orders [REDACTED]. Interview, on 10/03/12 at 7:45 PM, with the Evening Supervisor revealed she had been trained on skin assessments, documentation of these, and Physician notification on 09/25/12. She stated she then inserviced 3:00 PM to 11:00 PM and 11:00 PM to 7:00 AM shift staff prior to starting their shift. Telephone interview on, 10/03/12 at 7:30 PM, with the Weekend Supervisor revealed he had received training on skin assessments, documentation related to these, and Physician notification. Interview, on 10/03/12 at 7:35 PM, with the Assistant Director of Nursing Services (ADNS) for the A and B units, revealed she had received inservice training on 09/25/12 from a Nurse Practitioner related to performing skin assessments, documentation, and Physician notification. She stated she was trained on inservicing other licensed staff, and had done so. Interview, on 10/03/12 at 8:00 PM, with the Staff Development Coordinator (SDC) revealed an Advanced Practice Registered Nurse (APRN) had educated her, the Unit Managers, Director of Nursing Services (DNS), and both ADNS' on skin assessments, documentation, and Physician Notification. She stated the other licensed staff were then trained by herself, or one of the others who had received the APRN's training. Interviews with licensed nursing staff on 10/02/12, on the 3:00 PM to 11:00 PM shift, on the A unit at 7:20 PM (LPN #31), at 7:45 PM (LPN #22), on the B unit at 7:20 PM (LPN #28), 7:25 PM (LPN #14); the C unit at 7:20 PM (LPN #2), revealed they had received inservice training on the performance of skin assessments, documentation of these, and Physician notification. Interview with licensed nursing staff on 10/02/12 on the D unit, at 7:15 PM (LPN #29) revealed she was an as needed (PRN) staff person and had just received the inservice training on skin assessments, documentation of these, and Physician notification prior to starting her shift that day. Telephone interviews with licensed nursing staff, on 10/03/12 on the 11:00 PM to 7:00 AM shift, on the A unit at 1:32 AM (RN #6); on the C unit at 1:43 AM (RN #7); and on the D unit at 1:50 AM (LPN #26), revealed they had received inservice training on how to perform skin assessments, document these, and on Physician notification. Interviews with licensed nursing staff on 10/03/12, on the 7:00 AM to 3:00 PM shift, on the A unit at 2:48 PM (LPN #15), at 2:55 PM (LPN #32); on the B unit at 11:45 AM (LPN #3), at 11:30 AM (LPN #13); on the C unit at 10:35 AM (LPN #1), at 12:05 PM (RN #8); on the D unit at 10:05 AM (LPN #7) revealed they had all had training on skin assessments, documentation of these, and Physician notification. Observation, on 10/02/12 and 10/03/12, revealed a sign at each nurse's station that stated, "ALL NEW SKIN CONDITIONS AS WELL AS CHANGES IN EXISTING AREAS NEED TO BE REPORTED TO THE NURSE IMMEDIATELY!!!!!!!!". Review of the facilities Performance Improvement Committee (PIC) meeting minutes revealed meetings were held on 09/21/12 to discuss the Immediate Jeopardy and on 09/26/12 to discuss and approve the Allegation of Compliance (AOC) to implement plans of correction to remove the IJ. Interview, on 10/03/12 at 8:40 PM with the Executive Director (ED) revealed she had participated in formulating and writing of the AOC, along with the DNS, Nurse Consultant, Quality Assurance (QA) Nurse, and Medical Director. She stated they had reviewed the cited deficiencies and developed the abatement plan. She ensured the skin assessments were performed as per the AOC, the Physician and family notifications were performed, and all licensed staff received the inservice training. The facility remained out of compliance at a lower scope and severity of a "D", an isolated deficiency with potential for more than minimal harm in order for the facility to develop and implement the Plan of Correction (POC).

Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to provide care for residents that maintained or enhanced each resident's dignity and respect for five (5) of forty-five (45) sampled residents (Residents #2, #11, #27, #34 and #45). The facility's failure, caused a negative psychosocial outcome for these residents, which resulted in actual harm. Resident #2 did not receive incontinence care in a timely manner after having loose stool on 02/23/12. The resident was noted to be crying and moaning during perineal care. Resident #11 had a loose stool incontinent episode in February 2012 while waiting for staff to respond to his/her call bell. Interview with Resident #11 revealed it made him/her feel like a dog. Interview with Resident #27 revealed he/she had incontinent episodes "about every couple of weeks" while waiting on staff to respond to the call bell and he/she felt "embarrassed". Resident #34 received a bed bath instead of a shower on 04/15/12. Interview with the resident revealed he/she woke up and smelled something "rank". Resident #45 received bed baths instead of showers for four (4) of the scheduled six (6) shower days. Interview with the resident revealed he/she did not feel as clean unless he/she had a shower early in the morning and he/she felt "awful". The findings include: Review of the facility's policy entitled "Call Light, Use Of", dated 09/23/03, revealed staff was to identify the location of the light, and answer the resident promptly. Review of the facility's policy entitled "Activities of Daily Living", with a revision date of 01/04/12, revealed Activities of daily living include the resident's ability to bathe and toilet. Further review of the policy revealed a resident's abilities in activities of daily living should not diminish unless the deterioration was unavoidable. Continued review of the policy revealed a resident's preferences should be respected and reasonable accommodations should be made to maximize the resident's functional abilities. Review of the facility's policy entitled "Angel Care", dated 04/26/10, revealed the Angel Care Program was a proactive approach to address requests or concerns before they become a complaint or grievance. Further review of the policy revealed staff was assigned to be "Angels" and responsible for assigned rooms. The "Angels" were to visit the assigned residents two (2) to three (3) times per week and document a note of the visit. In addition, during the visits the "Angel" should cover any concerns the resident had related to staff members or the facility's services. During a resident group meeting with six (6) alert and oriented residents, on 03/27/12 at 3:30 PM, Resident #27 indicated sometimes aides were slow answering call bells, especially on the 3:00 PM to 11:00 PM shift. Further interview revealed it took approximately twenty (20) minutes for call bells to be answered. 1. Review of Resident #2's medical record revealed the facility admitted the resident on 12/27/07, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 01/31/12, revealed the facility assessed the resident as moderately impaired in cognitive skills for decision making, as requiring extensive assistance of one staff for transfers and toileting, and as always continent of bowel and bladder. Review of the Bladder Evaluation, dated 02/17/12, revealed the resident was assessed to have Stress Incontinence and Functional Incontinence and was usually continent with occasional episodes of incontinence. Review of the Bowel Evaluation, dated 02/17/12, revealed the resident required two (2) to assist with transfers, was able to tell the need to defecate, and was to be toileted every two (2) hours and as needed. Review of the Comprehensive Plan of Care, with a problem date of 01/30/09, revealed the resident had an alteration in elimination related to requiring assistance with toileting and had further declines in continence secondary to decreased mobility and impaired cognitive status. The goal stated the resident would have no more than seven (7) episodes of bladder incontinence a week and no more than two (2) episodes of bowel incontinence with interventions. The interventions included toileting Resident #2 every hour and as needed with the assistance of one person. Review of the facility's abuse investigation, dated 02/23/12, revealed Certified Nursing Assistants (CNA) #9 and CNA #10 were caring for another resident at the time Resident #2 needed incontinence care. Further review revealed Resident #2 became agitated when the CNAs explained they would be with her/him in a few minutes as they were providing care for an unsampled resident. The investigation stated Resident #2's agitation increased and the resident began mumbling, and the CNAs could not understand her/him. The CNAs provided incontinence care as well as toileted the resident and set the resident up for her/his lunch tray. Further review revealed the Speech Therapist came in to work with Resident #2 during the lunch meal and Resident #2 starting crying and stated "they were mean to me" and the Resident indicated it was CNA #9 and CNA #10. An interview was attempted with Resident #2 with the assistance of a CNA, on 03/27/12 at 12:40 AM, however Resident #2 had slurred speech. Interview with CNA #9, on 03/29/12 at 9:15 AM, revealed Resident #2 was waiting with Licensed Practical Nurse (LPN) #3 in the hallway while he and CNA #10 finished giving a shower to an unsampled resident. CNA #9 further revealed Resident #2 had an incontinent episode with a loose stool. He stated the resident was moaning during incontinence care and upset as she/he was usually continent. Further interview with CNA #9, on 05/09/12 at 2:50 PM, revealed Resident #2 had to wait approximately ten (10) minutes for incontinence care. He stated there were two (2) CNAs on the unit at the time. Interview with CNA #10, on 03/29/12 at 12:50 PM, revealed she and CNA #9 were assisting an unsampled resident in the shower room and couldn't get to Resident #2 quick enough. She further stated, Resident #2 was crying when they finally got to him/her as he/she had a bowel movement. Further interview, on 05/10/12 at 3:00 PM, with CNA #10 revealed Kentucky Medication Aide (KMA) #1 was the staff member who informed her and CNA #9 of Resident #2 needing to be toileted. She stated it took approximately five (5) minutes before they were able to check on Resident #2 and the resident was incontinent of a diarrhea stool. Continued interview revealed Resident #2 needed two (2) to assist with transfer at that time due to her/his legs were wobbly. Interview, on 05/10/12 at 4:00 PM, with KMA #1 revealed Resident #2 told her, while she was administering medications, to "come here" and informed her that she/he either needed incontinence care or needed to go to the bathroom. She stated she informed CNA #9 and CNA #10 who were both assisting an unsampled resident with a shower. Further interview revealed at that time, Resident #2 needed two (2) to assist with transfers and she was unable to find anyone to assist her with transferring Resident #2. She stated the only CNAs on the unit were giving a shower, LPN #3 was in a meeting, and although she went to the Reflections unit for help, all the staff was busy. She further stated she went to Resident #2's room to inform her/him they would be there soon when CNA #9 and CNA #10 arrived in the resident's room to assist. She stated she was unsure of exactly how long it took before help arrived after the resident's request for assistance; however, she thought it was one (1) to two (2) minutes. Interview with LPN #3/Unit Manager, on 03/28/12 at 2:05 PM, revealed she occasionally had complaints from residents about not getting to the bathroom in time, but it was infrequent. Further interview revealed she did not remember anything unusual or hectic on the day of the alleged incident. Interview, on 05/11/12 at 5:15 PM, with the Director of Nursing (DON) revealed if a resident indicated he/she needed to go to the bathroom or needed incontinence care they would need assistance in a timely manner. She stated ten (10) minutes would be too long to wait if a resident had an incontinent episode of stool and further stated KMA #1 could have gone to the "C" wing which was attached to the "D" wing for assistance. 