Every finding on record at Grayson Nursing and Rehab Center

Based on observation, interview, and review of facility policy, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Observation of the kitchen on [DATE], revealed Cook1's hair net was not properly covering her hair while she was preparing food trays at the holding table. Additional observations of the kitchen, revealed refrigerator1 contained expired food and food that was not sealed after opening. Further, other kitchen refrigerators and freezers contained food that had been opened, but was not sealed or covered when stored. Furthermore, the kitchen dry storage area, revealed a box of spaghetti noodles in the original container, which was opened and not sealed when stored. Additionally, observation of the kitchen, on [DATE], revealed breakfast freezer1 had a box of biscuits in the original package that had been opened, but not sealed or covered when stored. Also, refrigerator1 had a box of bacon in the original container that had been opened and was in a large plastic bag, but was not sealed or covered when stored. The findings include: Dietary policies related to use of hairnets was not provided. Review of the facility policy titled, Food Storage, dated 2019, revealed food would be stored by methods designed to prevent contamination. Continued review revealed leftover food would be stored in covered containers or wrapped carefully and securely. All foods should be covered, labeled, and dated in refrigerators and freezers, and would be checked to assure that foods (including leftovers) would be consumed by their safe use by dates, frozen, or discarded. Observation of the kitchen during dinner meal service, on [DATE] starting at 4:20 PM, revealed Cook1 had her hair pulled up in a bun on top of her head which was covered by a hairnet. However, there was approximately ,d+[DATE] inches of hair around the sides and back of her head that was exposed while she was preparing food trays at the holding table. In an interview with Cook1, on [DATE] at 4:20 PM, she stated she had worn the hairnet properly when she put it on and all her hair was covered, but she was unsure when it had pulled upward to the bun and exposed the other sections of hair. Continued observation of the kitchen on [DATE] at 4:30 PM, revealed refrigerator1 had a sealed plastic container with bologna that was expired. Further, there was bacon in the original container that had been opened, but was not sealed or covered when stored. Further observation on [DATE] at 4:35 PM in the hall beside the kitchen prep area, revealed a juice refrigerator with a pureed dessert cup which was unsealed. Additional observation on [DATE] at 4:40 PM of the kitchen dry storage area, revealed a box of spaghetti noodles in the original container, which was opened and not sealed when stored. Continued observation on [DATE] at 4:50 PM of the kitchen area which contained additional freezers, revealed 3-door Freezer1 contained a large original container of mixed vegetables, which had been opened, but was not sealed or covered. An additional observation of the kitchen, on [DATE] at 9:45 AM, revealed breakfast freezer1 had a box of biscuits in the original package that had been opened, but not sealed or covered when stored. Continued observation revealed refrigerator1 had a box of bacon in the original container that had been opened and was in a large plastic bag, but was not sealed or covered when stored. In an interview with Cook1, on [DATE] at 11:00 AM, she stated hairnets should be worn to prevent hair and other contaminants in residents' food. She stated not only would residents be upset if they found hair in their food, but this could potentially make them sick. She further stated the correct way to wear a hairnet was ensuring all hair was covered. In further interview, she stated food stored in the refrigerator was to be dated and with a used by date of three days. She stated if food was not being discarded past the use by date, residents could be served spoiled food and this could cause illness. Cook1 stated when food was received from the delivery truck it was to be dated with the received date. She further stated when boxes were opened and stored in the refrigerator or freezer they should be sealed and a use by date added to prevent spoilage of food or contamination. She further stated following these guidelines would ensure residents were safe. In an interview with Cook2, on [DATE] at 11:15 AM, she stated hairnets were required to prevent contaminants like hair from getting into the residents' food. She further stated a hairnet should cover all of your hair. Cook2 stated a resident may get angry if they were eating and found a hair in the food and staff should work to prevent this from happening. In further interview, she stated food stored in the refrigerator that was outdated should be discarded. She stated anything stored in the refrigerator should include a use by date of 3 days. She further stated residents could get sick if food was expired and served to them. Cook2 stated all stored food items when opened were to be sealed and dated and staff should ensure they were following the facility's policies and procedures on food storage. She stated staff should do their job correctly to keep residents safe. In an interview with Cook3, on [DATE] at 9:30 AM, she stated she had worked in the facility for seven months and was a breakfast and lunch cook. She further stated hairnets were important because they helped to prevent staff's hair from falling into the food. In further interview, she stated refrigerated food had a stored date and a three day use by date. She stated residents could get a food borne illness if they were served expired or contaminated food. She further stated food that had been stored after opening was to be resealed and the container closed and dated with the opened date. Cook3 stated all dietary staff was responsible to follow guidelines to ensure residents were not served food that could cause food borne illnesses. She further stated the facility was the resident's home and they should be happy and feel safe. In an interview with the Dietary Director (DD) on [DATE] at 8:51 AM, she stated she expected all kitchen staff to to have hair pulled up or back with a hairnet worn to cover all hair. She stated if hairnets were not worn properly hair could fall into the food causing potential bacteria or foodborne illness for residents. In further interview, she stated when food was stored unsealed or left open to air, contamination could cause resident sickness. She stated all food items were to be sealed and covered when stored in the refrigerator or freezer. The DD stated it was her expectation staff follow the facility's policies and procedures regarding food storage and expiration dates to ensure residents were not served outdated foods in order to prevent potential sickness. In continued interview, the DD stated education was the first step when staff had not followed dietary procedures, and if staff was found non-compliant a second time, a meeting would occur for more one-on-one instruction. She stated failure to follow the facility's policies and procedures regarding hair nets and proper food storage was not acceptable because the resident's age, medical conditions, and lower immunity could increase the potential for sickness if food safety guidelines were not followed. During an interview with the Administrator, on [DATE] at 10:58 AM, he stated it was his expectation dietary staff wear hairnets properly to prevent infection control concerns and to ensure resident's did not find hair in their food. Further, he stated it was his expectation staff conduct daily checks of expiration dates and throw out expired foods. He further stated food items should be sealed and covered when stored in the refrigerator or freezer. Additionally, he stated staff should follow facility policies and procedures and stay up-to-date on education and utilize that guidance to ensure resident's receive quality care.

Based on observation, interview, record review, and facility policy, it was determined the facility failed to implement interventions for six (6) residents of eleven (11) residents (Residents #1, #2, and #3). Resident #1, #2, and #3 related to the implementation of fall interventions in care plans; Resident #5 related to 1:1 care plan supervision interventions not being implemented. Additionally, Residents #8 and Resident #9's medications were administered outside the before and after hour window. The findings include: Review of facility policy, undated and titled, Care Planning & Implementation policy, revealed the purpose of the policy was to ensure all services required by the resident, while considering their rights, to maintain their highest and most practical well-being. Care plans were to be reviewed and changed as necessary by nursing related to falls, care, behaviors, and etc. Care plans are able to be viewed in the Kardex section in plan of care (POC) for the nurse assistant. Review of facility policy, undated and titled, Using the Care Plan, revealed the care plan was used in developing the residents daily care routines and will be available to staff personnel who have the responsibility for providing care or services to residents. 1.) Record review revealed the facility admitted Resident #1 on 11/20/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Assessment Scoring Report, dated 07/12/2021, revealed Resident #1's Brief Interview Mental Status was fifteen (15), signifying Resident #1 was cognitively intact. Review of Resident #1's Care Plan, target date of 10/07/2021 and titled, Resident #1 is low risk for falls related to gait/balance problems, working with therapy to build strength up to go home. The following interventions were placed: gray mat beside bed near door with date of intervention initiated 02/22/2021. However, on 02/26/2021 fall intervention assessment documentation revealed the resident to be at high risk for falls with a score of 85. Review of Resident #1's SRNA Safety care plan revealed devices to be a gray mat beside bed near door, (02/21/2021). Observation, on 07/13/2021 at 10:22 AM, 12:35 PM, and 4:05 PM, revealed Resident #1's fall mat to be rolled up to the head of the bed, and bed not in low position. 2). Record review revealed the facility admitted Resident #2 on 07/28/2016 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of 07/112/2021 Assessment Scoring Report revealed Resident #2 had a BIMS score of three (03) signifying the resident had severe cognitive impairment. Observation on 07/12/2021 at 4:15 PM and 4:45 PM revealed Resident #2's bed at knee level, bed alarm pad in resident's chair across the room, and alarm box under the head board frame of his/her bed. Observation on 07/19/2021 at 1:18 PM revealed Resident #2's bed to be at knee level and not in low position. Interview with SRNA #4, on 07/19/2021 at 1:18 PM, revealed Resident #1's bed should have been a low bed because if resident fell would not want the bed high because it could be a worse injury. Observation on, 07/12/2021 at 4:53 PM, with Unit Manager (UM) #1 revealed Resident #2's bed at knee level and a bed alarm in the resident's chair across the room and alarm box under head board frame of residents bed. Interview with Unit Manager (UM) #1, on 07/12/2021 at 4:53 PM, revealed Resident #2's care plan and State Certified Nurse Aide (SRNA) careplan (Kardex) required a low bed and a bed sensor alarm. UM #1 then stated Resident #2 was to be on low bed, and careplanned for a bed sensor alarm, and they should have been in place. Interview with State Certified Nurse Aide (SRNA) #1, on 07/12/2021 at 4:56 PM, revealed he had gotten busy and forgot to to go back and put the alarms in place. The fall interventions for Resident #2 was a low bed, and the resident was to always have an alarm on the bed. Review of Resident #2's Care plan for falls revealed the following interventions: bed in lowest position at all times with the date of 04/02/2020, sensor alarm to mattress and check for placement and functioning, landing strip (gray mat) to left side of bed for safety awareness, and follow facility fall protocol. Review of Resident #2's SRNA Safety careplan revealed the following interventions: Bed in lowest position at all times (dated 04/02/2020), gray mat to left side of bed for safety awareness, Sensor alarm to mattress check for placement and functioning. 3). Record review revealed the facility admitted Resident #3 on 07/20/2017 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of 07/12/2021 Assessment Scoring report revealed Resident #3 had a BIMS of four (04) signifying severe cognitive impairment. Review of Resident #3's Care Plan dated 10/10/20 included the following interventions: fall mat to right side of bed dated 08/06/2020, and a low bed. Review of Resident #3's SRNA safety care plan, dated 08/06/2020, revealed a gray mat was to be on the right side of the bed. Observation on, 07/12/2021 at 4:25 PM, revealed Resident #3's fall mat (at door side) was under his/her bed frame. Interview with State Certified Nurse Aide (SRNA) #1, on 07/19/2021 at 12:43 PM, revealed he was assigned the rooms of Resident #1 and #3. The rooms were to be checked every two hours, and follow the careplans, make sure the fall mats were on the floors and call lights in reach and if the bed was in the low position. The SRNA knows the interventions by looking at the residents Kardex, and it is everyone's responsibility to follow careplans. 4). Record review revealed the facility admitted Resident #5 on 03/30/2021 with initial admission on 01/30/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Quarterly Minimum Data Set, dated dated dated [DATE] revealed a BIMS of (00) and requiring extensive to limited assistance with activities of daily living with no behaviors noted. Review of 05/22/2021 Assessment Scoring Report of Resident #5's BIMS of one (01) , revealing resident had severe cognitive impairment. Review of Resident #5's progress notes dated 06/13/2021 at 3:14 PM, revealed Resident #5 yelling and reaching out and hitting Resident #6 on forearm. On 06/14/2021 at 2:17 PM, Resident #5 sent to a behavioral health facility. Further review of progress and behavior notes: revealed Resident #5 was sent to the behavioral unit on 06/14/2021 and returned to facility on 06/25/2021 at 14:48 PM. Behavior note for 07/15/2021 at 2:05 AM, revealed the resident was cursing, punching and trying to kick the nurse as she attempted to give feeding and med's for 3:00 AM time frame. Review of investigation dated 06/13/2021 revealed Resident #5 hit Resident #6 on the arm as he/she was rolling past the resident in the hallway with investigation substantiated. Review of Event Evaluation, dated 06/13/2021, revealed Resident #5 was yelling at Resident #6 and had hit Resident #6 on his/her arm. Review of Event Evaluation, dated 06/27/2021 at approximately 12:30 PM, revealed Resident #5 to have an altercation with yelling and cursing at Resident #7, and Resident #7 stating Resident #5 had hit him/her on the arm. Resident #5 was placed on 1:1 watch until further notice. Review of supervision sheets revealed Resident #5 to be on 1:1 supervision until 07/16/2021, and was then transferred out to another facility. Observation, on 07/14/2921 at 4:35 PM, of SRNA #2 revealed she was coming out of the double doors (in the back hall) dining room. Observation of Resident #5, on 07/14/2021 at 4:35 PM, sitting in wheelchair in his/her hallway with no staff in close proximity. Interview with SRNA #2, on 07/14/2021 at 4:40 PM, revealed she was the aide that was to be providing 1:1 supervision of Resident #5, the SRNA stated she was trying to get the resident coffee when she stepped away. Interview with Registered Nurse (RN) #3, on 07/14/2021 at 4:38 PM, revealed SRNA #2 was supposed to be with Resident #5. Additionally, RN #3 stated that everyone follows a residents care plan. Interview with SRNA #3, on 07/14/2021 at 4:45 PM, revealed SRNA #2 was not in view of Resident #5 and she should not leave at any time and the Certified Medication Technician (CMT) had stayed behind because the resident was alone. SRNA#2 had gone to get something but had not said anything to them and the SRNA could have taken the resident with her. Interview with Charge Nurse/Licensed Practical Nurse (LPN) #3, on 07/14/2021 at 4:50 PM, revealed everyone should follow the care plan and everyone should make sure that interventions were done. If a resident is on 1:1, someone should be with them at all times. Review of Resident#5's Behavior careplan revealed resident to have a behavior problem (yelling/screaming, increase in wandering due to disease process,Traumatic Brain Injury (TBI)], and resident tends to have sexual behaviors related to the disease process of TBI. Interventions/Tasks placed include 1:1 watch with initiation date of 07/03/2021. Review of Kardex for Resident #5 revealed monitoring of 1:1 for the resident. Interview with LPN # 4, on 07/19/2021 at 4:10 PM, revealed the purpose of interventions are to keep anything from happening or reoccuring. The purpose of 1:1 supervision was to keep the resident in eyesight to make sure he/she did not do it again and make sure that someone was sitting 1:1 with the resident, and if someone went to get coffee then someone else would need to know. Interview with Assistant Director of Nursing (ADON), on 07/19/2021 at 5:09 PM, revealed everyone should follow the careplans of residents. Not following the care plan could result in more falls and the resident not receiving the right care. Additionally, the ADON stated that it was the responsibility of the SRNA's, CMT's, and nurses with the nurse ensuring that the intervention was implemented and functioning. Additionally the ADON stated that the SRNA's look at the Kardex for updates, have a message board as well on the kiosk, and the SRNA was supposed to read the kardex and they got report from other nurse aides. The ADON stated 1:1 means staff was within eyesight of the resident. If the staff must leave the resident, they need to notify another staff member so the resident could be in eyesight. The ADON would have expected the SRNA to have notified another staff member of her leaving so that the staff member could be in eyesight. 5). Observation, on 07/13/2021 at 9:47 AM, revealed CMT #1 administering Resident #8's 8:00 AM medications, which consisted of: [MEDICATION(S)] (diuretic) forty (40) milligrams (mg), [MEDICATION(S)] (atypical antipsychotic) 40 mg, [MEDICATION(S)] (proton pump inhibitor) 20 mg, Potassium (electrolyte)] 10 milliequivalents (Meq) two (2) tabs. Record review revealed the facility admitted Resident #8 on 04/21/2015 with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #8's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #8's July 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] ., Potassium (electrolyte) were given at 8:00 AM including day of 07/13/2021. Review of activities of daily living (ADL) careplan, dated 08/08/2021, for Resident #8, revealed the intervention of: may crush all meds together and give related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 6). Observation on 07/13/2021 at 9:58 AM revealed CMT #1 administering Resident #9's 8:00 AM medications at approximately 9:58 AM, which consisted of: [MEDICATION(S)] (corticosteroid) inhaler 160/4.5 mcg (2) two puffs, Alluporinol (Anti-gout, Anti-hyperuricemic agents 100 mg tab daily, [MEDICATION(S)] (opthalmic claucoma agents) 1% (1) one drop both eyes, Pantroprazole (proton pump inhibitor) 40 mg, Respridone(Antipsychotic, Atypical Antipsychotic medication) 1 mg, MVI (vitamin deficiency due to poor diet of certain illnesses) one time daily. Record review revealed the facility admitted Resident #9 on 04/07/2019 with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #9's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 9's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #9's careplans dated 08/19/2021 and entitled: Resident has the potential to be physically aggressive with interventions of administer medications as ordered and monitor/document for side effects and effectiveness. A care plan revealed the resident had a congestive heart failure diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Cardiac medications were to be administered as ordered. Care plan revealed the resident had GERD with an intervention to give medications as ordered and to monitor for side effects and effectiveness. The resident was also care planned to use [CONDITION(S)] medication for a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had a care plan for a mood problem related to dementia with intervention to administer [CONDITION(S)] medication as ordered by physician and to monitor for side effects and effectiveness. Interview with Certified Medication Assistant (CMT) #1, on 07/13/2021 at approximately 10:00 AM, 07/18/2021 at approximately 2:40 PM revealed, they have an hour window before and after to give medications. CMT #1 further stated she was aware of this through her CMT course, the training at the facility and she assumed that was what she was supposed to do because it was the standard as well. CMT #1 stated that if they are behind they can tell the nurse and they will followup and report to the doctor. ahe nurses are available to help if they let them know. CMT #1 stated the outcome of giving medications later than allotted time frame of hour window would be a medication error and probably affect the next dose. Interview with CMT #1, on 07/19/2021 at 11:30 AM, revealed she did not know she was behind, she thought the medications were to be given at 9:00 AM. She should look at the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Medications can be given hour before and hour after the time on the MAR. Additionally, CMT #1 stated she had not noticed the 8:00 AM so she did not realize they were out of the hour before and hour after window to let the nurse know; she stated she had not realized it so she did not inform the nurse that she was outside the hour window. The CMT stated she would let nurse know. Interview with Licensed Practical Nurse (LPN) #2, on 07/19/2021 at 3:35 PM, revealed she had not been informed of any medications given outside of time frame by CMT #1, but if medication was given out of time and the medicine needed to be given then she would call the physician and ask if the medication could be given. Interview on 07/19/2021 at 3:55 PM with LPN #1 revealed that CMT #1 had informed LPN #1 that the medications were not given outside the before or after hour window. LPN #1 further stated the outcome could be that giving medications outside the hour window could interfere with the other medications; that the first thing would be to contact the doctor to see what to do and then to notify the Assistant Director of Nursing (ADON), Director of Nursing (DON) and the Power of Attorney/Resident Representative (POA/RR). Interview with Registered Nurse #1, on 07/17/2021 at 11:09 AM, revealed that if the staff get behind on medication administration they are instructed to notify the nurse. The physician was to be notified to make sure the medication can still be given. RN #1 further stated that if medications are out of compliance they could interfere with the next dose. Interview with Assistant Director of Nursing (ADON), on 07/19/2021 at 5:09 PM, revealed the medication administration window was one hour before and one hour after prescribed time and if staff were getting out of time frame they were to notify the nurse for help. The nurse could notify the physician to see if the medications could be given. The ADON stated the outcome could be that this could interfere with the next dose, and the nurse should be notified immediately. Interview with Director of Nursing (DON), on 07/13/2021 at 4:30 PM, revealed the nurse should oversee medications given and if the CMT gets behind, they let us know and there was an hour window before and after the ordered medication administration time frame. DON further stated that her expectation was that the medications would be given in the hour before and hour after window and the outcome of medications not being given could affect blood pressure and antibiotics should be given. Additionally, the DON stated the outcome depends on the medication or if not given timely may take longer to get in system.

Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to ensure residents' environment remained free of accidents/hazards, ensured adequate supervision and assistive devices to prevent accidents for six (6) residents in a sampled size of ten (10) residents. Resident #1, #2, #3 had falls with interventions that were observed not implemented. Resident #5 had been involved in a resident-to-resident altercation and was placed on 1:1 supervision with supervision not in affect. Resident # 8 and Resident # 9, medications were given outside physician ordered time frames. The findings include: Review of facility policy, dated 08/20/2019 and titled, Accident/Incident Investigation and Reporting, revealed the purpose was to identify any injuries obtained from an accident or incident and to provide written record of facts in deviations from the standard of care. This also provided a written record of corrective measures taken/needed to prevent recurrence. The scope was Applied to all Nursing staff/Certified Medication Assistants (CMAs)/Certified Nursing Assistants (CNA's) processes. Preventative measures should be implemented, as appropriate. Comprehensive care plans should be updated as needed and new information was to be added to the resident profile on Kiosk, as appropriate. Steps should be made for updating of the care plan by putting interventions into place for the incident. Review of Facility Policy undated and entitled, Fall Assessment Policy, revealed; The resident care plan was reviewed/revised by the charge nurse as appropriate to assure the identified fall risk issue(s) were identified, that altered interventions were initiated, if appropriate and that preventative measures were addressed. Review of facility policy dated 05/20/2019 and titled, Behavior Management revealed; behavior management was an individual plan of care for specific residents with mood/behavior issues. This plan of care was included in the interdisciplinary care plan that was initiated upon admission/readmission and reviewed/revised at least quarterly and with any identified change of condition of the resident. Each resident will be provided with a safe place of residence. Review of facility policy undated and entitled, Prohibiting Abuse, Neglect, Misappropriation & Exploitation, revealed; the policy was to provide a homelike environment that includes a culture and environment that treats each resident with respect and dignity while protecting the health and welfare of each resident; to assure that each resident was free from verbal, sexual, physical, and mental abuse; corporal punishment, neglect, involuntary seclusion, misappropriation, exploitation and injuries of unknown origin. Prevention: Residents with needs and behaviors which might lead to conflict or neglect are identified, assessed and have a careplan developed through the RAI process. These residents are monitored and reassessed according to their needs. Review of facility policy dated 05/12/2019 and titled, Close Watch Policy Initiation, revealed, The purpose of this policy is to ensure that those residents that exhibit socially inappropriate behaviors such as but not limited to suicidal ideation, sexual behaviors, hitting, etc. would be appropriately monitored so that no harm would come to resident/staff or other residents. One on One (1:1) can be initiated if deemed appropriate. 1). Record review revealed Resident #1 was admitted by the facility on 11/20/2020 with diagnoses which included [CONDITION(S)] ([CONDITION(S)]), [CONDITION(S)] Pectoris, Acute [CONDITION(S)] Infarctions ([NAME]), Arthropathy, [CONDITION(S)] Heart Disease and the Presence of a Cardiac Pacemaker. Review of Assessment Scoring Report, dated 07/12/2021, revealed Resident #1 Brief Interview Mental Status to be (15) fifteen, signifying Resident #1 was cognitively intact. Review of fall investigation, signed 02/22/2021, revealed Resident #1 was found beside the right side of the bed laying in the floor and was sent to the emergency room for evaluation after sustaining a goose egg on the back of his/her head. Review of History and Physical (H & P) Report, dated 02/22/2021, revealed Resident #1 fell while at Skilled Nursing Facility (SNF) on 02/21/2021 and complained of back pain with resident being sent to emergency room for evaluation. Resident was noted to have elevated white blood cell count, possible pneumonia noted on chest x-ray, and a sacral fracture that is suspected to be new. Resident #1 was sent back to the SNF and then was a direct admit on 02/22/2021 due to continued symptoms and [CONDITION(S)] (decrease in oxygen). Additionally the H & P states that resident had radiology exams on 02/22/2021 with the following impression of CT lumbar spine without contrast-impression: Mildly displaced fracture of the S4 segment of the sacrum, new compared to 11/13/2020 and probably acute. Review of 03/2021 through present fall documentation, provided by facility on 07/14/2021, revealed Resident #1 had one fall on 05/01/2021 with additional information provided regarding a fall on 02/21/2021; Resident #2 had (10) ten falls but facility provided an additional fall for Resident #2 for 04/2021. Resident #3 list included (3) three falls since the month of 03/2020. Review of Resident #1's 02/12/2021 and 02/26/2021 fall intervention assessment documentation, revealed no previous falls but resident known to have an impaired gait, and to be weak with a low fall risk of 40. 02/26/2021 fall intervention assessment documentation revealed resident with previous falls to have impaired weak gait, and to be weak and to be at high risk for falls at a score of 85. Review of 02/21/2021 Fall Intervention Follow-up dated 02/21/2021 revealed Interventions/Careplan Revisions to be Gray mat beside bed near door and signed 02/22/2021. Review of 04/08/2021 Fall Assessment documentation revealed Resident #1 to has a history of falls, to have weak impaired gait and to be weak. 05/06/2021 Fall Assessment for Resident #1 revealed Resident with a history of falls, with 1-2 falls in the past (3) three months to have a weak impaired gait and to be weak. Review of 05/01/2021 and 05/02/2021 Fall Intervention Follow-up revealed the Interventions/Careplan revisions were gripper/non-skid socks on feet while out of bed Review of Neurological Assessment of Resident #1 dated 02/21/2021 and 05/01/2021 revealed consecutive Neuro checks for two days following falls. Review of chart documents (CT of Lumbar without contrast) dated 02/21/2021 revealed Resident #1 to have a Sacral Fracture ,mildly displaced fracture of S-4 segment of sacrum when compared to 11/13/2020. Review of Resident #1's care plan with target date of 10/07/2021 and entitled, Resident #1 was low risk for falls related to gait/balance problems, working with therapy to build strength up to go home with following interventions placed: gray mat beside bed near door with date of intervention initiated 02/22/2021. However, on 02/26/2021 fall intervention assessment documentation revealed resident to be at high risk for falls at a score of 85. Review of Resident #1's SRNA's Safety careplan revealed Devices: gray mat beside bed near door, (02/21/2021). Observation, on 07/13/2021 at 10:22 AM, 12:35 PM, and 4:05 PM, revealed Resident #1 with fall mat to door side of bed to be rolled up to the head of the bed, and bed not lowered to low bed level. Observation, on 07/14/2021 at 11:22 AM, revealed Resident #1 bed was at low bed level. Interview with Resident #1, 07/13/2021 at 10:22 AM, revealed he/she had fallen three (3) times, the fall mat is supposed to go beside the bed but the resident did not really know who had placed the mat rolled up at the head of the bed, and it was noted the bed was not placed at low level. Interview with Certified Medication Technician (CMT)#2, on 07/13/2021 at 10:34 AM, revealed that if a resident is a fall risk and they have fall mats or alarms in their rooms. Interview with Nurse Aide (NA) #1 , on 07/13/2021 at 4:10 PM, revealed the residents fall interventions that are on the Kardex can be viewed on the Kiosk, but did not speak to the fall mat being rolled up to the head of the bed. Interview with Registered Nurse (RN) #2, on 07/13/2021 at 4:12 PM, revealed several staff had been in Resident #1's room on 07/13/2021 and the resident probably had a fall and was care planned for a fall mat. Additionally, RN #2 stated that the outcome could be that the resident would get a bruise, and the fall mat should not be rolled up at the head of the bed (HOB). 2). Record review revealed the facility admitted Resident #2 on 07/28/2016 with the following diagnoses: Cerebral Infarction due to Embolism of unspecified Cerebral Artery, [CONDITION(S)], [CONDITION(S)], Type II Diabetes Mellitus, Acute Kidney Failure, Anxiety Disorder, Dependence on Wheelchair, Repeated Falls, History of Falling, Muscle Weakness, Limitation of Activities due to Disability, Anorexia, Primary Hypertension, unspecified Dementia without Behavioral Disturbance, and unspecified [CONDITION(S)]. Review of 07/14/2021 list of falls document provided by facility revealed Resident #2 to have had (10) ten falls and one other fall in April 2020 not listed. Review of 07/112/2021 Assessment Scoring Report revealed Resident #2 to have the following BIMS score of (03) three signifying resident to have severe cognitive impairment. Review revealed Resident #2 to have fall intervention follow-ups with the following dates: 06/29/2020, 06/30/2020, 07/17/2020,07/17/2020, 08/23/2020, 01/01/2021, 01/01/2021, 01/04/2021, 01/26/2021, 01/27/2021, 01/28/2021, 01/29/2021, 06/15/2021, 06/16/2021. Record review revealed Resident #2's to have the following dated fall assessments and consecutive fall risk scores: on 01/23/2020 score 55 high risk for falling, on 04/05/2020 score 85 high risk for falling, on 04/13/2020 score 85 high risk for falling, on 07/13/2020 score 75 high risk for falling, on 09/21/2020 score 75 high risk for falling, on 10/19/2020 score 75 high risk for falling, on 01/19/2021 score 75 high risk for falling, on 04/09/2021 score 55 high risk for falling, and on 07/07/2021 score 55 high risk for falling. Review of unwitnessed fall dated 04/02/2020 revealed intervention placed was bed in lowest position, and resident had a gray mat during fall beside the bed. Review of Resident #2's 04/02/2020 Progress notes revealed resident had a fall beside bed with complaint of Left hip pain. Left hip x-ray completed with conclusion of acute intertrochanteric/subtrochanteric fracture of left femur with medial and superior displacement with resident sent to the ER and resident admitted to acute care facility for left hip fracture and surgery performed on 04/03/2020. with resident returning to facility on 04/05/2020 with surgical incision to left hip and (10) ten staples to incision site and IV in left AC of Ivanz (antibiotic used to prevent infection in people having certain types of surgery). Review of Resident #2 Careplan for falls revealed the following interventions: Bed in lowest position at all times with the date of 04/02/2020, sensor alarm to mattress check for placement and functioning, landing strip (gray mat) to left side of bed for safety awareness, and follow facility fall protocol. Review of Resident #2's SRNA Safety careplan revealed included the following interventions: Bed in lowest position at all times (dated 04/02/2020), gray mat to left side of bed for safety awareness, Sensor alarm to mattress check for placement and functioning. Observation, on 07/12/2021 at 4:15 PM and 4:45 PM of Resident #2's bed, found it to be at knee level, bed alarm pad in resident's chair across the room and alarm box was under the head board frame of his/her bed. Interview and observation on, 07/12/2021 at 4:53 PM of Unit Manager (UM) #1 related to Resident #2's bed at knee level, bed alarm pad in resident's chair across the room, and alarm box under head board frame of residents bed revealed UM #1 looking at the careplan and State Certified Nurse Aide (SRNA) careplan (Kardex) of Resident #1. UM #1 then stated Resident #1 is to be on low bed, and care planned for a bed sensor alarm, and they should have been in place. Interview with State Certified Nurse Aide (SRNA) #1, on 07/12/2021 at 4:56 PM, revealed that the fall interventions for Resident #2 was a low bed, and resident was to always have an alarm on the bed; but he had gotten busy and forgot to go back and put the alarm in place. Observation on 07/19/2021 at 10:20 AM, 10:45 AM, 11:30 AM and 1:18 PM revealed Resident #2's bed at below knee cap level and above the ankle level with Resident to not be on low bed per careplan. Interview with SRNA #4, on 07/19/2021 at 1:18 PM, revealed Resident #2 is supposed to be on low bed and his/her bed should have been low because if he/she should fall, one would not want the resident on a high bed. 3). Record review revealed facility admitted Resident #3 on 07/20/2017 to include the following diagnoses: Cerebral Infarction, Unspecified Dementia without Behavioral Disturbance, Unspecified Convulsions, Muscle Weakness, Abnormal Posture, Unspecified Arthritis, Personal History of [CONDITION(S)], and Personal History of Malignant Neoplasm of Breast. Review of 07/12/2021 Assessment Scoring report revealed Resident #3 to have a BIMS of (04) four signifying severe cognitive impairment. Review of list of falls provided by facility on 07/14/2021 revealed Resident #3 to have had (3) three falls between 03/24/2020 and 04/19/2021. Review of fall careplan, with target date of 10/10/2021, for Resident #3 included the following interventions: fall mat to right side of bed 08/06/2020, low bed, perimeter defined mattress obtain UA with (C&S) culture & Sensitivity related to / increased confusion Review of SRNA safety careplan for Resident #3 revealed, gray mat to right side of bed 08/06/2020. Review of physician orders dated 07/08/2021 revealed order for gray mat to right side of bed. Observation on 07/12/2021 at 4:25 PM revealed Resident #3's fall mat (at door side) was under his/her bed frame. Interview with State Certified Nurse Aide (SRNA) #1, on 07/19/2021 at 12:43 PM, revealed he was on the hall of Resident #1 and Resident #3 and aides are to check the rooms every two hours, follow careplans, make sure the fall mats are on the floors, call lights within reach and low beds, Additionally, SRNA #1 stated that the SRNA's knows the interventions by looking at residents Kardex, and it was the responsibility of everyone to follow careplans. 4). Record review revealed facility admitted Resident #5 on 03/30/2021 with initial admission on 01/30/2021 and diagnoses to include: Alzheimer's Disease, Anxiety Disorder, Unspecified [CONDITION(S)] due to a Substance or Unknown Physiological Condition, Major Depressive Disorder, Dementia in Other Diseases Classified Elsewhere with Behavioral Disturbance, and Essential History of [CONDITION(S)]. Review of 04/06/2021 Quarterly Minimum Data Set revealed BIMS of (00) signifying severe cognitive impairment and resident required extensive to limited assistance with activities of daily living (ADLs) with no behaviors noted. Review of 05/22/2021 Assessment Scoring Report of Resident #5's BIMS of (01) one, revealed resident had severe cognitive impairment. Review of Resident #5's progress notes dated 06/13/2021 at 3:14 PM and 06/14/2021 at 2:17 PM revealed Resident #5 yelling and reaching out and hitting Resident #6 on forearm, and then Resident #5 was sent to a behavioral health facility. Further review of progress and behavior notes: revealed Resident #5 was sent to behavioral unit on 06/14/2021 and returned to facility on 06/25/2021 at 14:48 PM. Behavior note for 07/15/2021 at 2:05 AM revealed Resident #5 cursed, punched, tried to kick nurse for attempting to provide feeding and medication's at 3:00 AM time frame. Review of substantiated investigation dated 06/13/2021 revealed Resident #5 had hit Resident #6 on the arm as he/she was rolling in the hallway past the resident. Review of 06/13/2021 Event Evaluation revealed Resident #5 had yelled at Resident #6 and hit Resident #6 on his/her arm. Review of 06/27/2021 at approximately 12:30 PM Event Evaluation revealed Resident #5 had an altercation of yelling and cursing at Resident #7, with Resident #7 stating Resident #5 had hit his/her arm and 1:1 watch of resident until further notice. Review of initiated supervision sheets revealed Resident #5 to be on 1:1 supervision until 07/16/2021, and transferred to another facility. Observation on 07/14/2921 at 4:35 PM of SRNA #2 revealed she was coming out of the double doors (in the back hall) dining room out of supervised 1:1 view of Resident #5 that she had been assigned. Observation of Resident #5 on 07/14/2021 at 4:35 PM sitting in wheelchair in his/her hallway with no staff in close proximity. Interview on 07/14/2021 at 4:40 PM with SRNA#2 revealed she was to be providing 1:1 supervision of Resident #5, with SRNA stating she was trying to get the resident coffee. Interview on 07/14/2021 at 4:38 PM with Registered Nurse (RN) #3 revealed SRNA #2 was supposed to be with Resident #5. Interview on 07/14/2021 at 4:45 PM with SRNA #3 revealed SRNA #2 was not in view of Resident #5 and had gone to get something but had not said anything to other staff and SRNA #2 could have taken the resident with her. SRNA #3 stated Certified Medication Technician (CMT) had stayed behind because the resident was alone. Interview with Charge Nurse/Licensed Practical Nurse (LPN) #3, on 07/14/2021 at 4:50 PM, revealed if a resident is on 1:1 then staff is with them at all times and needs to be close. Additionally, Charge Nurse/LPN #3 stated knowing Resident #5's behaviors she would question not being close. Review of Resident#5's Behavior care plan revealed resident to have a behavior problem (yelling/screaming, increase in wandering due to disease process [CONDITION(S)] (TBI), and resident tends to have sexual behaviors related to disease process of TBI. Interventions/Tasks placed included 1:1 watch with initiation date of 07/03/2021. Review of Kardex for Resident #5 revealed monitoring of 1:1 for the resident. Interview on 07/19/2021 at 4:10 PM with LPN # 4 revealed the purpose of 1:1 supervision was to keep the resident in eyesight, to make sure he/she does not do it again, make sure that someone is sitting 1:1 with the resident, and if someone went to get coffee then someone else needs to know about it. Interview, on 07/19/2021 at 5:09 PM, with Assistant Director of Nursing (ADON) revealed everyone follows the care plans of residents, with outcome of not receiving the right care. Additionally, ADON stated that it is the responsibility of the SRNAs, CMTs, and nurses; with the nurse ensuring that the interventions are implemented and functioning. Additionally ADON stated SRNAs look at the Kardex for updates, have a message board as well on the kiosk, and are supposed to read the kardex as well as getting report from other nurse aides. ADON stated that 1:1 means that staff is within eyesight of resident and they are going to leave a resident, the staff needs to notify another staff member so the resident can be in eye sight, but can not tell a certain amount of feet away; just as long as the staff member has told another staff member that would be fine. ADON stated she would expected the SRNA to have notified another staff member before leaving so that the staff member would be in eyesight. 5). Observation, on 07/13/2021 at 9:47 AM, revealed CMT #1 was administering Resident # 8's 8:00 AM medications, which consisted of: [MEDICATION(S)] (diuretic) forty milligrams (40 mg), [MEDICATION(S)] (atypical antipsychotic) forty milligrams (40 mg), [MEDICATION(S)] (proton pump inhibitor) twenty milligrams (20 mg) and Potassium (electrolyte) ten milliequivalents (10 Meq) two (2) tabs. Record review revealed Resident #8 was admitted by the facility on 04/21/2015, with diagnoses which included Unspecified Sequelae of Unspecified [CONDITION(S)] Disease, Heart Failure, [CONDITION(S)] in other Chronic Diseases classified elsewhere, [CONDITION(S)], Type II Diabetes mellitus, [CONDITION(S)] Disorder, major Depressive Disorder, Essential Hypertension, and Gastroesophageal Reflux Disorder (GERD). Review of Resident #8's Physician orders dated July 2021 revealed [MEDICATION(S)] (diuretic) forty milligrams (40 mg), [MEDICATION(S)] (atypical antipsychotics) forty milligrams (40 mg), [MEDICATION(S)] (proton pump inhibitors) twenty milligrams (20 mg) and Potassium (electrolyte) were to be given at 8:00 AM Review of Resident #8's July 2021 Medication Administration Record (MAR), revealed [MEDICATION(S)] (diuretic) forty milligrams (40 mg), [MEDICATION(S)] (atypical antipsychotic) forty milligrams (40 mg), [MEDICATION(S)] (proton pump inhibitor) twenty milligrams (20 mg) and Potassium (electrolyte) were given at 8:00 AM including day of 07/13/2021. Review of Resident #8's activities of daily living (ADL) careplan, dated 08/08/2021, revealed interventions staff could crush all meds together, give cardiac medications as ordered, and administer diuretic medications as ordered by the Physician and administer medications as ordered while watching for side effects/effectiveness. 6). Observation, on 07/13/2021 at 9:58 AM, revealed CMT #1 was administering Resident #9's 8:00 AM medications at approximately 9:58 AM, which consisted of: [MEDICATION(S)] (corticosteroid) inhaler 160/4.5 mcg (2) two puffs, Alluporinol (Anti-gout, Antihyperuricemic agents 100 mg tab daily, [MEDICATION(S)] (opthalmic [CONDITION(S)] agent) 1 % (1) one drop both eyes, Pantroprazole (proton pump inhibitor) 40 mg, Respridone(Antipsychotic, Atypical Antipsychotic medication) 1 mg and MVI (vitamin deficiency) once daily. Record review revealed Resident #9 was admitted by the facility on 04/07/2019 which included diagnoses: Heart Failure, hypertensive Chronic Kidney disease with Stage V chronic Kidney Disease or End Stage Renal Failure, Unspecified Dementia without Behavioral Disturbance, [CONDITION(S)], Unspecified Protein-Calorie Malnutrition, Major Depressive Disorder, Other Hemorrhagic Disorder due to [MEDICATION(S)] Circulating Anticoagulants, Antibodies, or Inhibitors, Dysphagia, Oropharyngeal Phase, Pain in Joints of Left Hand, Stiffness of Left Hand, and Contracture of Muscle, Left Hand. Review of Resident #9's physician orders dated July 2021 revealed [MEDICATION(S)] (corticosteroid) inhaler 160/4.5 mcg (2) two puffs, Alluporinol (Anti-gout, Antihyperuricemic agent) 100 mg tab daily, [MEDICATION(S)] (opthalmic [CONDITION(S)] agent) 1 % (1) one drop both eyes, Pantroprazole (proton pump inhibitor) 40 mg, Respridone(Antipsychotic, Atypical Antipsychotic medication) 1 mg and Tab-A-Vite (MVI) were to be given at 8:00 AM. Review of Resident #9's Medication Administration Record revealed [MEDICATION(S)] (corticosteroids) inhaler 160/4.5 mcg (2) two puffs, Alluporinol (Anti-gout, Antihyperuricemic agent) 100 mg tab daily, [MEDICATION(S)] (opthalmic [CONDITION(S)] agent) 1 % (1) one drop both eyes, Pantroprazole (proton pump inhibitor) 40 mg, Respridone (Antipsychotic, Atypical Antipsychotic medication) 1 mg and Tab- A- Vite (MVI) were to be given at 8:00 AM and initialed that they were given at 8:00 AM. Review of Resident # 9's care plans, target dates of 08/19/2021 and titled, Resident has the potential to be physically aggressive. Care plan interventions for CHF, GERD and the use of psychotropics include administering medications as ordered to include psychotropics, monitor and document side effects and effectiveness. Additionally, Resident #9's Careplan-resident had congestive heart failure diagnosis, at risk for signs/symptoms of congestive heart failure revealed the following intervention: give cardiac mediations as ordered. Careplan- the resident had GERD related to to takes medication and has diagnoses of GERD with the following intervention: Give medications as ordered. Monitor for side effects and effectiveness. Careplan-the resident uses [CONDITION(S)] medications related to diagnoses of depression revealed the following intervention: Administer [CONDITION(S)] medication as ordered by physicians. Monitor for side effects and effectiveness every shift. Careplan the resident has a mood problem related to dementia revealed the following intervention: Administer [CONDITION(S)] medication as ordered by physicians. Monitor for side effects and effectiveness. Careplan-the resident has potential for pressure ulcer development related to requires assistance with bed mobility revealed the following intervention: Administer [CONDITION(S)] medication as ordered by physicians. Monitor for side effects and effectiveness. Interview with Certified Medication Technician (CMT) #1, on 07/13/2021 at approximately 10:00 AM, revealed they have a one (1) hour before and after window to administer medications. CMT #1 further stated she was aware of this through her CMT course, the training at the facility and she assumed that is what supposed to do because it is the standard as well. CMT #1 stated that if they are behind they were to tell the nurse and they will follow up and report to doctor, and the nurses are available to help if they make them aware. CMT #1 stated the outcome of giving medications later than allotted time frame would be medication error and possibly could alter the next dose. Interview with CMT #1, on 07/19/2021 at 11:30 AM and 1:22 PM, revealed she did not know she was behind, she thought the medications were to be given at 9:00 AM, that she should look at the Medication Administration Record (MAR) to see the time medications are to be given; and medications can be given hour before and hour after the time on the MAR. Additionally, CMT #1 stated she had not noticed the 8:00 AM so she did not realize they were out of the hour before and hour after window to let the nurse know. She stated she had not realized it so she did not inform the nurse that she was outside the hour window. CMT#1 stated she would let the nurse know. CMT #1 stated at approximately 1:22 PM that she had discussed the medication administration with another CMT and had realized that the medications were for 8:00 AM but she did not remember giving them late, and she had been training another staff member. Interview with Licensed Practical Nurse (LPN) #2, on 07/19/2021 at 3:35 PM, revealed she had not been informed of any medications given outside of time frame by CMT #1, but if medication were given out of the time frame and the medicine needed to be given, then she would call the physician and ask if the medication could be given. Interview with LPN #1, on 07/19/2021 at 3:55 PM, revealed CMT #1 had informed LPN #1 that the medications were not given outside the before or after hour window. LPN #1 further stated giving medications outside the hour window could interfere with the other medications. The nurse would contact the doctor to see what to do and then the nurse was to notify the Assistant Director of Nursing (ADON), Director of Nursing (DON) and the Power of Attorney/Resident Representative (POA/RR). Interview with Registered Nurse #1, on 07/17/2021 at 11:09 AM, revealed if the staff get behind on medication administration, they are instructed to notify the nurse and the physician to make sure the medication can still be given. RN #1 further stated that if medications are out of compliance they could interfere with the next dose. Interview with Assistant Director of Nursing (ADON), on 07/19/2021 at 5:09 PM, revealed the medication administration window was one hour before and one hour after the prescribed time. If staff were getting out of time frame they were to notify the nurse for help and the nurse would notify the physician to see if the medications could be given. The ADON stated the outcome could be that this could interfere with the next dose, and the nurse should be notified immediately. Interview with Director of Nursing (DON), on 07/13/2021 at 4:30 PM, revealed the nurse should oversee medication administration and if the CMT gets behind, they let the nurse know. There is an hour window before and after the ordered medication administration time frame. The DON further stated that her expectation was that the medications would be given in the hour before and hour after window.