2. Review of the medical record revealed the facility admitted Resident #11 to the A-Wing Rehab Unit, on 01/31/12, with [DIAGNOSES REDACTED]. Review of Resident #11's Admission MDS Assessment, dated 02/07/12, revealed the facility assessed the resident as being cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15/15, as being continent of bowel, utilizing a catheter for bladder, and requiring the total assistance of two (2) or more persons for toileting. Review of Resident #11's Comprehensive Plan of Care, dated 01/31/12, revealed Resident #11 had problems providing self care and was dependent upon others for daily care needs related to being in a car accident in December of 2011. Individualized approaches to the plan of care included catheter care for urine and monitor bowel movements related to being at risk for constipation due to decreased mobility and medications. Review of the Certified Nursing Assistant (CNA) assignment/flow sheet, with an origination date of 01/31/12, revealed Resident #11 was continent of bowel. Interview with Resident #11, on 03/29/12 at 2:00 PM and on 04/20/12 at 10:45 AM, revealed he/she rang the call light one evening about a month ago (sometime in February) and it took an hour and a half before anyone came to the room and his/her bowels had moved while waiting. Resident #11 stated he/she could not wait that long and he/she felt like a "dog, because a dog is locked up in a house and has to rely on someone to let it out to go to the bathroom and when that doesn't happen the dog has an accident and feels ashamed". Review of Resident #11's Flow Sheet Record, for 02/01/12 through 02/29/12, revealed Resident #11 was continent of bowel except for two (2) incontinent episodes where the resident had loose stool on 02/10/12 and 02/19/12 during the three (3) PM to eleven (11) PM shift. Interview with CNA #12, on 04/20/12 at 11:40 AM, revealed Resident #11, as well as other residents on the A-Wing were in their "right mind" and they knew what they needed so when they used the call bell they needed it answered right away. Further interview revealed one evening in February, Resident #11's call bell was going off but she was already in a room assisting another resident to the toilet. It was about thirty (30) minutes before she could get to the resident, and by the time she got to Resident #11, the resident had a large loose bowel movement. Further interview revealed when one staff person was on break that left only two people to answer call bells. Additional interview revealed if she was already in a room with a resident then she would have to complete that task and wait until there was another aide available to assist her with a resident who required a two person assistance to the toilet. Interview with CNA #28, on 04/20/12 at 4:00 PM, revealed there was one time during her evening shift in February when she responded to Resident #11's call bell in less then five (5) minutes but the resident had diarrhea prior to her getting to the resident's room. She indicated CNA #12 came to assist her shortly after with incontinence care for Resident #11. Further interview revealed she was unaware of any other time when the resident had an incontinent episode. Interview with RN #2, on 05/08 at 2:15 PM, revealed she was the Unit Manager of the A-Wing Rehab Unit as well as Resident #11's "Angel". RN #2 indicated she made rounds on her unit daily as well as twice weekly talking with Resident #11 related to any concerns the resident might have. RN #2 stated Resident #11 was an outspoken person and if there had been any concerns the resident would definitely had let her know. A review of RN #2's documented visitations with Resident #11 revealed there were no documented concerns voiced by Resident #45 related to having an incontinent episode due to having to wait for staff to answer the call bell. 3. Review of the medical record revealed the facility readmitted Resident #27 to the D-Wing Rehab Unit, on 02/09/12, with [DIAGNOSES REDACTED]. The facility assessed Resident #27, in a Significant Change MDS Assessment, dated 02/16/12, as being cognitively intact with a BIMS score of 15/15, as requiring extensive assistance of two (2) people for toilet use, and was frequently incontinent of bowel and bladder. Review of the Urinary Incontinence Care Area Assessment Summary (CAAS), dated 02/22/12, revealed Resident #27 was temporarily incontinent related to not being able to get to the toilet in time due to physical disability, external obstacles or problems thinking or communicating. Further review of the CAAS revealed Resident #27 was expected to regain full control of his/her bladder when he/she was more mobile and self sufficient. Additional review of the CAAS as well as the Comprehensive Plan of Care, dated 02/24/12, revealed Resident #27 was encouraged to call for help at the first indication of the need to void rather than waiting until the urge was strong. Review of Nurse's Notes, dated 03/31/12 at 2:45 PM, revealed when the nurse asked Resident #27 if he/she had a Certified Nursing Assistant (CNA) assist him/her to the toilet that morning the resident stated "No, I had my call light on for a long time and no one came to help me so I put myself on the toilet". Further review of the Nurse's Notes revealed the CNA had come once during the night to help, but no one had come that morning. Additional review of the Nurse's Notes revealed the nurse discussed with Resident #27 the importance of waiting for staff to come and assist him/her when needed. An interview conducted with Resident #27, on 03/29/12 at 1:15 PM, revealed he/she "sometimes" had to wait thirty (30) minutes for staff to respond to his/her call light, and that he/she had incontinent episodes "about every couple of weeks" while waiting on staff to respond. He/she revealed his/her longest waits had been on the three (3) to eleven (11) shift, usually around 10:00 PM, and that he/she felt embarrassed with him/her self and upset with staff when he/she was incontinent. Interview, on 05/10/12 at 3:00 PM, with LPN #14 who wrote the Nurse's Notes dated 03/31/12 at 2:45 PM, revealed Resident #27 complained he/she had the call bell on and was not checked on for a long period of time on the night shift on 03/30/12. Further interview revealed CNA #9 was the CNA assigned to him/her. The LPN stated she did not think she mentioned the call bell issue to the DON or ADON. Interview, on 05/09/12 at 2:45 PM, with Certified Nursing Assistant (CNA) #9, who was assigned to Resident #27 on 03/30/12, during the night shift, revealed he had never witnessed Resident #27 to be incontinent as she/he used the bed pan during the time he/she had a fractured foot and the resident was always up out of the bed by 4:30 AM per his/her request. He denied not checking on the resident through the night and not anwering the call bell. He further stated, he was the only CNA when he worked the "D" Wing and he did rounds including incontinence care at 12:30 AM, 3:00 AM and 5:30 AM. Continued interview revealed he had to help with rounds on the Reflections Unit also nightly because there was only one CNA on the night shift on the Reflections Unit and the residents on that unit sometimes had behaviors. Continued interview revealed Licensed Practical Nurse (LPN) #13 usually worked when he was working and would not answer call bells when he was off the unit. He stated he could hear bells ringing when he was off the unit and did not think it was safe because the bed alarms and call bells were not answered promptly by this nurse. Further interview revealed he had taken this matter to the Assistant Director of Nursing (ADON) and Licensed Practical Nurse (LPN) #3/Unit Manager. Interview, on 05/10/12 at 7:00 PM, with LPN #13, who worked the night shift on 03/30/12 according to the schedule, revealed there was she and two (2) aides to cover the "D" wing for the Reflections Unit and rooms outside the Reflections Unit on the night shift. She stated Resident #27 had never complained to her about call bells not being answered and the resident was checked on more frequently than every two (2) hours at the time he/she fractured his/her foot and was unable to toilet self. She stated she did not do incontinence rounds with the CNAs; however, she would cover the Reflections Unit if the CNA from the Reflections Unit was needed to assist with a resident who required a two (2) person transfer or position in bed. She further stated she always answered call bells and did rounds every two (2) hours to ensure call bells were in reach, water was in reach and incontinence care had been completed. Interview, on 05/08/12 at 12:30 PM and on 05/09/12 at 4:15 PM, with LPN #3/Unit Manager where Resident #27 resided revealed she had not received complaints related to not being able to complete care or call bells not being answered, and she felt there was adequate staff on all three (3) shifts for the "D" Wing. Interview, on 05/09/12 at 3:20 PM, with the Assistant Director of Nursing, revealed there was sixteen (16) resident on the "D" Wing outside of the Reflections Unit, and there was one (1) nurse and one (1) aide on the night shift. He stated he did not remember being notified of any concerns related to staffing or call bells being answered for this unit. 4. Review of the medical record revealed the facility admitted Resident #34 to the A-Wing Rehab Unit, on 04/09/12, with [DIAGNOSES REDACTED]. Review of the Admission Nursing Evaluation, dated 04/09/12, revealed Resident #34 was alert and oriented and had a BIMS score of 15/15, required assistance of two (2) for transfer and bed mobility and needed physical help in part of bathing activity. Review of an initial plan of care, dated 04/09/12, revealed Resident #34 was to have a shower for personal hygiene. Review of the CNA Assignment/Flow sheet revealed Resident #34 was to have a shower on Wednesdays and Sundays during the 7 AM-3 PM shift. Interview with Resident #34, on 04/17/12 at 3:45 PM, revealed he/she had been at the facility for nine (9) days and had only had one (1) shower. Further interview revealed he/she should have had a shower two (2) days ago (Sunday) but there wasn't enough staff to get him/her up and take him/her to the shower. Resident #34 indicated he/she woke up this morning and smelled something "rank". He/she stated the CNAs were all nice to him/her and tried to do the best they could with how many people they had to take care of, and he/she didn't want to get the CNAs in trouble. Review of Resident #34's Nurse Aide Flow Sheet Record, from 04/09/12 through 04/20/12, revealed Resident #34 was given a shower during the 3 PM-11 PM shift on Wednesday (04/11/12) and a bed bath on Sunday (04/15/12). Interview with Resident #34's family while in the room with Resident #34, on 04/17/12 at 4:00 PM, revealed Resident #34 had bowel movements up and down the resident's back on Wednesday (04/11/12) at approximately 7:30 PM when they visited Resident #34 and staff stated they were going to give the resident a bed bath. The family indicated staff had told them the first shift did not have time to give the resident a shower and the resident was suppose to get a shower on the 3 PM-11 PM shift, but they didn't have time to have two (2) CNAs get him/her up with the mechanical lift and take him/her to the shower. The family stated they went to the nurse's station and had to argue with staff and demand to give Resident #34 a shower because he/she "smelled rank and like[***]. Additional interview revealed they finally gave Resident #34 a shower around 10:00 PM. The family continued that today (04/17/12) they walked in and he/she smelled "stinky" because he/she was only given a bed bath on Sunday (04/15/12) so they were going to have to give him/her a bed bath and demand another shower. Interview with CNA #12, on 04/20/12 at 11:40 AM, revealed she worked all three (3) shifts. CNA #12 indicated on Sunday (04/15/12) the first shift did not have time to give the resident a shower and it was probably because he/she was a mechanical lift and they put if off onto second shift. Additional interview revealed she worked second shift on 04/15/12 and didn't have time to give the shower either, so she gave the resident a bed bath because that wouldn't take as much time or require the assistance of two (2) CNAs. Additional interview, on 05/07/12 at 3:00 PM, revealed some CNAs would say or document that a resident had refused a shower because they didn't want to get in trouble for only giving a bed bath and not a shower. Interview with CNA #28 and CNA #34, on 04/20/12 at 12:00 PM, revealed Resident #34 had refused a shower during the 7 AM- 3 PM shift on 04/15/12 and stated a bed bath would be fine. Review of NNs and the Nurse Aide Flow Sheet Record, for 04/15/12, revealed no documented evidence Resident #34 had refused a shower. Interview with Registered Nurse (RN) #3, on 05/11/12 at 2:15 PM, revealed she was told by the CNAs Resident #34 refused a shower and he/she received a bed bath. Further interview revealed she was unaware Resident #34 had wanted a shower instead of a bed bath. RN #3 indicated if the CNAs needed help with getting the resident to the shower because the resident was a two (2) person assist then they could let her know and she could have assisted. Interview, on 05/08/12 at 2:55 PM, with the Registered Dietitian (RD), who was Resident #34's "Angel", revealed she visited Resident #34 twice a week since admission and no concerns had been brought to her attention related to the resident not getting a shower. Review of the RD's bi-weekly visitations with Resident #34, from 04/09/12 through 04/30/12 revealed there were no concerns voiced by Resident #34 related to not getting a shower. 5. Review of the medical record revealed Resident #45 was readmitted to the A-Wing Rehab Unit of the facility, on 03/23/12, with [DIAGNOSES REDACTED]. Review of an Admission MDS, dated [DATE], revealed the facility assessed Resident #45 as having no behaviors, required extensive assistance of one person for personal hygiene, physical help in part of bathing, and had a BIMS score of 14/15, which indicated the resident was cognitively intact. Review of the Comprehensive Plan of Care for Resident #45, dated 04/09/12, revealed Resident #45 was to be taken to the shower room two (2) times per week and as needed. Review of the CNA Assignment/Flow Sheet for Resident #45, not dated, revealed Resident #45 was to be taken to the shower room on Mondays and Thursdays during the 7 AM-3 PM shift and the resident was to "get up by 10:00 AM daily". Review of Resident #45's Nurse Aide Flow sheet Record, from 04/01/12 through 04/20/12, revealed Resident #45 only received a shower on two (2) of the scheduled six (6) days. Resident #45 received a shower on Monday, 04/09/12 and 04/16/12, and did not receive a shower on Monday (04/02/12), or Thursdays (04/05/12, 04/12/12 and 04/19/12). Observation, on 04/20/12 at 2:00 PM, revealed Resident #45 was sitting up in his/her wheelchair in the dining/activity area of the C-Wing. Interview with Resident #45 at that time revealed he/she did not feel clean and felt "awful". Resident #45 indicated he/she was suppose to have a shower early that morning, but staff was busy giving a shower to another resident and he/she did not want to wait to have a shower after 10:00 AM because he/she liked going to the 10:00 AM activity or morning therapy group exercise. Further interview revealed Resident #45 had to miss getting a shower almost once a week due to the facility not having enough staff to give him/her a shower in the morning as he/she preferred. Resident #45 indicated he/she did not feel clean unless he/she had a shower and he/she felt "awful". Review of Nurse's Notes (NN), dated 04/27/12, revealed Resident #45 refused a late morning shower related to wanting to go out to eat with Activities. Review of NNs, dated 05/03/12, revealed Resident #45 refused a shower after being informed a shower would not be given until after lunch. Further review of the NNs revealed the resident stated he/she wanted showers in the morning. Review of NNs, dated 05/07/12, revealed Resident #45 requested to have a bed bath that morning related to not wanting to wait for a shower. During an interview with RN #3, on 05/11/12 at 2:15 PM, RN #3 revealed it was difficult for the CNAs starting work at 7:00 AM to give a resident a shower because they had to get residents up and ready for breakfast. Further interview revealed if a resident wanted an early morning shower it would have to be given around 6:00 AM. RN #3 indicated Resident #45 should get a shower early in the morning if that was his/her preference. Interview, on 05/08 at 2:55 PM, with the Registered Dietitian (RD), who was Resident #45's "Angel", revealed she visited Resident #45 two (2) times a week since admission and no concerns had been brought to her attention related to the resident not getting a shower. Additional interview revealed the only concern Resident #45 had was related to wanting his/her food preferences changed. Review of the bi-weekly visitations with Resident #45 revealed there was only one (1) concern voiced by Resident #45 related to wanting his/her food preferences changed. Interview with CNAs #28 and #33, on 04/20/12 at 3:30 PM, revealed residents on the A-Wing Rehab Unit were more "needy" and it was difficult to meet all the residents' needs and sometimes showers couldn't be given during the scheduled first shift so they had to verbally inform the second shift a resident needed to be given a shower. Additional interview revealed Resident #34 and #45 were large people and required the use of a mechanical lift and two (2) CNAs to take the residents to the shower room. Further interview revealed if there were only three (3) CNAs on the unit then this could not always be done because that would leave only one (1) CNA to take care of the needs of the other twenty-nine (29) residents. Continued interview revealed Resident #45 wanted to take his/her shower earlier in the morning because the resident enjoyed going to the morning group activity and if they didn't have time to take the resident before 10:00 AM, the resident would refuse the shower and would accept a bed bath. Interview with CNA #6, on 04/16/12 at 9:15 PM, revealed it was difficult to answer the call bells, give showers, assist residents to the toilet, and feed residents with only having three (3) CNAs on the A-Wing Rehab Unit. Further interview revealed sometimes showers were missed, especially for residents who required a mechanical lift with assistance of two staff. She indicated if showers could not be given then the on-coming shift would be given a verbal report as to who still needed showers, or the residents would be given a bed bath. Interview with LPN #10, on 04/16/12 at 9:55 PM, revealed she felt like the A-Wing Rehab Unit needed four (4) CNAs because with only three (3) CNAs they had to rush through everything and didn't have time to interact with residents. An interview with CNA #26, on 04/18/12 at 3:40 PM, revealed she didn't feel like she had enough time to get everything done during her 3:00 PM to 11:00 PM shift on the A-Wing Rehab Unit. She indicated she usually had to stay over to complete her work, seldom getting out on time. CNA #26 revealed sometimes showers were missed, and if she was unable to get something completed she would tell the on coming staff. An interview with CNA #11, on 04/17/12 at 3:50 PM, revealed she took over and helped with staffing about three (3) weeks ago. She indicated she felt resident care suffered as a result of being understaffed, with no time available to talk to residents. Further interview revealed the facility only scheduled three (3) CNAs on the A-Wing and D-Wing Rehab Unit per budget, but there really needed to be at least four (4) CNAs on each unit to meet the residents' needs. Additional interview revealed some CNAs worked a lot of overtime and were exhausted and couldn't always meet residents' needs. Interview with the Administrator and Director of Nursing, on 04/19/12 at 3:00 PM, revealed they were not aware of any residents' complaints of call bells not being answered timely before residents had incontinent episodes, or complaints that residents did not receive their scheduled showers. Further interview revealed the facility had an "Angel Program" where management staff was assigned a certain number of residents and each staff was to check on the resident at least two (2) times per week for any concerns. Additional interview revealed if there were concerns, staff was to discuss it during the morning "stand-up" meetings, but nothing had been discussed related to call bells not being answered timely, or showers not being given.

Based on observation, interview, record review, and review of facility policies, it was determined the facility failed to ensure residents received adequate supervision to prevent accidents for two (2) of twenty-two (22) sampled residents (Residents #1 and #4). On 07/02/11, Resident #1, who the facility assessed as having Dementia and multiple safety risks, left facility grounds without facility staff's knowledge or supervision. The resident was found approximately three-tenths mile from the facility on the highway in a wheelchair. The facility failed to provide supervision as specified in their smoking policy to Resident #4 while smoking on 07/10/11. This failure prevented the facility from ensuring safety to its residents. Resident #4 was outdoors smoking unsupervised, and assisted an intoxicated drug-seeking individual to enter the facility without staff knowledge. These facility failures placed residents at risk for serious injury, harm, impairment, or death. Immediate Jeopardy and Substandard Quality of Care were determined to exist on 07/02/11. An acceptable Allegation of Compliance was received on 07/20/11, which alleged removal of Immediate Jeopardy on 07/21/11. The State Agency determined the Immediate Jeopardy was removed on 07/21/11, prior to exit, which lowered the scope and severity to "D" while the facility monitors the effectiveness of the systemic changes and quality assurance activities. The findings include: A review of the facility's Accidents and Supervision to Prevent Accidents policy/procedure (revised 04/28/11), Patient Supervision and Monitoring policy/procedure (revised 04/28/11), and Smoking policy/procedure (revised 04/28/11) revealed the facility would provide supervision to each resident to prevent avoidable accidents, and assess residents to determine if supervision was necessary. The policies stated the facility would clearly define mechanisms and procedures which help to mitigate the risk of a resident leaving a safe area without staff supervision. The policies included center-focused and patient-directed approaches to evaluate accident risks as well as monitoring processes to ensure interventions were implemented and effective related to resident supervision, smoking, resident risks, and environmental hazards to include falls and unsafe wandering or elopement. The policies directed that residents would be provided supervision when smoking outdoors after sunset and before sunrise, and when the resident presented with conditions that placed themselves or others at risk for harm. 1. Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident #1's Care Area Assessment (CAA) dated 04/12/11, and Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #1 as severely cognitively impaired, only able to make simple wishes known, only able to sometimes understand, and to utilize a wheelchair for all mobility. Resident #1's Comprehensive Care Plan, dated 06/29/11, indicated the resident had decreased safety awareness, displayed crying and tearfulness, had repetitive questions/verbalizations, and voiced anxious complaints/concerns. The intervention listed on the Care Plan was to have staff assess Resident #1 for suicidal tendencies as indicated. In addition, the facility assessed Resident #1 to be at increased risk for falls, and staff was to observe the resident for attempts to self-transfer and provide the resident with increased and close supervision. Although the facility's comprehensive assessments identified numerous supervision and safety risk factors for Resident #1, a review of a Wander/Elopement Risk Evaluation completed on 04/03/11, for Resident #1 indicated the resident displayed no risk factors for elopement, which included assessing the resident to have no cognitive impairment or impaired decision-making skills that decreased his/her awareness of safety. The evaluation also indicated the resident expressed no desire to leave the facility. However, a review of the facility's investigation (undated completion) and interviews with LPN #1 on 07/11/11, at 5:00 PM, and 07/13/11, at 9:25 AM, on 07/12/11, at 10:30 AM, with CNA #2, and on 07/12/11, at 12:36 PM, with CNA #3 revealed Resident #1 had displayed behaviors of sitting by the C Wing exit doors frequently requesting to go out, attempting to go out when others would go in or out the doors, and at times push on the doors in an attempt to open them. The facility's investigation, interview with the Administrator and DON on 07/12/11, at 3:25 PM, and interview with LPN #1 on 07/11/11, at 5:00 PM, revealed LPN #1 was not assigned to care for Resident #1 on 07/2/11, but opened the door and assisted the resident outside to smoke while other residents were already outside smoking during a scheduled smoke break supervised by CNA #27. LPN #1 voiced being "concerned" about Resident #1 going outside to smoke due to being unfamiliar with Resident #1's needs. LPN #1 specifically recalled