Based on observation, interview, record review and facility policy, it was determined the facility failed to ensure professional standards of practice related to notification of medications given outside the prescribed time for Resident #8 and Resident #9. The findings include: Review of policy that facility utilized for Professional Standards, titled Gerontologist Nursing by Mosby 2nd ed., revealed The Seven Rights: Rules for Giving Medications revealed the seven (7) rights for giving medications were the same no matter who was giving them. The rules or seven rights for giving medication administration were the right drug, the right dose, the right patient, the right route, the right time, the right technique, the right documentation. The right time means to check the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . All routine medications should be given within thirty minutes of the scheduled time. Furthermore, a drug should never be left at the patients bedside. Drugs to be taken on an empty stomach should be given 1 hour before meals or 2 hours afterwards. Review of facility policy, dated 05/21/2019 and titled, Change in Residents Condition or Status/regulation. The charge nurse should notify the resident's attending physician per facility protocol and / or when deemed necessary or appropriate in the best interest of the resident. Unless otherwise instructed by the resident, the charge nurse would notify the residents family/responsible party at any time the charge nurse/Administrator/DON deemed it appropriate. Regardless of the residents mental or physical condition, nursing services will inform the resident of any changes in his/her medical care or nursing treatments. The charge nurse would record in the residents medical record any changes in the residents medical condition or status as well as those notified, the times of notification, and responses received. Review of facility policy, undated and titled, Medication Pass Schedule, revealed the Policy Purpose was to establish medication pass times. General medication pass times were as follow: 7 AM, 11 AM, 4 PM, 8 AM, 12 PM, 5 PM, 9 AM, 1 PM and 6 PM. All mediation pass times were subject to change based on resident preference and physician orders. Staff has a window of one (1) hour before to one (1) hour after the scheduled time to administer the medication. Review of facility policy, undated and titled Facility, Oral Medications, revealed staff were to verify the physicians medication order for resident's name, drug name, dose, time and route of administration. Medications should be taken to the resident's room at the correct time. Reporting and Documentation should have included the following information should be reported to the staff/charge nurse and should be documented in the resident's medical record. The drug name, dose, time, date, and route of administration should be documented on the resident's medication administration (MAR) immediately after the drug was given. 1). Observation on, 07/13/2021 at 9:47 AM, revealed CMT #1 administered Resident #8's 8:00 AM medications, which consisted of: [MEDICATION(S)] (diuretic) forty (40) milligrams (mg), [MEDICATION(S)] (atypical antipsychotic) forty (40) mg (milligrams), [MEDICATION(S)] (proton pump inhibitor) twenty milligrams (20 mg) and Potassium (electrolyte) ten milliequivalents (10 Meq)two (2) tabs. Record review revealed the facility admitted Resident #8 on 04/21/2015 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #8's physician orders, dated July 2021, revealed [MEDICATION(S)] (diuretic) 40 mg once daily, [MEDICATION(S)] (atypical antipsychotic) 40 mg once daily, [MEDICATION(S)] (proton pump inhibitor) 20 mg once daily, and Potassium three times daily (TID), the first doses were to be given at 8:00 AM. Review of Resident #8's July 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of target dated 08/08/2021, Resident #8's activities of daily living (ADL) care plan revealed the intervention may crush all meds together and give related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident is on diuretic therapy related to a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan for Resident#8, revealed to administer medications as ordered and monitor for side effects and effectiveness. 2). Observation on, 07/13/2021 at 9:58 AM, revealed CMT #1 administered Resident #9's 8:00 AM medications at approximately 9:58 AM, which consisted of [MEDICATION(S)] (corticosteroid) inhaler 160/4.5 mcg two (2) puffs, Alluporinol (Anti-gout, Anti-hyperuricemic agents100 mg tab daily, [MEDICATION(S)] (opthalmic [CONDITION(S)] agent) 1 % one (1) drop both eyes, Pantroprazole (proton pump inhibitor) 40 mg, Respridone (Antipsychotic, Atypical Antipsychotic medication) 1 mg and MVI (vitamin deficiency due to poor diet or certain illnesses) one time daily. Record review revealed Resident #9 was admitted by the facility, on 04/07/2019, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #9's physician orders, dated July 2021, revealed [MEDICATION(S)] (corticosteroid) inhaler 160/4.5 mcg two (2) puffs, Alluporinol (Anti-gout, Antihyperuricemic agents 100 mg tab daily, [MEDICATION(S)] (opthalmic [CONDITION(S)] agent) 1% one (1) drop both eyes, Pantroprazole (proton pump inhibitor) 40 mg, Respridone (Antipsychotic, Atypical Antipsychotic medication) 1 mg and Tab-A-Vite (MVI) were to be given at 8:00 AM. Review of Resident #9's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #9's care plan, target dated 08/19/2021 and titled Resident has the potential to be physically aggressive when medications were administered as ordered. The resident should be monitored and documentation entered for side effects and effectiveness. Review of the Care plan revealed to give medications as ordered as well as anti-[CONDITION(S)] medications and to monitor for side effects and effectiveness every shift. Interview with Certified Medication Technician (CMT) #1, on 07/13/2021 at approximately 10:00 AM, and on 07/18/2021 at approximately 2:40 PM, revealed there was an hour window before and after administration time to give medications. CMT #1 further stated she was aware of this through her CMT course, training at the facility and she assumed that is what they were supposed to do because it was the standard as well. CMT #1 stated if they were behind on their medication pass, they were to tell the nurse, who will then follow-up and report to doctor. Additionally, CMT #1 stated nurses were available to help, if they were made aware. CMT #1 stated the outcome of giving medications later than the allotted administration time would be a medication error and would affect the next dose. Interview with CMT #1, on 07/19/2021 at 11:30 AM, revealed she did not know she was behind and thought the medications were to be given at 9:00 AM. She also revealed she should look at the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The CMT stated she would let the nurse know the medication was given outside of the hour window Interview with Licensed Practical Nurse (LPN) #2, on 07/19/2021 at 3:35 PM, revealed she had not been informed of any medications given outside of time frame by CMT #1. She revealed the physician should have been notified if a medication were given out of the allotted time frame to determine if the late medication should be given. Interview with LPN #2, on 07/19/2021 at 3:55 PM, revealed that CMT #1 had informed LPN #1 that the medications were not given outside the before or after hour window. LPN #1 further stated the outcome of giving medications outside of the hour window could interfere with other medications. The Physician should be contacted for further orders. The Assistant Director of Nursing (ADON), Director of Nursing (DON), and the Power of Attorney / Resident Representative should be notified as well. Interview with Registered Nurse #1, on 07/17/2021 at 11:09 AM, revealed that if staff get behind on their medication administration pass, they were to notify the nurse and then the physician should be notified to make sure they can still give the medication. RN #1 further stated that if medications are administered out of compliance, they could interfere with the next dose. Interview with the ADON, on 07/19/2021 at 5:09 PM, revealed the medication administration window was one hour before and one hour after prescribed time and if staff are getting out of time frame they were to notify the nurse for assistance. The nurse should notify the physician to see if the medications can be given. ADON stated the outcome could be that this could interfere with the next dose, and the nurse should be notified immediately. Interview with the DON, on 07/13/2021 at 4:30 PM, revealed the nurse should oversee medications given and if the CMT gets behind, they are to let the nurse know, as there was an hour window before and after the ordered administration time. The DON further stated that her expectation was that the medications would be given within the hour window. If not given on time, the effects of the medication could be affected. in the hour before and hour after window.

Based on observation, interview,record review, and review of facility policy, it was determined the facility failed to ensure medications were administered within the prescribers order for two (2) residents (Resident #8 and Resident #9). During observation of medication administration pass on 07/13/2021, for Resident #8 and Resident #9, 8:00 AM prescribed medications were given at 9:47 AM and 9:58 AM consecutively. The findings include: Review of facility policy, undated and titled, Medication Pass Schedule, revealed the purpose of the policy was to establish medication pass times. General medication pass times were as follows: 7:00 AM, 11:00 AM, 4:00 PM, 8:00 PM, 12:00 PM, 5:00 PM, 9:00 AM, 1:00 PM and 6:00 PM. All medication pass times were subject to change based on resident preference and physician orders. Staff has a window of 1 hour before to 1 hour after the scheduled time to administer the medication. Review of facility policy, undated and titled, Facility, Oral Medications, revealed staff should verify the physicians medication order for resident's name, drug name, dose, time and route of administration. Medications should to taken to the resident's room at the correct time. When reporting and documenting: the following information, should be reported to the staff/charge nurse and should be documented in the resident's medical record. The documentation should contain the drug name, dose, time, date, and route of administration. The information should be documented in the resident record after the medication has been administered. 1). Observation on, 07/13/2021 at 9:47 AM, revealed Certified Medication Technician (CMT) #1 administered Resident #8's 8:00 AM medications, which consisted of: [MEDICATION(S)] (diuretic) forty milligrams (40 mg), [MEDICATION(S)] (atypical antipsychotics) forty milligrams (40 mg), [MEDICATION(S)] (proton pump inhibitors) twenty milligrams (20 mg) and Potassium(electrolyte) ten milliequivalents (10 meq) two tablets. Record review revealed the facility admitted Resident #8 on 04/21/2015 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #8's physician orders, dated July 2021, revealed [MEDICATION(S)] (diuretic) forty milligrams (40 mg), [MEDICATION(S)] (atypical antipsychotic) forty mg (40 mg), [MEDICATION(S)] (proton pump inhibitor) twenty milligrams (20 mg) and Potassium (electrolyte) were to be given at 8:00 AM. Review of Resident #8's July 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] ., [MEDICATION(S)] (atypical antipsychotic) 40 mg., [MEDICATION(S)] (proton pump inhibitor) 20 mg., and Potassium (electrolyte) were given at 8:00 AM including day of 07/13/2021. 2). Observation, on 07/13/2021 at 9:58 AM, revealed CMT #1 administered Resident # 9's 8:00 AM medications at approximately 9:58 AM, which consisted of: [MEDICATION(S)] (corticosteroids) inhaler 160/4.5 mcg (2) two puffs, Alluporinol (Antigout, Antihyperuricemic agents100 mg tab daily, [MEDICATION(S)] (opthalmic [CONDITION(S)] agent) 1% (1) one drop both eyes, Pantroprazole (proton pump inhibitor) 40 mg., Respridone(Antipsychotic, Atypical Antipsychotic medication) 1 mg and MVI (vitamin deficiency due to poor diet or certain illnesses) one time daily. Review of Resident #9's Activities of Daily Living (ADL) care plan, dated 08/08/2021, revealed interventions to include: may crush all medications together and give related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review revealed the facility admitted Resident #9 on 04/07/2019, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #9's physician orders, dated July 2021, revealed [MEDICATION(S)] (corticosteroid) inhaler 160/4.5 mcg two (2) puffs, Alluporinol (Anti-gout, Antihyperuricemic agent) 100 mg. tab daily, [MEDICATION(S)] (opthalmic [CONDITION(S)] agent) 1% (1) one drop both eyes, Pantroprazole (proton pump inhibitor) 40 mg., Respridone (Antipsychotic, Atypical Antipsychotic medication) 1 mg and Tab-A-Vite (MVI) were to be given at 8:00 AM. Review of Resident 9's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . tab daily, [MEDICATION(S)] (opthalmic [CONDITION(S)] agents) 1% (1) one drop both eyes, Pantroprazole (proton pump inhibitor) 40 mg., Respridone (Antipsychotic, Atypical Antipsychotic medication) 1 mg. and Tab- A- Vite (MVI) were to be given at 8:00 AM and initialed that they were given at 8:00 AM. Review of Resident # 9's care plans dated 08/19/2021 revealed the resident had the potential to be physically aggressive related to the administration of medications. Per the care plans, staff were to administer medications as ordered, monitor/document for side effects and effectiveness. Interview with Certified Medication Assistant (CMA), on 07/13/2021 at approximately 10:00 AM and on 07/18/2021 at approximately 2:40 PM, revealed they have an hour window before and after to give medications. CMA #1 further stated she was aware of this through her CMA course, the training at the facility and she assumed that is what supposed to do because it is the standard as well. CMA #1 stated that if they were behind they should tell the nurse and they will follow-up and report to doctor, and the nurses are available to help if they let them know. CMA #1 stated the outcome of giving medications later than allotted time frame of a one hour window would be a medication error and possibly affect the next dose. Interview with CMA #1, on 07/19/2021 at 11:30 AM, revealed she did not know she was behind, she thought the medications were to be given at 9:00 AM, that she should look at the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally, CMA #1 stated she had not noticed the 8:00 AM so she did not realize they were given out of the hour window and she did not inform the nurse accordingly. Interview with Licensed Practical Nurse (LPN) #2, on 07/19/2021 at 3:35 PM, revealed she had not been informed of any medications given outside of time frame by CMA #1, but if medication were given out of time and the medicine needed to be given then she would call the physician and ask if the medication could be given. Interview with LPN #1, on 07/19/2021 at 3:55 PM, revealed that CMA #1 had informed LPN #1 that the medications were given outside the before or after hour window. LPN #1 further stated the outcome could be that giving medications outside the hour window would be that it could interfere with the other medications; the first thing that would be done is to contact the doctor to see what to do and then to notify the Assistant Director of Nursing (ADON), Director of Nursing (DON) and the Power of Attorney/Resident Representative (POA/RR). Interview with Registered Nurse #1, on 07/17/2021 at 11:09 AM, revealed that if staff get behind on medication administration they are instructed to notify the nurse and the physician, to make sure the medication can be given. RN #1 further stated that if medications are out of compliance they could interfere with the next dose. Interview with Assistant Director of Nursing (ADON), on 07/19/2021 at 5:09 PM, revealed the medication administration window is one hour before and one hour after prescribed time. If staff are administrating outside of time frame, they are to notify the nurse for help. The nurse can notify the physician to see if the medications should be given. ADON stated the outcome could be that this could interfere with the next dose, and the nurse would be notified immediately. Interview with Director of Nursing (DON), on 07/13/2021 at 4:30 PM, revealed the nurse should oversee medications being given and if the CMA gets behind, they should notify the DON. The DON further stated her expectation was for the medications to be given in the hour before and hour after window. The outcome of medications not being given could affect the blood pressure (BP) if the medication was a blood pressure medication. Additionally, the DON stated the outcome depends on the medication or if not given timely, may take longer to get into the system.