instructing CNA #27 to make sure Resident #1 was returned inside the building after smoking. However, CNA #27 reportedly failed to hear the nurse's instruction, and returned inside the building at approximately 4:45 PM, leaving Resident #1 outside unsupervised. The facility's investigation and interview with LPN #2 on 07/11/11, at 5:20 PM, revealed the facility failed to identify that Resident #1 had left facility property, and was unaware of the resident's whereabouts for approximately 30 minutes. LPN #2 stated that at approximately 5:15 PM, the facility began to receive numerous notifications from the community regarding an elderly individual "rolling down the highway" in a wheelchair. Interviews conducted with Police Officer #1 on 07/13/11, at 6:00 PM, and Police Officer #2 on 07/13/11, at 7:05 PM, detailed how at approximately 5:20 PM, the facility staff and Police located Resident #1 at approximately the same time, three-tenths mile from the facility on the highway in a wheelchair. Both Police Officers #1 and #2 described Resident #1's situation as "very dangerous" considering the facility's driveway was "downhill" and the resident "making it all the way" to the main highway. Police Officer #1 recounted having to escort Resident #1 back to the facility in a police cruiser due to the resident's refusal to cooperate with facility staff. Review of a Police Department Dispatching Report dated 07/02/11, revealed Resident #1 was returned to the facility at 5:30 PM on 07/02/11. Interview with Resident #1 on 07/11/11, at 4:15 PM, revealed the resident to be alert but unable to consistently answer questions appropriately. When questioned about the incident Resident #1 stated, "Honey, I wanted to go to (home town)," and indicated he/she had been "walking home." Resident #1 also voiced having made previous attempts to leave the facility "four or times." Resident #1 voiced a continued desire to leave the facility and return home firmly expressing, "No one is going to stop me." 2. A review of Resident #4's medical revealed on 06/24/11, the facility assessed the resident as having no cognitive impairment. A review of the resident's smoking evaluation dated 07/06/11, revealed the resident was an "Independent Smoker." According to the evaluation, "Independent Smoker" meant the resident could smoke in designated smoking areas, must follow the facility's smoking policy, may not carry his/her own smoking materials, and smoking outdoors after sunset and before sunrise must be supervised by a staff member (within line of sight). However, a review of Resident #4's care plan dated 04/06/11, revealed the resident required staff to be in attendance during smoking and to provide supervision at all times. An interview on 07/13/11, at 4:05 PM, with Resident #4 confirmed he/she was outside, unsupervised, smoking when a male approached the facility. According to Resident #4, staff was aware the resident was outside. The resident stated he/she often smoked outside unsupervised late at night. The resident stated he/she would hide cigarettes and lighters or would obtain lighted cigarettes from the ash tray after staff had discarded the cigarette. Resident #4 explained the male that approached the facility asked if nurses were present in the building and when Resident #4 acknowledged there were, the male stated, "I need to see the head nurse." Resident #4 stated, "I told him to push the red button and go in; I thought he was a visitor or something, I didn't know he was a drug addict." LPN #7 confirmed in interview on 07/13/11, at 3:50 PM, that on 07/10/11, at approximately 12:30 AM, the LPN returned from the bathroom and found a man at the medication cart who stated that he was an addict and needed drugs. LPN #7 told the male there were no drugs in the facility and suggested he go to the hospital. LPN #7 voiced being "terrified" and called the police after the male had exited the building. LPN #7 discovered after the male had exited the building that Resident #4 had been outside smoking unsupervised, and had instructed the male on how to enter the building through C Wing doors without staff knowledge. Interview with a Police Department Dispatcher on 07/13/11, at 2:45 PM, and review of a Police Department Dispatching Report dated 07/10/11, revealed on 07/10/11, at 12:33 AM, the Police Department received a call from LPN #7, who the dispatcher described as "very upset" because she had discovered a "strange man" in the facility standing at her medication cart requesting drugs. The dispatcher stated LPN #7 voiced the male had exited the building but had "no idea how he got in" the facility. Interview with Police Officer #3, who was dispatched to the facility, revealed the male was found walking near the facility and arrested for alcohol intoxication on 07/10/11, at 12:41 AM. Police Officer #3 stated the male was "obviously" intoxicated. Further interview with the Dispatcher revealed the LPN was contacted at 12:45 AM, and notified the male was no longer a threat to the facility. At that time the Dispatcher questioned LPN #7 as to how the male was able to gain entrance into the facility, and LPN #7 reportedly told the Dispatcher that a resident was outside smoking unsupervised when the male approached the facility and the resident instructed the male on how to enter the building. Interview with the DON on 07/13/11, at 5:00 PM, revealed he was notified on 07/10/11, of the incident, but had not initiated an investigation as to why Resident #4 was smoking outside unsupervised or as to how the male had gained access into the facility. The DON stated that he did not feel any residents had been in danger, and no further action was taken. While the facility had developed a care plan that required that staff supervision be provided at all times for Resident #4 while smoking, the facility failed to ensure the supervision was provided and failed to ensure the smoking policy was implemented by staff. An interview was conducted on 07/19/11, at 11:05 AM, with the District Director (DO), District Director of Clinical Operations (DDCO), and the newly appointed Administrator (Administrator #2). During the interview, the DDCO insisted there was "no reason for anyone to question" how the male had entered the building on 07/10/11, at approximately 12:30 AM. The DDCO stated the facility was "not a prison" and anyone could come and go in the facility at any time, day or night. The DDCO stated that A Wing doors and C Wing doors were unlocked at all times, and the only requirement for entering the building would be to "push the big red button (adjacent to the doors) which anyone could see and figure it out." The facility failed to identify an intoxicated drug-seeking male entering the facility at approximately 12:30 AM on 07/10/2011, as a situation which placed facility residents in danger. Additionally, the facility took no action to ensure resident safety by continuing to allow unlimited, unsupervised access into the facility at all times, day or night. While the facility had developed a care plan that required staff supervision be provided at all times for Resident #4 while smoking, the facility failed to ensure the supervision was provided and failed to ensure the smoking policy was implemented by staff. A review of the allegation of compliance revealed the following: On 07/02/11, a Licensed Practical Nurse (LPN) conducted a head to toe assessment of Resident #1 and no injuries were identified. On 07/02/11, Resident #1's comprehensive care plan was revised to include risk for wandering and elopement with interventions including a Wanderguard bracelet, 1:1 supervision; and being placed in the wander/elopement book. On 07/03/11, the Certified Nursing Assistant (CNA) Assignment Sheet was revised for Resident #1 to include risk for elopement, 1:1 supervision, and the implementation of a Wanderguard bracelet. On 07/02/11, the Medical Records Director (MRD) conducted an audit of all facility residents to validate that all assessments and care plans were current. On 07/03-04/11, the Director of Nursing Services (DNS), the Staff Development Coordinator (SDC), the Transitional Care Unit Program Director (TCUPD), Minimum Data Set Coordinator (MDSC), and Unit Managers (UMs) completed a wander/elopement risk evaluation and a safety risk assessment for all in-house patients. A smoking evaluation was conducted for all residents identified who smoke. Care plans were reviewed to ensure that all areas related to accident hazards/resident safety were care planned with appropriate interventions. On 07/03-04/11, the Reflections Program Director (RPD) conducted interviews of staff to determine if any resident had exhibited exit-seeking behaviors within the past 30 days, and if so, that all appropriate steps were implemented. On 07/03/11, a policy change was made and implemented to ensure that all residents who wished to go outside were accompanied by staff and that no resident was outside unattended. On 07/05/11 and 07/08/11, assessments were conducted on residents who requested to go outside. On 07/14/11, residents who requested to go outside were re-assessed and a policy change was made. The change was to assess residents upon their request to determine their ability to go outside independently without staff supervision. The resident must be assessed and must meet the assessment criteria prior to being allowed to go outside unsupervised. In addition, no resident is allowed to be outside between the hours of 11:00 PM and 6:00 AM without supervision, regardless of assessment status. On 07/02/11, the SDC, DNS, and Weekend Supervisor (WS) initiated education with all facility staff related to wandering, elopement, accident hazards, supervision, and policy change related to residents going outside without staff supervision, as no resident was to be outside without staff supervision. Education will be ongoing until all facility staff members have attended. On 07/15/11, this in-service was repeated with staff to include a policy change related to residents going outside without staff supervision, based on their individual resident assessment. Education will be ongoing until all facility staff members have attended. On 07/07/11, the Activities Director (AD) educated residents on door alarms, resident safety, and the need for residents to seek staff assistance with doors. On 07/02/11, the Maintenance Assistant (MA) audited all facility doors and Wanderguard bracelets to validate proper functioning. On 07/03/11, the MA changed the code for the door system and the Assistant Executive Director (AED) posted signage at all facility entrance doors to notify visitors that no resident was to be assisted outside the facility and to check with staff for the code, as it will change frequently. After 9:00 PM, all facility entrance doors have been and continue to be on a timed lock, except for A Wing and C Wing doors to allow staff and emergency entrance. Effective 07/20/11, the A Wing and C Wing outside entrance button will be disabled between 9:00 PM and 6:00 AM daily, until these entrance doors can be engineered with a timed lock during these hours. A doorbell has been installed at the entrance to A Wing and C Wing to be utilized by visitors and emergency personnel. The Maintenance Director (MD) initiated education with all facility staff on 07/20/11, related to the change in the door system. The Executive Director (ED)/Administrator will also validate through the weekly PIC meeting by review of the smoke time supervision audits, review of the wander/elopement audits, review of any environmental rounds, and implementation of the credible allegation. All event reports are reviewed daily by the ED and the DNS. Event reports are reviewed to identify any potential accident hazard related to environment and supervision. The District Director of Clinical Operations (DDCO) also reviews all resident events with the DNS on a weekly basis to identify any potential accident hazard related to environment and supervision. Effective 07/03/11, at least one resident smoke time is monitored daily by a Department Manager, as designated by the ED, to ensure that during smoke times there is one staff person to five residents, that other outside areas have no unattended residents, that any resident outside with a family member is signed out, and to identify any outside accident hazards. Any concerns were corrected immediately. This monitoring will occur daily until deemed unnecessary by the Performance Improvement Committee (PIC). Effective 07/03/11, the DNS or the SDC, or designee will conduct one wander elopement drill per month (alternating shifts) until deemed unnecessary by the PIC. The PIC will meet weekly or more often as necessary until the facility has demonstrated sustained compliance of the corrective actions described in the AOC. Members of the PIC include, but are not limited to, the ED, AED, DNS, SDC, MD, SSD, Nutrition Services Manager (NSM), Registered Dietitian (RD), AD, BOM, Case Manger (CM), RPD, and the TCUPD. Ad hoc PIC meetings were held on 07/04/11 and 07/15/11, to review the implemented corrective action. The surveyors validated the corrective action taken by the facility as follows: A review of the progress notes revealed a head to toe assessment was conducted for Resident #1 on 07/02/11, at 5:45 PM, with no injuries noted to the resident. A review of Resident #1's medical record revealed the resident's care plan was updated on 07/02/11, to include interventions for wandering and elopement. Observations conducted for Resident #1 on 07/22/11, at 2:38 PM, revealed the resident was being provided one to one supervision. An interview conducted with CNA #17 on 07/22/11, at 2:38 PM, revealed the resident was receiving one to one supervision due to being an elopement risk. A review of Resident #1's assignment sheet revealed interventions were implemented on 07/03/11, for one to one supervision and implementation of a Wanderguard bracelet. Interview conducted with CNA #17 on 07/22/11, at 2:38 PM, revealed the CNA was aware of the level of supervision and elopement risk for Resident #1. A review of the Wander/Elopement Risk Evaluations and Safety Risk assessment tools revealed a form had been completed for each resident on 07/03/11 and 07/04/11. Each resident who smoked had a smoking evaluation form completed and an updated care plan with interventions for smoking safety. An interview with the DDCO and the Administrator on 07/22/11, at 1:10 PM, revealed Wander/Elopement and Safety Risk Assessments had been completed on all residents. In addition, the DDCO and Administrator stated smoking evaluations had been completed on residents who smoked and the residents' care plans were updated. A review of staff interviews conducted by the facility revealed staff was interviewed regarding exit-seeking behaviors displayed by residents. A review of the facility policy dated 07/02/11, revealed the policy had been revised to reflect no resident was to be outside without family/staff supervision. Further review revealed staff was educated on the policy revision on 07/03-04/11. Review of attendance rosters revealed an in-service was initiated on 07/15/11, regarding policy changes related to residents going outside without supervision based on individual resident assessments. All working staff members were in-serviced and education was ongoing for employees who were off work. Staff was not allowed to work without first being in-serviced. Interviews conducted with CNAs, nurses, and Unit Managers on 07/21/11, at 12:30 PM, to 07/22/11, at 3:30 PM, revealed staff was knowledgeable regarding residents going outside without supervision. A review of Resident Outside/Outdoors Facility Assessments dated 07/05/11, 07/08/11, and 07/14/11, revealed assessments were completed for all residents who express a desire to go outside. A review of the record for Resident #4 revealed a resident outside/outdoors assessment was completed on 07/14/11, and the resident was assessed to be outdoors independently. Observations conducted on 07/22/11, at 2:39 PM, revealed Resident #4 was outside the facility waiting for transportation for a shopping trip with facility staff. A review of the attendance roster for in-service related to wandering/elopement, accident hazards, and supervision regarding residents being outside without staff supervision revealed staff was educated on the policy revision on 07/03-04/11, by the Staff Development Coordinator, the DON, and the Weekend Supervisor. Further review of interviews conducted with CNAs, nurses, and Unit Managers from 07/21/11, at 12:30 PM, to 07/22/11, at 3:30 PM, revealed staff was knowledgeable of the policy regarding wandering/elopement, accident hazards, and the supervision of residents outside of the facility. A review of a resident council meeting conducted on 07/07/11, by the Activities Director revealed residents were in-serviced regarding codes to the door and resident safety. Interviews conducted on 07/21/11, with Resident #7 at 3:00 PM, Resident #9 at 2:00 PM, and with Resident #8 on 07/22/11, at 10:30 AM, revealed the residents had been instructed on the door codes and resident safety. A review of the wandering resident alarm/lock system audit completed on 07/02/11, revealed facility staff checked the doors/Wanderguard system for proper functioning. On 07/22/11, at 2:45 PM, an environmental tour with the Maintenance Director revealed all doors were secure and functioning properly. Observation of the exit doors on the A and C Wings revealed a sign was posted stating no resident was to be assisted outside the facility and to check with the staff as the code will change frequently. A Wanderguard bracelet was checked on the D Wing at the exit door and was observed to be functioning properly. Interview with the Maintenance Director on 07/22/11, at 2:30 PM, revealed the door codes were changed frequently to ensure resident safety. Further interview with the Maintenance Director revealed the A and C Wing doors are disabled between the hours of 9:00 PM and 6:00 AM daily. A doorbell was installed at the A and C Wing doors to alert staff when visitors and emergency personnel need to enter during those hours. An observation of the A and C Wing doors on 07/22/11, at 3:30 PM, revealed the doors were equipped with a lock system and a doorbell was on the outside of A and C Wing doors. A review of an in-service attendance roster dated 07/20/11, revealed staff had attended an in-service regarding policy change of A and C Wing doors being locked between 9:00 PM and 6:00 AM. Interview with the Administrator on 07/22/11, at 3:15 PM, revealed the PIC met weekly to review all monitoring that is conducted for the action plan. Further interview revealed the Administrator was responsible for monitoring accident hazards, resident supervision, and assistive devices to prevent accidents, environmental audits for smoke time monitoring, and wander/elopement drills/audits to ensure implementation of the AOC. Interview with the Administrator and the DNS, on 07/22/11, at 3:15 PM, revealed event reports are reviewed daily regarding accident hazards supervision. An interview with the DDCO on 07/22/11, at 2:00 PM, revealed she reviews event reports weekly. A review of the smoking monitoring tool revealed daily monitoring of one smoke break had been conducted on 07/03/11, and was ongoing. Observation of a smoke break on 07/22/11, at 2:35 PM, revealed one staff person with two residents smoking in the designated area. Interview with the interim DON on 07/22/11, at 3:15 PM, revealed the Department Managers were required to check the smoke breaks daily and had not identified any concerns with residents being outside unattended. A review of documentation revealed a wander elopement drill was conducted on 07/06/11. Interview with the Administrator and the DNS on 07/22/11, at 3:15 PM, revealed the PIC met weekly to review all monitoring conducted for the action plan. A review of ad hoc attendance rosters revealed meetings were conducted on 07/07/11, 07/20/11, and 07/21/11. A review of Performance Improvement (PI) Meeting Attendance and Agendas revealed PI meetings were conducted on 07/07/11 and 07/15/11. The State Agency determined the Immediate Jeopardy was removed on 07/21/11, prior to exit, which lowered the scope and severity to "D" while the facility monitors the effectiveness of the systemic changes and quality assurance activities.

Based on interview and record review, it was determined the Administrator failed to effectively administer the facility in a manner that promoted the highest physical wellbeing of each resident. The facility's administration failed to have an effective system in place to ensure policies/procedures were implemented. The facility's Administrator failed to identify, through their investigation, that neglect occurred, failed to protect residents from abuse, and failed to report allegations of abuse to the appropriate state agencies. The facility's Administration failed to ensure residents received adequate supervision to prevent accidents, and failed to provide an environment as free from accident hazards as possible. On 07/02/11, Resident #1, a cognitively impaired resident, eloped from the facility. The facility failed to recognize the resident was missing from the facility until alerted by community members that the resident was on the highway in a wheelchair. Although facility Administration initiated an investigation to ensure the elopement was not the result of abuse and neglect, the facility failed to report the elopement as a possible negligent act in accordance with state law as required. The facility's Administration also failed to ensure Resident #4 abided by the facility's smoking policy, and failed to ensure the environment inside the facility remained as safe for residents as was possible. Resident #4 was outside unsupervised at approximately 12:30 AM on 07/10/11. The staff failed to recognize Resident #4 was smoking unattended, and Resident #4 assisted an intoxicated drug-seeking individual into the facility without staff knowledge. These facility failures placed residents at risk for serious injury, harm, impairment, or death. Immediate Jeopardy and Substandard Quality of Care were determined to exist on 07/02/11. An acceptable Allegation of Compliance was received on 07/20/11, which alleged removal of Immediate Jeopardy on 07/21/11. The State Agency determined the Immediate Jeopardy was removed on 07/21/11, prior to exit, which lowered the scope and severity to "D" while the facility monitors the effectiveness of the systemic changes and quality assurance activities. The findings include: A review of the facility's Accidents and Supervision to Prevent Accidents policy/procedure (revised 04/28/11), Patient Supervision and Monitoring policy/procedure (revised 04/28/11), Resident Elopement policy/procedure (revised 10/31/07), and Smoking policy/procedure (revised 04/28/11) revealed the facility would provide supervision to each resident to prevent avoidable accidents, and provide an environment that was free of accident hazards over which the facility had control. The policies/procedures directed staff to determine the root cause of an event including any performance failures which could indicate neglect on the part of the staff to determine the direction of the investigation. The policies/procedures also detailed how all abuse/neglect investigations would be reported to officials in accordance with state law, and the appropriate state agencies would be notified of resident elopements. The policies/procedures also indicated smoking outdoors after sunset and before sunrise would be supervised. On 07/02/11, Resident #1, who the facility assessed as having Dementia and multiple safety risks, left facility grounds without facility staff's knowledge and without staff supervision. The resident was found approximately three-tenths mile from the facility on the highway in a wheelchair. Administration initiated an investigation into Resident #1's elopement in an effort to determine if abuse/neglect had occurred; however, the facility failed to recognize multiple failures of staff to be aware of Resident #1's safety needs, and failures to take action when Resident #1 was observed to be in a situation that was likely to cause harm to the resident. Interview on 07/13/11, at 10:15 AM, with the District Director of Clinical Operations (DDCO) revealed that due to the facility never assessing Resident #1 to require one to one supervision at any time, and the investigation finding no evidence of "willful intent" to leave Resident #1 outside unattended, the facility "never suspected neglect and determined none had occurred." Interview with Administrator #1 and the Director of Nursing (DON) on 07/12/11, at 3:25 PM, revealed that although an investigation was initiated to rule out abuse/neglect and determined the incident should be reported to the appropriate state agencies, the facility's District Director of Clinical Operations (DDCO), who was notified of Resident #1's elopement on 07/02/11, instructed the DON not to report the incident to the appropriate state agencies as required. On 07/10/11, at 12:33 AM, Resident #4 was