Based on observation, interview,record review, and review of facility policy, it was determined the facility failed to ensure one residents medication, in a sample size of 11 residents, (Resident # 9) were not left at the bedside in a medication cup from view of nursing staff. Resident #9's medications were left on the bedside table in a medication cup out of view of staff, while Certified Medication Technician (CMT) #1 retrieved napkins for eye drops. The findings include: Review of facility policy, undated and titled, Facility, Oral Medications, revealed staff should remain with the resident until he/she has taken all of his/her medications. The staff should not leave medications on the bedside table. 1). Observation, on 07/13/2021 at 9:50 AM, revealed CMT #1 pulled and placed medications in medication cup for Resident #9, to include: [MEDICATION(S)] (Anti-gout, Antihyperuricemic agents)one hundred milligans (100 milligrams mg), [MEDICATION(S)] (proton pump inhibitor) forty milligrams (40 mg), [MEDICATION(S)] (Antipsychotic, Atypical Antipsychotic medication) one milligram (1 mg), and a Multivitamin. CMT #1 went to administer Resident #9's medications and placed them on the bedside table at 9:58 AM, leaving the room to obtain napkins needed for the administration of eye drops, where the medications were out of view of the CMT. Interview with CMT #1, on 07/13/2021 at approximately 10:00 AM, and 07/18/2021 at approximately 2:40 PM, revealed she normally would take the medications with her when leaving the room, but she was nervous. Additionally, CMT #1 stated the policy of leaving medications on the bedside table was they are not supposed to leave the medication. The outcome could be that someone could come get the medication or the medication could be lost. However, CMT #1 stated that Resident #9 is blind, cannot move out of the bed,and she did not think it was a risk to him/her. Review of a list of wanderers in the facility, on 07/19/2021 at 5:15 PM, revealed there were three (3) wanderers in the facility. The list was provided by Assistant Director of Nursing (ADON). Interview with Registered Nurse (RN) #1, on 07/17/2021 at 11:09 AM, revealed that medications are to be in sight of the CMT at all times and should never be left in the room of a resident unattended. The resident might not take them or another resident could take them. RN#1 also revealed that if medications were given out of compliance, it could interfere with the next dose. Interview with the ADON, on 07/19/2021 at 5:09 PM, revealed the nursing staff should be in sight of medications at all times. An outcome of medications being left at the bedside could be the resident does not get the dose or another resident could retrieve the medication and take it. The ADON reported her expectation is the aide would be in eyesight of the medications. Interview with the Director of Nursing (DON), on 07/13/2021 at 4:30 PM, revealed the nurse should oversee medications given.

Based on interview, record review, facility policy review, and hospital record review, it was determined the facility failed to revise the Comprehensive Care Plan for one (1) of three (3) sampled residents (Resident #1). Resident #1 had an unwitnessed fall without injury on 01/03/2020 at approximately 8:45 PM; however, the facility failed to put a new intervention in place to address the resident getting up and ambulating without assistance. On 01/04/2020 at approximately 6:20 AM, Resident #1 had another unwitnessed fall that resulted in a Subdural Hematoma, Nasal Fracture and Right Proximal Humerus Fracture. The findings include: Review of the facility policy titled. Care Planning and Implementation not dated, revealed care plans are reviewed and changed as necessary by nursing related to falls, care, dignity, behaviors, preferences, etc. Record review revealed the facility admitted Resident #1 on 08/17/2018, with diagnoses, which included weakness, and Unspecified Dementia without behavioral disturbances. Review of the quarterly Minimum Data Set (MDS) assessment dated , 10/14/2019, revealed the facility assessed Resident #1's cognition as moderately impaired with a Brief Interview for Mental Status (BIMS) score of nine (9) which indicated the resident was interviewable. Review of a facility investigation, dated 01/03/2020 at 8:45 PM, revealed Resident #1 had a fall with no injury when attempting to transfer without calling for assistance from staff per care plan. However, review of Resident #1's Comprehensive Care Plan for at risk for falls related to weakness, assist needed with Activities of daily living (ADL's), and Dementia revealed there was no documented evidence the care plan was updated with a new intervention after the fall on 01/03/2020, to address the resident attempting to get up without assistance. Review of a facility investigation dated 01/04/2020 at 6:20 AM, revealed Resident #1's was found lying on his/her right side in a puddle of blood from his/her nose. The resident indicated he/she was trying to get up. The resident was assessed for head injury, and it was identified his/her nose was swollen and there was an abrasion above the right eye. The Physician ordered resident sent out for evaluation and treatment. Review of hospital Discharge Summary dated 01/08/2020, revealed the resident's discharge [DIAGNOSES REDACTED]. Interview with Resident #1 on 01/28/2020 at 11:45 AM and 1:45 PM, revealed she was tired and wanted to put his/herself to bed on 01/03/2020, and fell out of his/her wheelchair and was not hurt. The resident stated he/she yelled for help, and staff came, picked him/her up, and put him/her back to bed. Resident #1 further revealed on the morning of 01/04/2020, he/she was trying to get out of his/her wheelchair, but does not remember why, and he/she fell flat on his/her face. The resident stated staff hauled him/her off to the hospital because they insisted he/she be checked out. Interview with Licensed Practical Nurse (LPN) #1 on 01/28/2020 at 3:08 PM, revealed Resident #1 had two (2) falls on her shift, and the first fall was on 01/03/2020 around 8:45 PM. LPN #1 stated the resident stated he/she was attempting to transfer his/herself from the wheelchair to the bed. The resident was assessed to have no injuries. She stated she did not recall if she had updated the care plan with a new intervention; however, she did remind the resident to use call light for assistance. LPN #1 reported the second fall occurred early in the morning of 01/04/2020 around 6:20 AM. She stated she heard a CNA yell out, so she ran down to Resident #1's room, to find the resident laying on his/her right side in a puddle of blood from his/her nose. She revealed she assessed the resident, and the resident had a swollen nose and an abrasion above the right eye. She called the physician and got an order to send the resident to the emergency room for evaluation and treatment. Interview with Advanced Registered Nurse Practitioner (ARNP) on 01/29/2020 at 10:33 AM, revealed if the facility policy indicated they were to update the care plan and attempt a new measure, then she would have expected them to follow their policy. She stated maybe the second fall could have been prevented but maybe not, She revealed the fall that occurred on 01/04/2020, resulted in a fracture but the resident did not require surgery and she is still at the same functioning level as prior to the fall. Interview with the Director of Nursing (DON) on 01/29/2020 at 9:41 AM and 11:31 AM, revealed LPN #1 called her on 01/03/2020, that evening to let her know Resident #1 had a fall with no injury. She stated she then received another phone call from LPN #1 that Resident #1 had fallen again on 01/04/2020 at 6:20 AM and was sent out to for evaluation and treatment. She revealed when reviewing the care plan she did not see where LPN #1 had added a new intervention after the first fall on 01/03/2020. She further stated she would have expected LPN #1 to add a new intervention to the care plan, in order to help try to prevent any future falls. Interview with the Administrator on 01/29/2020 at 2:10 PM revealed he was under the impression a new intervention had been added to Resident #1's care plan. He stated he expected the facility to have followed the falls policy, and added a new intervention, even if the resident was opposed to the safety intervention, so at least we could show we tried a new safety measure.

Based on interview, record review, facility policy review, and hospital record review, it was determined the facility system to ensure adequate supervision and assistive devices were in place to prevent accidents was ineffective for one (1) of three (3) sampled residents (Resident #1). Resident #1 had an unwitnessed fall with an injury on 01/03/2020 due to attempting to transfer without assistance; however, the facility failed to address the resident's attempting to transfer without assistance with a new intervention by repeating an intervention to educate resident to use call light. Resident #1 sustained another fall on 01/04/2020 attempting to transfer without assistance, which resulted in a Subdural Hematoma, Nasal Fracture, and Right Proximal Humerus fracture. The resident did not require surgery and remained at the same functional level. The findings include: Review of facility policy titled, Falls Assessment Policy, not dated, revealed the resident's care plan is reviewed/revised (by the charge nurse) as appropriate, to assure that the identified fall risk issue (s) is identified, that altered interventions are initiated, if appropriate; and that preventive measures are addressed. If current care plan includes potential for injury related to falls, add additional problem statement/goal/interventions for actual injury, if present. If no identified injury, review current interventions present for the potential for injury and revise as appropriate. Record review revealed the facility admitted Resident #1 on 08/17/2018, with [DIAGNOSES REDACTED]. Review of Resident #1's quarterly Fall assessment dated [DATE] revealed a score of fifty (50), which indicated the resident was at high risk for falls. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/14/19, revealed the facility assessed Resident #1's cognition as moderately impaired with a Brief Interview for Mental Status (BIMS) score of nine (9) which indicated the resident was not interviewable. Further review of the MDS revealed the facility assessed Resident #1's required extensive assistance of two (2) persons for bed mobility and transfers. Review of Resident #1's Comprehensive Care Plan for falls, not dated revealed the resident was at risk for falls related to weakness, assistance needed with Activities of daily living (ADL's), and Dementia. Further review of the care plan revealed interventions to re-educate resident on importance of call light, waiting for staff assistance, waiting for staff assistance before standing, and pulling call cord in restroom. In addition, there were intervention for resident to be taken to and given showers in the shower chair, wheelchair to be out of reach while in bed, be sure the resident's call light is within reach, and resident needs prompt response to all request for assistance. Review of the facility investigation, dated 01/03/2020 at 8:45 PM, revealed Resident #1 was observed lying on his/her right side, and denied hitting his/her head. The resident told the nurse he/she slid from wheel chair, and may have been trying to transfer self to bed. The resident was assessed for injury with nothing found and the resident's call light was not going off, so the resident was informed to use the call light when needing help to bed which he/she had been reminded of before. However, further review of the record and the resident's care plan revealed there was no documented evidence staff developed a new intervention to address the resident's continued attempts to transfer/ambulate without assistance. Review of the facility investigation, dated 01/04/2020 at 6:20 AM, revealed the nurse was sitting at nurse's station and heard someone yell. The Certified Nurse Aide (CNA) ran to his/her room and the resident was laying on his/her right side in a puddle of blood from his/her nose. A washcloth was applied to his/her nose and the bleeding stopped. The resident indicated he/she was trying to get up when he/she fell . Further review of the investigation revealed the nurse assessed the resident and identified the resident's nose was swollen and there was a abrasion above the right eye. The Physician was notified and ordered resident sent out for evaluation and treatment. Review of hospital Discharge Summary dated 01/08/2020, revealed Resident #1 was admitted on [DATE], and discharged back to the facility on [DATE]. Further review revealed the resident's discharge [DIAGNOSES REDACTED]. The patient should wear a sling and be non-weight bearing with that arm. Interview with Resident #1 on 01/28/2020 at 11:45 AM, revealed on the morning of 01/04/2020, he/she was seated up in his/her wheel chair already dressed and ready for breakfast. He/she stated he/she was trying to get out of his/her wheel chair, but does not remember why. Resident #1 stated he/she fell flat on his/her face, and smashed it and the facility hauled him/her off to the hospital. Further interview with Resident #1 on 01/28/2020 at 1:45 PM, revealed she was tired and wanted to put him/herself to bed on 01/03/2020, and fell out of his/her wheel chair and was not hurt. Resident #1 stated he/she yelled for help, and they came, picked him/her up, and put him/her back to bed. He/she further stated, I just wished the hell you would quit asking me about my falls, yes I fell and I'll probably fall again. If they would just leave me the hell alone I would be just fine. Interview with CNA #1 on 01/28/2020 at 2:20 PM, revealed on the morning of 01/04/2020, he and CNA #4 assisted Resident #1 up and helped him/her get dressed. CNA #1 stated the resident was his/her usual self, nothing was different. CNA #1 further revealed Resident #1 was is two (2) assist with care, dressing and transfers, and was alert, oriented, friendly, and really likes his/her smoke breaks. CNA #1 revealed he was not around when the resident fell . Interview with CNA #4 on 01/29/2020 at 10:41 AM, revealed on the morning of 01/04/2020 she and CNA #1 had already gotten Resident #1 up and dressed for the day. She stated the resident wearing shoes and seated up in the wheelchair near the bedside table waiting for breakfast. CNA#4 further revealed during her morning rounds with another CNA, she was going down the hall giving report, and she heard a loud noise coming from Resident #1's room. She stated she immediately went to the room, and found Resident #1 lying on the floor in front of his/her wheelchair, with blood on the floor. The other CNA yelled for the nurse, who came and assessed the resident. CNA #4 stated Resident #1 started cussing like his/her normal self, and stated the wheel chair rolled away from him/her as he/she was trying to get up. She further stated Resident #1's call light was within reach when she and CNA #4 had left the room only about five (5) minutes earlier or maybe ten (10) minutes. Interview with Licensed Practical Nurse (LPN) #1 on 01/28/2020 at 3:08 PM, revealed Resident #1 actually had two (2) falls on her shift. The first fall her and told me Resident #1 was lying on the floor next to his/her bed. She stated she immediately went down to assess the resident, who indicated he/she was attempting to transfer his/herself from the wheel chair to the bed. The resident was assessed to have no injuries and the resident indicated he/she had not hit his/her head. She revealed she initiated Neuro-checks as it was a unwitnessed fall, and that was the facility's policy. She stated she was not sure if she had updated the care plan with a new intervention; however, she did remind the resident to use call light for assistance. Then she notified the family and the physician. She revealed the second fall occurred early in the morning 01/04/2020 around 6:20 AM. She stated she was seated at the nurse's station when she heard a CNA yell out, and she ran down to Resident #1's room, to find him/her laying on his/her right side in a puddle of blood from his/her nose. She stated she assessed the resident, and the resident had a swollen nose, and an abrasion above the right eye. She called the physician and got an order to send to the emergency room for evaluation and treatment. She stated she then called the daughter to let her know the resident had fallen again, and was sent out to ER for evaluation and treatment. Interview with Advanced Registered Nurse Practitioner (ARNP) on 01/29/2020 at 10:33 AM revealed the facility did call and make her aware of Resident #1's two (2) falls. She stated, With an unwitnessed fall it is hard to establish why the fall happened. She revealed she was fairly familiar with the resident, as she has seen the resident on several occasion for a variety of reasons and the resident was very head strong, and opinionated. She stated she was not sure what other measure to put in place that would help try to prevent a future fall for Resident #1 and sometimes no matter how hard you try to prevent a person from falling, they are still going to fall. She further revealed if the facility policy indicated they were to update the care plan and attempt a new measure, then she would have expected them to follow their policy so maybe the second fall could have been prevented, and maybe not. She stated the resident did have a fracture with the second fall that occurred on 01/04/2020; however, the resident did not require surgery and he/she is still at the same functioning level as prior to the fall. Interview with the Director of Nursing (DON) on 01/29/2020 at 9:41 AM and 11:31 AM, revealed LPN #1 called her on 01/03/2020, to let her know Resident #1 had a fall with no injury and that she had implemented neuro-checks. She stated she then received another phone call from LPN #1 that Resident #1 had fallen again on 01/04/2020 at 6:20 AM and was transferred out for evaluation and treatment. She revealed it was not until later in the day that she found out the resident was transferred to another hospital for further testing. She revealed Resident #1 returned to the facility on [DATE], and did not require surgical interventions and came back with an order to be followed up by neurology consult in two (2) weeks. She stated the resident is still able to self-propel his/herself down to the smoke area, and does so numerous times throughout the day. Interview with the Administrator on 01/29/2020 at 2:10 PM revealed, he was under the impression the facility had updated the resident's care plan with a new intervention. He did not realize they had added an intervention already in place to re-educate the resident. He further stated staff should have at least tried something new even if the resident would have discontinued the measure, then it would at least show they tried something new.

Based on observation, interview, and facility policy review, it was determined the facility failed to post nurse staffing information in a prominent place readily accessible to residents and visitors. The findings include: Review of facility policy titled, Staffing Policy, not dated, revealed the facility shall post staffing on a daily basis that includes the facility name, the current date, the resident census, and the actual number of nursing staff on duty each shift. The posting shall be displayed in a public place. Observation on 10/08/19 at 1:20 PM and 3:30 PM revealed staffing was posted behind a shelf at the receptionist desk which was not visible to residents and visitors Interview with Receptionist #1, on 10/09/19 at 1:22 PM, revealed she was responsible for posting the staffing sheets. She stated she posted them on the inside of her desk as she had been trained. She further stated the staffing sheets were not visible to residents and visitors. Interview with Director of Nursing (DON) on 10/08/19 at 3:30 PM revealed staffing was not posted in a visible location. Interview with Administrator on 10/09/19 at 4:25 PM revealed posting should be visible to residents and visitors.

Based on interview, record review and review of facility policy, it was determined the facility failed to adequately supervise one (1) of three (3) sampled residents (Resident #3) to prevent sexual behaviors towards another resident. Resident #3 had a history of [REDACTED]. On 08/10/19, Resident #3 was observed rubbing Resident #2's breast in the hallway. Resident #3 was placed on 15 minute checks even though this type of incident could happen again in less than 15 minutes. A short time later, Resident #3 was observed to go toward Resident #2 again prior to the next 15 minute check, and was redirected down the hall; however, increased supervision (one to one) was not put in place at this time. On 08/11/19, Resident #3 was observed to grab Resident #2's breast. The findings include: Review of a facility policy, not titled or dated, revealed the purpose of the policy was to ensure that those residents that exhibit socially inappropriate behaviors such as but not limited to suicidal ideation, sexual behaviors, hitting etc. will be appropriately monitored so that no harm will come to resident/staff or other residents. Record review revealed the facility admitted Resident #2 on 10/08/12 with [DIAGNOSES REDACTED]. Review of a quarterly Minimum Data Set (MDS) assessment, dated 07/12/19, revealed the facility assessed Resident #2's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of zero (0) which indicated the resident was not interviewable. Record review revealed the facility admitted Resident #3 on 06/03/16 with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment, dated 08/14/19, revealed the facility assessed Resident #3's cognition as moderately impaired with a BIMS score of nine (9). Further review revealed the facility did a BIMS assessment as part of this allegation investigation and the resident's cognition was severely impaired with a BIMS score of three (3). Review of a Behavioral Health note, dated 11/27/17, revealed Resident #3 was started on [MEDICATION NAME] (hormone) for inappropriate sexual behaviors. The resident was ordered [MEDICATION NAME] 0.5 mg on Monday, Wednesday, Friday and Saturdays Review of Resident #3's Comprehensive Care Plan for potential behavior problem of inappropriate comments and touching of female staff, dated 06/10/19, revealed interventions for staff to explain/reinforce why behavior is inappropriate and/or unacceptable to the resident; to intervene as necessary to protect the rights and safety of others; and, to approach/speak in a calm manner, divert attention, remove from situation, and take to alternate location as needed. Review of a Behavior Note for Resident #3, dated 08/10/19 at 6:05 AM, revealed the resident was observed by a nurse rubbing the breast of Resident #2 in the hallway. Resident #3 was escorted to his/her room and told that was inappropriate behavior and the resident stated the other resident wanted him/her to do it. The resident was then placed on every fifteen (15) checks even though this could happen in less then 15 minutes. Further review of the Note revealed a short time later, Resident #3 went toward Resident #2 when he/she was wheeling back down the hallway before the first 15 minute check; however, staff still did not increase the resident's supervision to one to one. Interview with Licensed Practical Nurse (LPN) #2 on 08/27/19 at 5:07 PM, revealed on 08/10/19, she came out of a resident's room and saw Resident #3 with his/her hand on Resident #2's left breast. She stated she immediately separated the residents and increased Resident #3's supervision to every fifteen (15) minutes checks. She further stated she thought 15 minutes checks were adequate. Further interview (Post Survey) with LPN #2 on 09/12/19 at 8:34 AM, revealed Resident #3 self propelled back to where Resident #2 was within the 15 minute time frame before the next 15 minute check was due. She stated she did not increase the resident's supervision because the CNA was there to intervene and the resident did not touch the other resident again. She further revealed it was usually the Social Services Director that would make the call about increasing supervision further unless the nurse felt it needed to be done sooner. Review of a Behavior Note for Resident #3, dated 08/11/19 at 12:23 PM, revealed the resident inappropriately touched Resident #2 and the resident was placed on one to one (1:1) supervision. Interview with State Registered Nurse Aide (SRNA) #1, on 08/28/19 at 2:58 PM, revealed she was assigned to do every fifteen (15) minute checks on Resident #3, on 08/11/19. She stated the resident was located in his/her room when she completed a fifteen (15) minute check and after that check was when the resident was seen with his/her hand on Resident #2's breast. She stated the resident was very quick and can self propel quickly from place to place. Interview with Housekeeper, on 08/28/19 at 9:33 AM, revealed she came out of a room and saw Resident #3 wheel up to Resident #2 and grab the resident's left breast on 08/11/19 at 12:20 PM. The resident was immediately redirected and the incident was reported to the nurse. Interview with the Director of Nursing (DON), on 08/27/19 at 3:08 PM, revealed she expected when an incident occurred the residents be separated and an intervention placed. She stated staff increased supervision after the incident on 08/10/19.

Based on observation, interview and review of facility policy it was determined the facility failed to ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety. Observations of the kitchen revealed dirty kitchen equipment and foods/drink in the refrigerators not dated when opened. Review of the facility Census and Condition dated 09/18/18 revealed sixty-seven (67) of seventy-one (71) residents received their meals from the kitchen. The findings included: 1. Review of the facility policy titled Food Production and Safety, dated 08/14/18, revealed the purpose is to provide clear guidelines for the preparation, delivery, and storage of safe food stuffs. It is the responsibility of all dietary staff to make sure all items placed in refrigerators are kept labeled and dated. Also, to make sure that any items in the refrigerator that are no compliant with regulations will be disposed of properly. Observation of the reach-in refrigerator on 09/18/18 at 11:10 AM revealed four (4) opened boxes of thickened liquids were not dated; a large plastic container of cottage cheese, mostly used, was not dated; and a tray of individual servings of peaches and cottage cheese, twelve (12) servings, were not dated. Interview with the Dietary Manager (DM) on 09/18/19 at 11:19 AM revealed the kitchen staff should have dated the items when opened and if they are not dated, the items are disposed of. 2. Review of facility policy titled, Food Services Cleaning Scheduled/Techniques, dated 08/14/18, revealed a cleaning schedule is to assure that the department is clean and sanitary at all times. Daily cleaning schedule includes cleaning of the microwave, blender, mixer, slicer, toaster and the can opener. Observation of the kitchen on 09/18/18 at 11:25 AM revealed the manual can opener had a brown stick substance around the edge of the blade and dried white flaky matter on the blade of the opener. Interview with the Dietary Manager (DM on 09/18/19 at 11:27 AM revealed she expected the can opener to be hand washed daily.