outside smoking, unsupervised, and assisted an intoxicated drug-seeking individual to enter the facility without staff knowledge. Interview with the DON on 07/13/11, at 5:00 PM, revealed he had been made aware of the incident on 07/10/11, but did not initiate an investigation into the incident and took no action to prevent reoccurrence or ensure resident safety. Per interview, the DON did not feel residents were in danger. Interview with the DDCO on 07/19/11, at 11:50 AM, revealed the facility was "not a prison" and anyone could come and go in the facility at any time, day or night. The DDCO stated that A Wing doors and C Wing doors are unlocked at all times, and anyone could enter through them at any time. There was no evidence the facility reported allegations of abuse/injuries of unknown origin to the appropriate state agencies for Resident #5 and Resident #6 timely. Additionally, the facility failed to follow their policies and procedures when they allowed an alleged perpetrator to continue working with residents after receiving an allegation of abuse to Resident #2. Furthermore, the facility failed to notify the Administrator and the state agencies timely. An interview conducted with the Facility Administrator on 07/22/11, at 11:00 AM, revealed the Administrator was not aware the facility's established abuse policies/procedures had not been followed related to the incidents which occurred involving Residents #2, #5, and #6. A review of the allegation of compliance revealed the following: On 07/14/11, the State Director of Risk Management conducted education with the district Director of Operations (DO), District Director of Clinical Operations (DDCO), Executive Director (ED)/Administrator, and the Director of Nursing Services (DNS/DON) regarding regulation F225 related to the identification and immediate reporting of alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property. On 07/04/11, the DO and DDCO conducted education with the ED and DNS on conducting an investigation. On 07/03/11, a policy change was made and implemented to ensure that all residents who wished to go outside were accompanied by staff and that no resident was outside unattended. On 07/05/11 and 07/08/11, assessments were conducted on residents who requested to go outside. On 07/14/11, residents who requested to go outside were re-assessed and a policy change was made. The change was to assess residents upon their request to determine their ability to go outside independently without staff supervision. The resident must be assessed and must meet the assessment criteria prior to being allowed to go outside unsupervised. In addition, no resident is allowed to be outside between the hours of 11:00 PM and 6:00 AM without supervision, regardless of assessment status. On 07/02/11, the SDC, DNS, and Weekend Supervisor (WS) initiated education with all facility staff related to wandering, elopement, accident hazards, supervision, and policy change related to residents going outside without staff supervision, as no resident was to be outside without staff supervision. Education will be ongoing until all facility staff members have attended. On 07/15/11, this in-service was repeated with staff to include a policy change related to residents going outside without staff supervision, based on their individual resident assessment. Education will be ongoing until all facility staff members have attended. On 07/07/11, the Activities Director (AD) educated residents on door alarms, resident safety, and the need for residents to seek staff assistance with doors. After 9:00 PM, all facility entrance doors have been and continue to be on a timed lock, except for A Wing and C Wing doors to allow staff and emergency entrance. Effective 07/20/11, the A Wing and C Wing outside entrance button will be disabled between 9:00 PM and 6:00 AM daily, until these entrance doors can be engineered with a timed lock during these hours. A doorbell has been installed at the entrance to A Wing and C Wing to be utilized by visitors and emergency personnel. The Maintenance Director (MD) initiated education with all facility staff on 07/20/11, related to the change in the door system. Effective 07/03/11, at least one resident smoke time is monitored daily by a Department Manager, as designated by the ED, to ensure that during smoke times there is one staff person to five residents, that other outside areas have no unattended residents, that any resident outside with a family member is signed out, and to identify any outside accident hazards. Any concerns were corrected immediately. This monitoring will occur daily until deemed unnecessary by the Performance Improvement Committee (PIC). Resident and family interviews are required to be conducted for all residents every four months, which ask specific direct questions related to resident treatment and abuse. All allegations of abuse, neglect, or mistreatment are required to be immediately reported to the ED and DNS to ensure residents are protected from further potential abuse/neglect/mistreatment. All event reports are reviewed daily by the ED and the DNS. Event reports are reviewed to identify any potential accident hazard related to environment and supervision. The ED and DNS will review all grievance forms and interviews weekly to identify any alleged violations. The ED will also ensure appropriate reporting and implementation of the credible allegation of compliance. The DDCO will review three grievance forms or interviews weekly to identify any alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property to ensure appropriate reporting. In addition, the DDCO will have oversight of the ED and DNS in the facility on a weekly basis to validate the implementation of the Credible Allegation of Compliance through review of audit and monitoring tools. The DDCO will also review all resident events with the DNS on a weekly basis to identify any potential accident hazard related to environment and supervision, to include the potential for neglect and/or abuse and to ensure appropriate reporting. The ED will also validate through the weekly PIC meeting by review of the smoke time supervision audits, review of the wander/elopement audits, review of any environmental rounds, and implementation of the credible allegation. The PIC will meet weekly or more often as necessary until the facility has demonstrated sustained compliance of the corrective actions described in the AOC. Members of the PIC include, but are not limited to, the ED, AED, DNS, SDC, MD, SSD, Nutrition Services Manager (NSM), Registered Dietitian (RD), AD, BOM, Case Manager (CM), RPD, and the TCUPD. Ad hoc PIC meetings were held on 07/04/11 and 07/15/11, to review the implemented corrective action. The surveyors validated the corrective action taken by the facility as follows: A review of documentation revealed the ED, DNS, and DDCO were provided with in-service training on 07/14/11, regarding reporting requirements by the State Risk Management Director. Interviews with the DDCO, DNS, and ED on 07/22/11, from 2:00 PM - 3:30 PM, revealed they were knowledgeable of reporting requirements related to mistreatment, abuse, neglect, and injuries of unknown source and misappropriation of resident property. A review of documentation revealed the ED and the DNS were provided with in-service training regarding conducting facility investigations on 07/14/11, by the DDCO. Interview with the ED and the DNS on 07/22/11, at 3:00-3:15 PM, revealed they were knowledgeable of investigation requirements. A review of the facility policy dated 07/02/11, revealed the policy had been revised to reflect no resident was to be outside without family/staff supervision. Further review revealed staff was educated on the policy revision on 07/03-04/11. Review of attendance rosters revealed an in-service was initiated on 07/15/11, regarding policy changes related to residents going outside without supervision based on individual resident assessments. All working staff members were in-serviced and education was ongoing for employees who were off work. Staff was not allowed to work without first being in-serviced. Interviews conducted with CNAs, nurses, and Unit Managers from 07/21/11, at 12:30 PM, to 07/22/11, at 3:30 PM, revealed staff was knowledgeable regarding residents going outside without supervision. A review of attendance roster for in-service related to wandering/elopement, accident hazards, and supervision regarding residents being outside without staff supervision, revealed staff was educated on the policy revision on 07/03-04/11, by the Staff Development Coordinator, the DON, and the Weekend Supervisor. Further review of staff in-services revealed the in-service was repeated on 07/14/11. Further review of interviews conducted with CNAs, nurses, and Unit Managers from 07/21/11, at 12:30 PM, to 07/22/11, at 3:30 PM, revealed staff was knowledgeable of the policy regarding wandering/elopement, accident hazards, and the supervision of residents outside of the facility. A review of a resident council meeting conducted on 07/07/11, by the Activities Director revealed residents were in-serviced regarding codes to the door and resident safety. Interviews conducted with Residents #7, #8, and #9 from 07/21/11, at 2:00 PM, to 07/22/11, at 11:00 AM, revealed the residents had been instructed on the door codes and resident safety. An observation of the A and C Wing doors on 07/22/11, at 3:30 PM, revealed the doors were equipped with a lock system and a doorbell was on the outside of the A and C Wing doors. Interview with the Maintenance Director on 07/22/11, at 2:30 PM, revealed the A and C Wing doors were disabled between the hours of 9:00 PM and 6:00 AM daily. A review of an in-service attendance roster dated 07/20/11, revealed staff had attended an in-service regarding a policy change of A and C Wing doors being locked between 9:00 PM and 6:00 AM. A review of the smoking monitoring tool revealed daily monitoring of one smoke break had been conducted from 07/03/11, and was ongoing. Observation of a smoke break on 07/22/11, at 2:35 PM, revealed one staff person with two residents smoking in the designated area. Interview with the interim DON on 07/22/11, at 3:15 PM, revealed the Department Managers were required to check the smoke breaks daily and had not identified any concerns with residents being outside unattended. A review of satisfaction surveys initiated on 07/12/11 and 07/20/11, for residents/responsible parties revealed no concerns had been addressed by the facility. Interviews with Residents #7, #8, and #9, and family of Resident #30, from 07/21/11, at 2:00 PM, to 07/22/11, at 11:00 AM, revealed no concerns regarding resident care and treatment at the facility. Interview with the Administrator and the DNS on 07/22/11, at 3:15 PM, revealed event reports are reviewed daily regarding accident hazards supervision and to ensure appropriate reporting of abuse/neglect. In addition, all grievance forms and interview forms were reviewed weekly for validation of alleged violations involving mistreatment, neglect/abuse, injuries of unknown source, and misappropriation to ensure appropriate reporting. An interview with the DDCO on 07/22/11, at 2:00 PM, revealed resident/family interviews, grievance forms, and event reports were reviewed weekly for identification of any alleged violations involving mistreatment, neglect, or abuse to ensure reporting as required. Interview with the Administrator and DNS on 07/22/11, at 3:15 PM, revealed the PIC met weekly to review all monitoring that was conducted for the action plan. Further interview revealed the Administrator was responsible for monitoring accident hazards, resident supervision, and assistive devices to prevent accidents, environmental audits for smoke time monitoring, wander/elopement drills/audits, all grievance forms and interview forms, employee suspensions, and end of shift contacts for validation of alleged violations involving mistreatment, neglect/abuse, injuries of unknown source, and misappropriation to ensure appropriate reporting and implementation of the AOC. A review of ad hoc attendance rosters revealed meetings were conducted on 07/07/11, 07/20/11, and 07/21/11. A review of Performance Improvement (PI) Meeting Attendance and Agendas revealed PI meetings were conducted on 07/07/11 and 07/15/11. The State Agency determined the Immediate Jeopardy was removed on 07/21/11, prior to exit, which lowered the scope and severity to "D" while the facility monitors the effectiveness of the systemic changes and quality assurance activities.