Based on observation, interview and review of the facility's policy and procedure, it was determined the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, for sixteen (16) medications on three (3) of five (5) medication carts. Observation of the three (3) of five (5) medication carts revealed twelve (12) bottles of medications that were opened but not dated with open date; two (2) medications that were labeled but expired; and two medications without labels. The findings included: Review of the facility policy titled Medication- orders/Reconciliation/Administration/Storage/Labeling/Refusal/Discontinued Procedure, dated [DATE], revealed the purpose of this procedure is to establish uniform guidelines in the receiving, administering, storage with safe secure locations, properly labeled in accordance with current state / federal regulations, discontinuation of medications, and recording of medication orders and to ensure that all orders received by physicians are accurate and maintained accurately. No discontinued, outdated, or deteriorated medications are available for use in the facility. All such medications are destroyed. Labels for floor stock medications must include: the name and strength of the drug; the lot and control number; the expiration date; appropriate accessory and cautionary statements; and directions for use. 1. Observation of West I Cart A on [DATE] on 12:47 PM revealed seven (7) 12 ounce bottles of Mi-Acid (liquid antacid), two (2) 473 milliliter bottles and two (2) 10 milliters bottles of [MEDICATION NAME] (cough suppressant), and one (1) 12 ounce bottle of Milk of Magnesia; were not dated when opened. In addition, there was a jar of Fleet suppositories with no label to include resident identification or open date. 2. Observation of West II Odd Cart revealed an [MEDICATION NAME] Diskus (Inhaler) with an open date of [DATE]. However, according to the facility provided Expiration Dates list produced per the PCA Pharmacy, the recommended discard date for the [MEDICATION NAME] Diskus was thirty (30) days after the opening of the foil pouch. Further observation revealed a [MEDICATION NAME] inhaler, with an open date of [DATE]. However, the Expiration Dates' list revealed the recommended discard date for [MEDICATION NAME] inhaler was sixty (60) days after opening of the foil pouch. On addition, there was one (1) bottle of ProMod (a dietary supplement) without a resident label or date of opening. Interview with the Director of Nursing (DON) on [DATE] at 1:45 PM revealed the administrative nursing staff had a calendar of rotation to check the carts and medication rooms two (2) times per month. She stated she would expect there not to be any undated or outdated medications in the medication carts. The DON revealed a pharmacy consultant also visits monthly and checks the medication carts and the medication rooms. The DON stated all medication bottles are to be dated when opened.

Based on observation, interview, record review, and review of the facility policy, it was determined the facility failed to ensure acceptable standards of quality was provided for one (1) of twenty (20) sampled residents (Resident #69). Observation on 09/19/18 revealed a Certified Medication Technician administered five (5) cardiovascular medications without checking Resident #69's blood pressure or pulse. The findings included: Review of the facility policy titled Medication-Orders/Reconciliation/Administration/Storage/ Labeling/Refusal/Discontinued Procedure, dated 08/17/18, revealed the purpose of this procedure is to establish uniform guidelines in the receiving, administering, storage with safe secure locations, properly labeled in accordance with current state/federal regulations, discontinuation of medications, and recording of medication orders and to ensure that all orders received by physicians are accurate and maintained accurately. Medication administration procedure included: perform pre-administration assessment (example: pulse rate or blood pressure), if necessary. Review of the Nursing (YEAR) Drug Handbook, revealed: A. Nursing considerations for [MEDICATION NAME]: monitor patient for toxicity. Toxic effects on the heart may be life-threatening and require immediate attention. Signs and symptoms of toxicity include anorexia nausea, vomiting, visual changes, and cardiac arrhythmia's. Alert: Excessively slow pulse rate (60 beats/minute or less) may be a sign of [MEDICATION NAME] toxicity. Withhold the drug and notify prescriber. B. Nursing considerations for [MEDICATION NAME]: [MEDICATION NAME] with [MEDICATION NAME] may increase levels and effects of both drugs. Monitor patient closely ad the dosage may need to adjusted. Always check patient's apical pulse rate before giving drug. If it's slower than 60 beats per minute (bpm), withhold the drug and call the prescriber immediately. C. Nursing Considerations for [MEDICATION NAME]: Alert - Monitor weight, Blood Pressure and pulse rate routinely with long-term use. BLACK BOX WARNING -- Drug is potent diuretic and can cause severe diuresis with water and electrolyte depletion, Monitor patient closely and adjust dose carefully. D. Nursing Consideration for [MEDICATION NAME]: Monitor patient's Blood Pressure, pulse rate and body weight frequently. E. Nursing Consideration for [MEDICATION NAME]: check blood pressure frequently when drug is initiated. Record review revealed the facility admitted Resident #69 on 08/21/18 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment, dated 08/28/18 revealed the facility assessed Resident #69's cognition as intact with a Brief Interview of Mental Status (BIMS) score of fifteen (15) indicating the resident was interviewable. Review of the (MONTH) (YEAR) Physician's Orders revealed [MEDICATION NAME] 20 milligrams (mg) every day; [MEDICATION NAME] 100 mg two (2) times per day; [MEDICATION NAME] 10 mg every day; [MEDICATION NAME] 125 micrograms (mcg) every day; and [MEDICATION NAME] 50 mg three times per day (TID). Observation of the Certified Medication Technician (CMT) on 09/19/18 at 8:23 AM revealed the CMT administered [MEDICATION NAME] (for irregular heart beat), [MEDICATION NAME] (for high blood pressure), [MEDICATION NAME] (diuretic), [MEDICATION NAME] (for high blood pressure), and [MEDICATION NAME] (for high blood pressure) and did not check the resident's blood pressure or pulse. Review of the Vital Sign Summary sheet revealed on 09/19/18 at 10:26 AM the Resident's blood pressure was 132/70 (normal range 120/80) and pulse 70 beats per minute (bpm) (normal pulse 60-100 bpm). Prior to 09/19/18, the Resident's blood pressure and pulse had not been checked since 09/16/18 at 2:07 PM. Interview with CMT on 09/19/18 at 8:30 AM revealed vital signs are not checked unless there is a doctor's order to do so. She stated she does not check vital signs (blood pressure or pulse) unless it is specified on the Medication Administration Record. Interview with the Director of Nursing on 09/19/18 11:07 AM revealed she expected the CMT to check blood pressure and pulse before administering cardiovascular medications and to at least check a pulse before giving [MEDICATION NAME].

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to prevent infection for one (1) of twenty (20) sampled residents (Resident #33). Observation on 09/19/18 revealed a licensed nurse failed to wash/sanitize his/her hands after removing soiled gloves and prior to donning clean gloves during wound care. The findings include: Review of the facility policy titled, Handwashing/Hygiene, dated 08/10/18, revealed the purpose was to provide guidelines for effective hand hygiene, in an effort to prevent the transmission of infections. Hand hygiene measures are the single most important strategy for preventing health care associated infections and each healthcare worker must adhere to the guidelines provided. Scope: applies to all employees/staff, the use of gloves does not replace hand washing, and a waterless antiseptic solution may be used an an adjunct to routine handwashing. Procedure: Indications for hand hygiene include: when coming on duty, when hands are visibly soiled, when using or having contact with medical equipment/supplies or other inanimate objects in close proximity to the patient, when entering/leaving an isolation room, before performing invasive procedures, before preparing or handling medication, and whenever in doubt-wash. Wash hands before each resident contact, before applying sterile gloves for any procedure that requires sterile technique, or applying gloves. Wash hands after coming in contact with resident's intact skin, working on a contaminated body site and then moving to a clean body site on the same resident, coming in contact with bodily fluids, resident's blood, mucous membranes, wound dressings, broken skin, etc. and hands are not visible soiled (handling specimen containers, urinals, catheters, bedpans, etc.) and after removing gloves. When using an alcohol based hand rub, it should be used only when hands are not visibly soiled. Void unnecessary touching of surfaces in close proximity to the resident to prevent both contamination of clean hands from the environmental surfaces and transmission of pathogens from contaminated hands to surfaces. Gloves are to be worn when contact with blood, bodily fluids, mucous membranes, dressings, when non-intact skin is anticipated. Gloves are a single use item. Record review revealed the facility admitted Resident #33 on 03/09/16 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the facility assessed Resident #33's cognition as intact with a Brief Interview for Mental Status score (BIMS) of fifteen (15) which indicated the resident was interviewable. Observation of Resident #33's bilateral buttocks pressure ulcer care on 09/19/18 at 8:23 AM by the Wound Care Registered Nurse (RN) revealed she removed the old dressing and placed the old dressing into the trash. She then removed her soiled gloves and immediately donned clean gloves without washing/sanitizing her hands; then cleansed the wound with normal saline and applied the clean dressings. Interview with the Wound Care RN on 09/19/18 at 8:45 AM, revealed she should have sanitized/washed her hands per the facility policy after removing the old dressing and prior to donning clean gloves. Interview on 09/19/18 at 9:15 AM with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) (Infection Control Nurse) revealed the Wound Care Nurse should have followed the facility hand washing policy and washed her hands after removing the old dressing and before applying gloves.

Based on observation, interview, and record review, it was determined the facility failed to ensure a resident who displays or is diagnosed with [REDACTED].#59). Resident #59 was had a [DIAGNOSES REDACTED]. The findings include: Interview on 09/21/18 at 9:55 AM with the Director of Nursing (DON) revealed the facility did not have a policy related to Dementia Care. She stated the staff has been trained on dementia care. Review of the Facility Care Area Assessment Process and Care planning dated 08/24/18 revealed the purpose of the procedure is to provide information about the Care Area Assessments, Care Area Triggers and the process for care plan development for nursing home residents. Record review revealed the facility admitted Resident #59 on 02/03/16 with [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set (MDS) assessment, dated 09/03/18 revealed the facility assessed Resident #59's cognition as severely impaired and he/she was rarely /never understood; therefore, a Brief Interview of Mental Status Score (BIMS) was not attempted. Review of Resident #59's Comprehensive Care Plans dated 02/03/16 revealed there was no care plan specific to Dementia Care. The focus of the care plan revealed the resident was dependent on staff for meeting emotional, intellectual, physical, and social needs; however, it did not address the resident's Dementia. In addition, interventions were for staff to converse with resident while providing care, encourage ongoing family involvement, invite the resident's family to attend special events, activities, and meals; and establish and record the resident's prior level of activity involvement and interests by talking with resident, caregivers, and family on admission and as necessary; however, the care plan did not specify what the resident interests were so staff would know what to talk about with the resident. Further review revealed the resident prefers to socialize with other residents and her family. In addition, the care plan revealed the resident was now bedridden after a fracture and no longer ambulates around the facility. However, there were no interventions to the residents specific needs due to Dementia and no specific activities or interests of the resident noted on the care plan. Observation of Resident #59 on 09/19/18 at 9:35 AM revealed he/she was in bed, lying on his/her back with eyes closed. Observation of Resident #59 on 09/20/18 at 8:45 AM and 10:44 AM revealed he/she was in bed and room quiet. Interview on 09/21/18 at 09:04 AM with LPN Minimum Data Set (MDS) Coordinator revealed Social Services was responsible for completing Dementia care plans. Interview with the Social Services Director on 09/21/18 at 9:09 AM regarding dementia care plans revealed the Comprehensive Care Plans should be resident centered and should include Dementia and specific interventions/tasks related to the resident. She stated the care plans were outdated and needed to be updated. She revealed since the resident broke a hip, he/she no longer walks. Interview with the Director of Nursing (DON) on 09/21/18 at 12:45 PM revealed she expected all Dementia residents to have Dementia Care Plans that were Resident Centered. She revealed the need for dementia care and care plans identified and developed during MDS and nursing assessments.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to provide a safe, sanitary environment to help prevent the development and transmission of communicable diseases and infections related to inappropriate hand hygiene for two (2) of twenty (20) sampled residents (Resident #33 and Resident #221). The findings include: 1. Review of the facility policy titled, Handwashing/Hygiene dated 08/10/18 revealed the purpose was to provide guidelines for effective hand hygiene, in an effort to prevent the transmission of infections. Hand hygiene measures are the single most important strategy for preventing health care associated infections and each healthcare worker must adhere to the guidelines provided. Scope: applies to all employees/staff, the use of gloves does not replace hand washing, and a waterless antiseptic solution may be used an an adjunct to routine handwashing. Procedure: Indications for hand hygiene include: when coming on duty, when hands are visibly soiled, when using or having contact with medical equipment/supplies or other inanimate objects in close proximity to the patient, when entering/leaving an isolation room, before performing invasive procedures, before preparing or handling medication, and whenever in doubt-wash. Wash hands before each resident contact, before applying sterile gloves for any procedure that requires sterile technique, or applying gloves. Wash hands after coming in contact with resident's intact skin, working on a contaminated body site and then moving to a clean body site on the same resident, coming in contact with bodily fluids, resident's blood, mucous membranes, wound dressings, broken skin, etc. and hands are not visible soiled (handling specimen containers, urinals, catheters, bedpans, etc.) and after removing gloves. When using an alcohol based hand rub, it should be used only when hands are not visibly soiled. Void unnecessary touching of surfaces in close proximity to the resident to prevent both contamination of clean hands from the environmental surfaces and transmission of pathogens from contaminated hands to surfaces. Gloves are to be worn when contact with blood, bodily fluids, mucous membranes, dressings, when non-intact skin is anticipated. Gloves are a single use item. Record review revealed the facility admitted Resident #33 on 03/09/16 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed Resident #33's cognition as intact with a Brief Interview for Mental Status (BIMS) score of fifteen (15) which indicated the resident was interviewable. Observation of pressure ulcer care for Resident #33 to bilateral buttocks on 09/19/18 at 8:23 AM by the Wound Care Registered Nurse (RN) revealed she removed the old dressing and placed the old dressing into the trash. However, she then removed her soiled gloves, and immediately donned clean gloves without washing/sanitizing her hands. She then cleansed the wound with normal saline and applied the clean dressings. Interview with the Wound Care RN on 09/19/18 at 8:45 AM, revealed she should have sanitized/washed her hands per the facility policy after removing the old dressing and prior to donning clean gloves. Interview on 09/19/18 at 9:15 AM with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) (Infection Control Nurse) revealed the Wound Care Nurse should have followed the facility hand washing policy and washed her hands after removing the old dressing and before applying gloves. 2. Review of the Long-Term Care Nursing Assistants Seventh Edition Copyright (YEAR) related to Urinary Catheter Care revealed the Urinary bag hangs from the bed frame, chair, or wheel. It must not touch the floor. Review of the Catheterization Implementation/Removal and Care Policy dated 08/15/18 revealed the purposes of this procedure are to provide for and maintain constant urinary drainage. The purpose of this procedure is to prevent infection of the resident's urinary tract-catheter care. A procedure point revealed the catheter tubing and drainage bag are kept off the floor and also ensure that Foley bag is covered in a dignity bag and tubing is not in contact with the floor. Record review revealed the facility admitted Resident #221's on 09/12/18 with [DIAGNOSES REDACTED]. Review of the initial Nursing assessment dated [DATE] revealed the facility assessed Resident #221 was alert and oriented and able to answer all questions appropriately. Review of the Certified Nurse Aide Care Plan Record dated (MONTH) (YEAR) revealed the resident has a Foley Catheter with Bag Cover. Observation on 09/19/18 at 8:32 AM revealed a urinary catheter bag lying on the floor without a bag cover and extremely full and distended. Interview with Certified Nurse Aide (CNA) #5 on 09/20/18 at 3:08 PM revealed the urinary catheter bag should never be placed on the floor. She stated the bag should never be placed above the bladder and if the resident is in a wheelchair, the bag should be hung with the clip from the seat. Interview with the Assistant Director of Nursing on 09/20/18 at 9:03 AM who is also the Infection Control Nurse revealed per policy, the catheter bag should always be kept off the floor. She stated if the resident is in a wheel chair, it should be off the floor and hanging below the waist. She further revealed the policy should be followed to decrease risk of infections.