Based on interview and record review, it was determined the facility failed to ensure that violations involving mistreatment, neglect, or abuse, including injuries of unknown source for four (4) of twenty-two (22) sampled residents (Residents #1, #2, #5, and #6) were immediately reported to the administrator of the facility, or other officials in accordance with state law. Additionally, the facility failed to protect residents from further abuse allowing a perpetrator to continue working with residents. Although the facility conducted an investigation regarding Resident #1 leaving the facility grounds without staff knowledge, the facility failed to report the incident as an act of possible negligence to the appropriate state agencies as required. The facility failed to report allegations of abuse/injuries of unknown origin to the appropriate state agencies for Resident #5 and Resident #6 timely. Additionally, the facility failed to follow their policies and procedures when they allowed an alleged perpetrator to continue working with residents after receiving an allegation of abuse to Resident #2. Furthermore, the facility failed to notify the administrator and the state agencies timely. The facility's failure to ensure all violations were reported as required placed residents at risk for serious injury, harm, impairment, or death. Immediate Jeopardy and Substandard Quality of Care were determined to exist on 07/02/11. An acceptable Allegation of Compliance was received on 07/20/11, which alleged removal of Immediate Jeopardy on 07/21/11. The State Agency determined the Immediate Jeopardy was removed on 07/21/11, prior to exit, and lowered the scope and severity to "D" level while the facility monitors the effectiveness of the systemic changes and conducts quality assurance activities. The findings include: 1. A review of the facility's policies/procedures regarding Abuse (revised 10/31/09), Conducting an Investigation (revised 06/30/06), and Resident Elopement (revised 10/31/07) revealed all abuse/neglect investigations were to be reported to officials in accordance with state law, and the appropriate state agencies would be notified of resident elopements. A review of Resident #1's medical record and a facility investigation (undated completion) revealed facility staff failed to return Resident #1 inside the building after staff assisted the resident outside to smoke. The facility remained unaware of the resident's whereabouts for approximately 30 minutes until alerted by members of the community that Resident #1 was approximately three- tenths mile from the facility in a wheelchair on the highway. Interview with Administrator #1 and the Director of Nursing (DON) on 07/12/11, at 3:25 PM, revealed an investigation was immediately initiated into Resident #1's elopement on 07/02/11, to ensure no abuse/neglect had occurred, and CNA #27 was immediately suspended from employment at the facility pending the results of the investigation. Administrator #1 and the DON stated an investigation was initiated to rule out abuse/neglect and determined the incident should be reported to the appropriate state agencies. Administrator #1 and the DON stated prior to notifying the state agencies, Resident #1's elopement was reported to the facility's District Director of Clinical Operations (DDCO) who instructed the DON not to report the incident to the appropriate state agencies as required. Interview with the DDCO on 07/13/11, at 10:15 AM, revealed Resident #1's elopement on 07/02/11, was not reported to the state agency because there was "no regulation requiring elopements to be reported" and the incident "did not meet the intent of the (abuse/neglect) regulation." Additionally the DDCO stated at the conclusion of the investigation it was determined no abuse/neglect had occurred, and therefore the incident was not required to be reported. Refer to F224 and F323. 2. Review of the medical record for Resident #5 revealed the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The facility assessed the resident on 06/14/11, as frequently incontinent of bowel and bladder. Review of Resident #5's care plan dated 06/20/11, determined that one staff person was to toilet/prompt Resident #5 with voiding every two hours. Record review also revealed that on 07/15/11, at 6:00 PM, CNA #10 transported Resident #5 to the dining room with wet clothing and refused to toilet the resident. An interview conducted with CNA #18 on 07/22/11, at 10:20 AM, revealed on 07/15/11, during the evening meal CNA #10 had transported Resident #5 to the dining room and had returned to the unit to transport another resident to the dining room. When CNA #10 returned to the dining room CNA #18 asked CNA #10 to assist Resident #5 to the Bathroom and the CNA refused, stating that the resident had just been toileted and had sat on the commode for thirty (30) minutes. Another CNA offered to toilet the resident and according to CNA #18 this incident was reported to LPN #9. An interview conducted with LPN #9 on 07/21/11, at 3:05 PM revealed the above incident was reported to LPN #9 on 07/15/11. LPN #9 instructed CNA #10 to toilet the resident and observed that the resident's pants were wet. LPN #9 then instructed the CNA to change the resident's clothing. According to the LPN the incident was reported to the facility social worker and the CNA was escorted to the time clock and was suspended from employment at the facility. An interview conducted with CNA #10 on 07/21/11, at 4:25 PM, revealed the CNA had taken Resident #5 to the dining room on 07/15/11, for the evening meal and was transporting another resident to the dining room when another CNA instructed CNA #10 to toilet Resident #5. According to CNA #10 the resident was toileted before going to the dining room and didn't use the bathroom. Further interview revealed that CNA #10 toileted Resident #5 after being told to do so by the supervisor. Interview with the facility Social Worker on 07/22/11, at 10:30 AM, revealed that LPN #9 reported CNA #10 for leaving Resident #5 in wet clothing after toileting the resident on 07/15/11, during the evening meal service. According to the Social Worker, the Administrator was contacted immediately and the CNA's employment at the facility was suspended. The Office of Inspector General was notified of the incident on 07/15/11, but the Social Worker was not aware of any notification to Adult Protective Services. A review of the facility investigation for the 07/15/11 incident regarding Resident #5 revealed no evidence Adult Protective Services was notified as required. An interview conducted with the Facility Administrator on 07/22/11, at 11:00 AM, revealed the Administrator was not aware that Adult Protective Services had not been notified of the 07/15/11 incident involving Resident #5. 3. Resident #2 was an [AGE] year-old resident admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of an initial report of an allegation of verbal abuse regarding Resident #2 revealed the allegation was forwarded to the required state agencies by the Facility Administrator on 07/20/11, at 5:40 PM. According to the initial report, CNA #11 was allegedly heard to tell Resident #2 to shut up (no date of incident noted). Interview with CNA #13 on 07/21/11, at 3:30 PM, revealed CNA #13 overheard CNA #11 tell Resident #2 to shut up on 07/19/11, at about 10:00 PM. CNA #13 stated this incident was reported to the Unit Supervisor (LPN #10). Interview with CNA #11 on 07/21/11, at 4:55 PM, revealed CNA #11 had provided care to Resident #2 but denied telling the resident to shut up. CNA #11 stated the CNA was not suspended from employment at the facility regarding this incident until 5:45 PM on 07/20/11. An interview conducted with LPN #10 on 07/21/11, at 4:05 PM, revealed the LPN reported the incident to the evening shift supervisor after LPN #10 became aware of the allegation. An interview conducted with the evening shift supervisor (RN #4) on 07/21/11, at 5:35 PM, revealed RN #4 started interviewing staff regarding the incident after the incident was reported to RN #4 on 07/19/11. RN #4 stated the Administrator was not immediately notified of the allegation and CNA #11 was not immediately suspended. RN #4 stated she left a note for the DON and the Administrator to inform them of the incident. An interview with the Administrator on 07/22/11, at 11:00 AM, revealed the Administrator was not made aware of the allegation of alleged abuse until 07/20/11, and was not aware that CNA #11 was not immediately suspended from employment after the incident was reported on 07/19/11. 4. A review of Resident #6's medical record revealed the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the nurse's notes and physician's orders [REDACTED]. hip extending to the left knee. The physician was notified and orders were received for an x-ray to be conducted of the resident's left hip on 07/17/11. The left hip x-ray was obtained with negative results on 07/17/11. Resident #6 continued to have bruising and [MEDICAL CONDITION] to the left thigh and physician's orders [REDACTED]. Resident #6 was admitted to the hospital for a fractured left hip on 07/20/11. Review of the facility investigation revealed an injury of unknown origin was identified for Resident #6 on 7/17/11; however, the appropriate state agencies were not notified of the injury of unknown origin until 07/20/11. Interviews with RN #3, LPN #8, SRNA #21, and SRNA #22 on 07/21/11, at 3:15 PM, 4:10 PM, 5:10 PM, and 5:20 PM, revealed Resident #6 had a bruise to the left hip identified by a family member on 7/16/11, at 10:30 PM. The staff was not aware of the cause of the injury. All staff was aware of the requirement to immediately report an incident of unknown origin to their supervisors. RN #3 reported the injury of unknown origin to the Director of Nursing on 07/17/11; however, the incident was not reported to the appropriate state agencies until 07/20/11. An interview with the Administrator on 07/22/11, at 11:00 AM, revealed the appropriate state agencies were not notified of the injury of unknown origin for Resident #6 until 07/20/11. A review of the allegation of compliance revealed the following: On 07/14/11, the State Director of Risk Management conducted education with the district Director of Operations (DO), District Director of Clinical Operations (DDCO), Executive Director (ED)/Administrator, and the Director of Nursing Services (DNS/DON) regarding regulation F225 related to the immediate reporting of alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property. On 07/04/11, the DO and DDCO conducted education with the ED and DNS on conducting an investigation. Resident and family interviews are required to be conducted for all residents every four months, which ask specific direct questions related to resident treatment and abuse. All allegations of abuse, neglect, or mistreatment are required to be immediately reported to the ED and DNS to ensure residents are protected from further potential abuse/neglect/mistreatment. All event reports are reviewed daily by the ED and the DNS. Event reports are reviewed to ensure appropriate reporting for neglect and/or abuse. The ED and DNS will review all grievance forms and interviews weekly to identify any alleged violations. The ED will also ensure appropriate reporting and implementation of the credible allegation of compliance. The DDCO will review three grievance forms or interviews weekly to identify any alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property to ensure appropriate reporting. In addition, the DDCO will have oversight of the ED and DNS in the facility on a weekly basis to validate the implementation of the Credible Allegation of Compliance through review of audit and monitoring tools. The DDCO will also review all resident events with the DNS on a weekly basis to identify any potential accident hazard related to environment and supervision, to include the potential for neglect and/or abuse and to ensure appropriate reporting. The ad hoc Performance Improvement Committee (PIC) will meet weekly to ensure alleged violations involving mistreatment, neglect or abuse, including injuries of unknown source and misappropriation of resident property are reported. Corrective action plans will be developed/implemented for any areas of concern identified, with meetings weekly or more often as necessary. Ad hoc PIC meetings were held on 07/04/11 and 07/15/11, to review the facility's action plan. The surveyors validated the corrective action taken by the facility as follows: A review of documentation revealed the ED, DNS, and DDCO were provided with in-service training on 07/14/11, regarding reporting requirements by the State Risk Management Director. Interviews with the DDCO, DNS, and ED, on 07/22/11, from 2:00 PM - 3:30 PM, revealed they were knowledgeable of reporting requirements related to mistreatment, abuse neglect, and injuries of unknown source and misappropriation of resident property. A review of documentation revealed the ED and the DNS were provided with in-service training regarding conducting facility investigations on 07/14/11, by the DDCO. Interview with the ED and the DNS on 07/22/11, at 3:00-3:15 PM revealed they were knowledgeable of investigation requirements. A review of satisfaction surveys initiated on 07/12/11 and 07/20/11, for residents/responsible parties revealed no concerns that had not been addressed by the facility. Interviews on 07/21/11, with Resident #9 at 2:00 PM, Resident #7 at 3:00 PM, and Resident #30's family member at 1:15 PM, and with Resident #8 on 07/22/11, at 10:30 AM, revealed no concerns regarding resident care and treatment at the facility. Interview with the Administrator and the DNS on 07/22/11, at 3:15 PM, revealed event reports were reviewed daily regarding abuse/neglect to ensure appropriate reporting. An interview with the DNS on 07/22/11, at 3:00 PM, revealed the DNS reviewed all grievance forms and interview forms weekly for validation of alleged violations involving mistreatment, neglect/abuse, injuries of unknown source and misappropriation to ensure appropriate reporting. An interview with the DDCO on 07/22/11, at 2:00 PM, revealed resident/family interviews and grievance forms were reviewed weekly for identification of any alleged violations involving mistreatment, neglect, or abuse to ensure reporting as required. Further interview with the Administrator and DNS on 07/22/11, at 3:15 PM, revealed the PIC met weekly to review all monitoring that had been conducted for the action plan. According to the Administrator, the monitoring of this information was conducted to ensure appropriate reporting and implementation of the AOC. The State Agency determined the Immediate Jeopardy was removed on 07/21/11, prior to exit, and lowered the scope and severity to "D" level while the facility monitors the effectiveness of the systemic changes and conducts quality assurance activities.

Based on interview, record review, and review of policy and procedures, it was determined the facility failed to provide services necessary to avoid physical harm for one (1) of twenty-two (22) sampled residents (Resident #1). The facility failed to follow their policy and procedure by not identifying through their incident investigation that neglect occurred. The facility assessed Resident #1 as severely cognitively impaired as having multiple risk factors related to safety. On 07/02/11, staff assisted Resident #1 outside to smoke with peers during a supervised "smoke break." However, facility staff left the resident unsupervised outside after the smoke break was over. Resident #1 left facility grounds without the facility's knowledge and without staff supervision. The facility did not become aware of the missing resident until a community member notified the facility. The facility's failure to protect the resident from neglect placed residents at risk for serious injury, harm, impairment, or death. Immediate Jeopardy and Substandard Quality of Care were determined to exist on 07/02/11. An acceptable Allegation of Compliance was received on 07/20/11, which alleged removal of Immediate Jeopardy on 07/21/11. The State Agency determined the Immediate Jeopardy was removed on 07/21/11, prior to exit, which lowered the scope and severity to "D" while the facility monitors the effectiveness of the systemic changes and quality assurance activities. The findings include: A review of the facility's Abuse Prevention policy/procedure (revised 04/28/09), Abuse policy/procedure (revised 10/31/09), and Identification of an Event That May Constitute Abuse policy/procedure (revised 07/22/10), revealed neglect of residents was strictly prohibited. According to the policies, the facility would identify residents most at risk for neglect, such as those with dementia, and develop interventions to prevent and/or reduce occurrences including deployment of staff to meet the needs of residents, ensuring that assigned staff had knowledge of the individual resident's care needs, and ensuring staff had access to specific resident information. The policies/procedures also identified the need to assess, care plan, and monitor residents with needs and behaviors which might lead to conflict or neglect. The policies/procedures directed staff to determine the root cause of an event including any performance failures on the part of the staff to determine the direction of the investigation. A review of the facility's Accidents and Supervision to Prevent Accidents policy/procedure (revised 04/28/11) and Patient Supervision and Monitoring policy/procedure (revised 04/28/11) revealed the facility would provide supervision to each resident to prevent avoidable accidents, and assess residents to determine if supervision was necessary. The policies stated the facility would clearly define mechanisms and procedures which help to mitigate the risk of a resident leaving a safe area without staff supervision. The policies included center-focused and patient-directed approaches to evaluate accident risks as well as monitoring processes to ensure interventions were implemented and effective related to resident supervision, smoking, resident risks, and environmental hazards to include falls and unsafe wandering or elopement. A review of Resident #1's Care Area Assessment (CAA) and Comprehensive care plan both dated 06/29/11, and Minimum Data Set assessment dated [DATE], revealed the facility assessed Resident #1 as severely cognitively impaired and having decreased safety awareness. Resident #1's [DIAGNOSES REDACTED]. A review of the facility's investigation, interview with Licensed Practical Nurse (LPN) #1 on 07/11/11, at 5:00 PM, and interview with Administrator #1 and the Director of Nursing (DON) on 07/12/11, at 3:25 PM, revealed although LPN #1 was not assigned to care for Resident #1 on 07/02/11, and was unfamiliar with the resident's care needs, the LPN opened the door and allowed Resident #1 to go outside to smoke with peers participating in a supervised smoke break supervised by CNA #27. According to Administrator #1 and the DON, CNA #27 was also unfamiliar with and unaware of Resident #1's health and safety needs. LPN #1 stated she had reservations about assisting Resident #1 outside due to not being familiar with the resident and his/her care needs, but stated she chose to do so anyway due to the Resident's repeated requests to go outside. LPN #1 stated she instructed CNA #27 to make sure Resident #1 was assisted back inside the building after the smoke break. However, according to LPN #1 and the facility's investigation, CNA #27 left Resident #1 alone outside unsupervised after the smoke break ended at approximately 4:45 PM. An interview conducted on 07/11/11, at 6:00 PM, with CNA #1 revealed she was outside on a personal smoke break at approximately 4:50 PM on 07/02/11, and encountered Resident #1 who asked the CNA for a cigarette. CNA #1 replied to the resident, "No, you have to wait to smoke during smoke breaks." CNA #1 voiced being unfamiliar with Resident #1, stating, "I knew (he/she) was a resident, but I had never seen (him/her) before," and stated she assumed the resident could be outside alone. CNA #1 returned inside the building also leaving Resident #1 outdoors alone and unsupervised. Based on the interview, CNA #1 made no attempt to contact staff assigned to care for Resident #1 to ensure they were aware of the resident's whereabouts or confirm that it was safe for the resident to be outside alone and unsupervised. An interview conducted on 07/12/11, at 12:36 PM, with CNA #3 and review of the facility's investigation revealed she had observed Resident #1 outside on 07/02/11, at approximately 5:00 PM, and asked staff at the nurses' station (unable to recall who) if Resident #1 was "OK to be outside." CNA #3 was informed that there was a staff member outside. However, none of the staff at the nurses' station or CNA #3 confirmed a staff member's presence outside with Resident #1. Interviews conducted on 07/12/11, with LPN #1 at 10:50 AM, and CNA #2 at 10:30 AM, and review of the facility's investigation, revealed both staff members had been assigned to provide care to Resident #1 on 07/02/11, but was not aware that Resident #1 had been outside the facility, and did not realize the resident was missing until approximately 5:15 PM, when community members began to come into/call the facility with reports of an elderly man/woman being on the highway in a wheelchair approximately three-tenths mile from the facility. A review of the facility's investigation revealed the findings of the investigation failed to recognize the circumstances of Resident #1's elopement as neglectful. Interviews conducted on 07/12/11, at 3:25 PM, with Administrator #1 and the DON, and on 07/13/11, at 10:15 AM, with the District Director of Clinical Operations (DDCO)revealed that, due to the facility having never assessed Resident #1 to require one to one supervision at any time, and the facility's investigation finding no evidence of "willful intent" to leave Resident #1 outside unattended, the facility "never suspected neglect and determined none had occurred." There was no evidence the facility had ensured the staff was knowledgeable regarding the facility's assessment that the resident had multiple risk factors related to safety and dementia to ensure appropriate supervision was provided for the resident to prevent potential elopement. Refer to F225 and F323. A review of the allegation of compliance revealed the following: The facility revised Resident #1's comprehensive care plan on 07/02/11, and added interventions related to the resident's "risk for wandering and elopement." The interventions added to the resident's care plan included wander guard bracelet in place; 1:1 supervision; and adventure boards placed in wander/elopement book. The facility revised Resident #1's CNA Assignment Sheet on 07/03/11, and added the resident was at risk for elopement, required "1:1" supervision, and a Wanderguard would be utilized for the resident. On 07/02/11, the Staff Development Coordinator (SDC), Director of Nursing Services (DNS/DON), and Weekend Supervisor (WS) initiated education with all facility staff related to wandering, elopement, accident hazards, supervision, and policy change related to residents not going outside without staff supervision. According to the in-service, there would be one staff person to every five residents when outside. If there were six residents, there must be two staff persons. No staff person is to return inside the facility without bringing in the resident(s) or without changing out with another staff person. According to the AOC, there were no exceptions to this policy and education will be provided until all facility staff members have attended. On 07/03/11, the Assistant Executive Director (AED) posted signage at all facility entrance doors to notify visitors residents were not to be assisted outdoors and to check with staff for the code as it will change frequently. Effective 07/03/11, the Executive Director (ED)/Administrator will designate a Department Manager to monitor at least one resident smoke break on a daily basis. The designated Department Manager will monitor to ensure there is one staff person for every five residents and that any resident outside with a family member was signed out. Any concerns are to be corrected immediately. This monitoring will occur daily until deemed unnecessary by the Performance Improvement Committee (PIC) which included the ED, Assistant Executive Director (AED), DNS, Staff Development Coordinator (SDC), MD, SSD, Nutrition Services Manager (NSM), Registered Dietitian (RD), Activities Director (AD), Business Office Manager (BOM), Case Manager (CD), Reflections Program Director (RPD), and the TCUPD. On 07/07/11, the Activities Director (AD) educated residents on door alarms, resident safety, and the need for residents to seek staff assistance with doors. Resident and family satisfaction surveys were initiated on 07/12/11, for each resident and/or responsible party. The questionnaires addressed multiple areas to include but were not limited to respect shown by staff, quality of care, adequate staffing, competency, resident safety, and security of personal belongings. The results of the survey will be sent to the ED for follow-up and resolution of any concern. The results will be reviewed in the Performance Improvement Committee (PIC). On 07/14/11, the State Director of Risk Management conducted education with the district Director of Operations (DO), District Director of Clinical Operations (DDCO), Executive Director, and the DNS regarding violations involving identification of neglect, including failure to answer a call light, leaving resident's unattended for long periods of time, etc. On 07/15/11, the SDC, Second Shift (SS) RN Nurse Supervisor, and Weekend Supervisor (WS) initiated re-education with all facility staff related to supervision and abuse/neglect. Education will be ongoing until all facility staff members have attended. No staff member was allowed to work without having been in-serviced. All event reports are reviewed daily by the ED and the DNS to identify any potential for neglect and/or abuse. Ad hoc PIC meetings were held on 07/04/11 and 07/15/11, to review the action plan. The PIC will meet weekly to ensure compliance and will discuss areas of concern identified through supervision and alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property. Corrective action plans will be developed/implemented for any areas of concern identified, with meetings weekly or more often as necessary. The surveyors validated the corrective action taken by the facility as follows: Record reviews conducted for Resident #1 revealed the resident's care plan was updated on 07/02/11, to include interventions for wandering and elopement. A review of the CNA assignment sheet for Resident #1 revealed the resident's assignment sheet was revised on 07/03/11, to include interventions for 1:1 staff supervision and a wander guard and to identify the resident as an elopement risk. Observations conducted for Resident #1 on 07/22/11, at 2:38 PM, revealed the resident was provided 1:1 staff supervision. Interview conducted with CNA #17 on 07/22/11, at 2:38 PM, revealed the resident was placed on 1:1 supervision due to being an elopement risk. A review of the attendance roster for staff in-service training related to supervision of residents outside the facility revealed staff was educated on the policy revision on 07/03-04/11, by the Staff Development Coordinator, the DON, and the Weekend Supervisor. Interviews conducted with CNAs, Nurses, and Unit Managers from 07/21/11, at 12:30 PM, to 07/22/11, at 3:30 PM, revealed staff was knowledgeable regarding supervision of residents who were outside of the facility. Observation of the A and C Wing exit doors on 07/22/11, at 2:45 PM, revealed a sign was posted stating no resident was to be assisted outside the facility and to check with the staff as the code will change frequently. A review of the smoking monitoring tool revealed daily monitoring of one smoke break had been conducted from 07/03/11, and was ongoing. Observation of a smoke break on 07/22/11, at 2:35 PM, revealed one staff person with two residents smoking in the designated area. Interview with the interim DON on 07/22/11, at 3:15 PM, revealed the Department Managers were required to check the smoke breaks daily and had not identified any concerns with residents being outside unattended. A review of a resident council meeting conducted on 07/07/11, by the Activities Director revealed residents were in-serviced regarding codes to the door and resident safety. Interviews conducted on 07/21/11, with Resident #7 at 3:00 PM, Resident #9 at 2:00 PM, and with Resident #8 on 07/22/11, at 10:30 AM, revealed the residents had been instructed on the door codes and resident safety. A review of satisfaction surveys initiated on 07/12/11 and 07/20/11, for each resident/responsible party revealed no concerns that had not been addressed by the facility. Interviews on 07/21/11, with Resident #9 at 2:00 PM, Resident #7 at 3:00 PM, and Resident #30's family member at 1:15 PM, and with Resident #8 on 07/22/11, at 10:30 AM, revealed no concerns regarding resident care and treatment at the facility. A review of documentation revealed the ED and the DNS were provided in-service training on 07/14/11, by the DDCO regarding neglect. Interview with the ED and the DNS on 07/22/11, at 3:00-3:15 PM, revealed they were knowledgeable of investigation requirements. Interview with the Administrator and the DNS on 07/22/11, at 3:15 PM, revealed event reports are reviewed daily regarding accident hazards supervision. According to the Administrator and the DNS, the PIC met weekly to review all monitoring conducted for the action plan. The State Agency determined the Immediate Jeopardy was removed on 07/21/11, prior to exit, which lowered the scope and severity to "D" while the facility monitors the effectiveness of the systemic changes and quality assurance activities.