Based on observation, interview and facility policy review, it was determined the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public during meal observation in the Churchill Dining Room. The findings include: Review of the facility policy titled, Instructions for the Timeliness of Cleaning of the Facility, dated 08/07/18, revealed the policy did not address water accumulating on the floor due to leaking from the ceiling. Observation 09/18/18 at 12:44 AM revealed there was water leaking from the ceiling onto the floor and an eight (8) inch in diameter puddle was noted. Interview with Maintenance staff on 09/21/18 at 8:30 AM, revealed the condensation from the ceiling had been leaking for a while and the facility was in the process of working with a Heating and Cooling company to repair the condensation leak from the ceiling. Interview with the Housekeeping Supervisor, on 09/21/18 at 11:14 AM, revealed staff try to keep the areas dry by using a dry mop when the condensation drops from the ceiling. She stated she expected the floor to remain dry for safety reasons. She stated they use a dry mop to attempt to keep the area dry. Interview with Director of Nursing (DON) on 09/21/18 at 8:50 AM, revealed she expected the floor to remain dry with no leaks. She stated the water leak was coming from condensation in the heating/cooling ductwork and the facility was in contact with a business that will make the needed repairs.

Based on interview, review of the Skilled Nursing Facility Beneficiary Protection Notifications, and facility form instructions review, it was determined the facility failed to issue the appropriate and required Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) Residents/beneficiaries when Medicare covered services were ending for two (2) of three (3) Medicare Discharges reviewed (Resident #18 and Resident A). Review of Resident A's and Resident #18's Medicare Discharge revealed the facility did not issue a SNFABN, CMS Form for Resident A and a Notice of Medicare Non-Coverage (NOMNC), CMS Form for Resident #18. The findings included: The facility provided Form Instructions when a policy was requested. Review of the Form Instructions for the SNFABN, Form CMS- revealed Medicare requires skilled nursing facilities to issue the SNFABN to original Medicare beneficiaries prior to providing care that Medicare usually covers, but may not pay for. Review of the Form Instructions for the NOMNC, CMS Form , revealed the NOMNC must be delivered, even if the beneficiary agrees with the termination of service. Medicare providers are responsible for the delivery of the NOMNC. 1. Review of the Skilled Nursing Facility Beneficiary Protection Notification Review (SNFBPNR) completed by the facility revealed the facility discharged Resident 'A' from Medicare Part A services with the last covered day being 09/06/18; however, the resident still had benefit days that were not exhausted. Further review of the SNFBPNR revealed the facility did not provide the SNF ABN CMS- to Resident 'A'. 2. Review of the Skilled Nursing Facility Beneficiary Protection Notification Review (SNFBPNR)completed by the facility revealed the facility discharged Resident #18 from Medicare A serviced with the last covered day being 05/07/18; however, the resident still had benefit days that were not exhausted. Further, review of the SNFBPNR revealed the facility did not provide the NOMNC, CMS Form to Resident #18. Interview with the Social Services Director (SSD) on 09/20/18 at 9:12 AM revealed she is responsible for issuing the Advanced Beneficiary Notices and the Notice of Medicare Non-Coverage notices to residents when discharges are facility initiated. The SSD stated she was not aware of and did not understand both the ABN and the NOMNC had to be issued for facility-initiated discharges.

Based on observation, interview, and record review, it was determined the facility failed to maintain a clean environment for one (1) of twenty (20) sampled residents (Resident #27). The findings included:Observations on 09/18/18 and 09/19/18 revealed Resident #27's geri-cushion was visibly soiled. The findings include: Interview with the Director of Nursing (DON) on 09/19/18 at 3:00 PM, revealed we do not have a policy on the cleaning of resident equipment. She stated she expected all resident equipment to be in good repair and clean. Record review revealed the facility admitted Resident #27 on 09/24/12 with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/12/18, revealed the facility assessed Resident #27's cognition as intact with a Brief Interview for Mental Status (BIM's) score of fourteen (14) which indicated the resident was interviewable. Review of Certified Nurse Aide Kardex report, print date 09/20/18, revealed Resident #27 required a full Geri chair cushion. Observation on 09/18/18 at 1:04 PM, revealed Resident #27 seated up in main dining area on a long light blue Geri chair cushion with the right arm rest visibly soiled with multiple brown, grayish-white crusted stains. Observation on 09/18/18 at 3:47 PM and 4:15 PM, revealed Resident #27 remained up seated on the full length Geri chair light blue cushion, visibly soiled with brown, grayish stains with smeared food particles. Observation on 09/19/18 at 8:26 AM revealed no change to light blue geri cushion right arm cushion remains visibly soiled, with grayish, brown, white spots and dried food particles. Observation on 09/19/18 at 8:43 AM, revealed two (2) staff transferred Resident #27 back to his/her bed, and the soiled geri cushion remained in seat of chair. Interview with Certified Nurse Aide (CNA) #6 on 09/19/18 at 9:23 AM, revealed she mentioned the soiled Geri chair cushion to one (1) of the nurses several weeks back, but she could not recall the name of the nurse. She stated she never mentioned the concern to laundry, and agreed the cushion was heavily soiled, and needed to be cleaned. Interview with CNA #7 on 09/19/18 at 9:38 AM, revealed she had already spoken to laundry this morning and they were in the process of getting the resident a new clean cushion for the geri chair. She stated The cushion is very stained, and she would not want any loved one of her's to be seated on a cushion that heavily soiled. Interview with Laundry Aide #7 on 09/19/18 at 9:44 AM, revealed the nurse aides usually bring the soiled/dirty cushions to the linen closet and we pick them up, wash them and let them dry. She stated laundry has several extra cushions to exchange out while the others are being washed and dried. She further revealed she could not wash the cushion if it was not brought to the linen closet, and stated, that cushion is very soiled. Interview with Certified Medication Aide (CMA) #8 on 09/19/18 at 9:48 AM, revealed no one should sit in something so nasty looking. Interview with Resident #27 on 09/19/18 at 10:35 AM, revealed the girl came in here a little bit ago, and took the dirty cushion, and said she was taking it to laundry, and placed a clean cushion in the chair. The resident stated, it has been dirty for several weeks now, it is about time they took it to the laundry. Interview with the Director of Nursing (DON) on 09/19/18 at 3:00 PM, revealed she would hope she could trust her staff to ensure that when they see something visibly soiled, they would see that it was taken to the laundry and cleaned. She stated no one should be expected to wear or be seated in something visibly soiled and it would be common sense that the resident should not be seated in something that was heavily soiled.

Based on observation, interview, record review and facility policy review, it was determined the facility failed to revise the care plan for two (2) of five (5) residents after a fall (Resident #1 and Resident #5). The findings include: Review of facility policy titled Fall Prevention, dated 07/07/17, revealed corrective action is implemented immediately, if possible, to prevent recurrence or identified causative factors of a fall. The resident care plan is reviewed and revised as appropriate, to assure identified fall risk issue(s) is identified, that altered interventions are initiated, if appropriate, and that preventive measures are addressed. 1. Record review revealed the facility admitted Resident #1 on 11/24/15 with [DIAGNOSES REDACTED]. Review of a Fall Investigation and Nursing Notes, dated 12/25/17 revealed Resident #1 was found on the floor in front of the bathroom door and stated he/she had fallen and hit head on the table going to the bathroom. However, review of the Fall Care Plan and Certified Nurse Aide Care Plan (kardex) for Resident #1 dated 10/02/17 revealed the care plan was not revised to include an intervention to address the resident's 12/25/17 fall. Interview on 03/01/18 at 1:10 PM with Licensed Practical Nurse (LPN) #1 revealed there was no intervention placed, and then stated skid socks were placed, and then stated she asked the resident's daughter to get different shoes. 2. Record review revealed the facility admitted Resident #5 on 06/18/16 with [DIAGNOSES REDACTED]. Review of a Fall Investigation dated 12/25/18 revealed Resident #5 was found sitting in floor in front of his/her recliner with a raised cushion in the recliner. Review of a Nursing Note, dated 12/26/17 revealed a roho cushion was placed. However, further review of the Comprehensive Care Plan for Risk for Falls, dated 05/30/17 and CNA Care Plan, revealed the care plan was not revised to include placing a roho cushion in chair. Review of a Fall Investigation dated 01/15/18, revealed Resident #5 was found sitting on floor in front of his/her wheelchair with wheels not locked. Further review revealed the resident had episodes of confusion especially in evening; however, there was no evidence an intervention was put in place to try to prevent further falls. Interview on 03/01/18 at 10:18 AM with Registered Nurse (RN) #2 revealed nurses revise the care plan as needed. Interview on 03/01/18 at 9:47 AM with Minimum Data Set (MDS) Registered Nurse (RN) revealed when a nurse develops an intervention they should update the care plan. Interview on 03/01/18 at 4:00 PM and 5:16 PM with the Director of Nursing (DON) revealed the roho cushion should have been on the care plan for Resident #5. She stated nursing staff can pull up the care plan in the computer system and add an intervention at the time of the fall.

Based on interview, record review and review of the facility policy and procedures, it was determined the facility failed to ensure two (2) of six (6) sampled residents (Resident #1 and Resident #2) received adequate supervision to prevent accidents. The facility failed to ensure the residents were supervised after being assessed and care planned as elopement risks due to attempts to exit the building unsupervised. The facility failed to ensure procedures were implemented related to keeping a dining room that was located at the West End of the facility and out of staffs' sight, secured. In addition, the facility failed to determine the root cause of the failure and failed to ensure all facility staff was re-educated as per the facility's policy after an actual elopement had occurred. On 08/24/14 at approximately 8:15 AM, Resident #1 and Resident #2 exited the building without staff knowledge. The residents entered an unlocked dining room door that was supposed to be locked when staff was not present and then proceeded to exit the building through the dining room exit door. The residents were found outside on the end of the sidewalk at the West End of the building by Certified Nursing Assistant #3 who was leaving work after her night shift. When staff investigated, it was determined the two (2) alarms on the exit door were not working and the door into the dining room from the hall was not locked per the facility policy and procedure. There was no evidence the facility had inserviced staff on the elopement. The facility's failure to provide supervision to prevent accidents has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 09/03/14 and determined to exist on 08/24/14. An acceptable Allegation of Compliance (AoC) was received on 09/09/14, and the State Survey Agency validated the Immediate Jeopardy was removed on 09/05/14, as alleged. The Scope and Severity was lowered to a "D" at CFR 483.20 Resident Assessment at F282, CFR 483.25 Quality of Care at F323 and CFR 483.75 Administration at F490, while the facility develops and implements the Plan of Correction (POC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility policy titled "Elopement", not dated, revealed "Residents are comprehensively assessed for wandering/elopement risk in order to minimize the potential for eloping from the facility." The policy additionally revealed, "Re-education of staff is conducted following any actual elopement event to critique staff performance and to assure that any improvements to the facility protocol are known to all staff." Interview with the Director of Nursing (DON), on 09/02/14 at 11:45 AM, revealed there was no written policy to keep the West End dining room door secured by locking it, but the procedure to lock the door at all times when not in use, and no staff was present for supervision. 1. Record review revealed the facility admitted Resident #1 on 03/31/13 with [DIAGNOSES REDACTED]. Review of the Elopement Risk Assessment revealed, on 08/14/14, the facility assessed Resident #1 to be as at risk for elopement. Review of the Comprehensive Care Plan, "Need for supervision due to wandering and exit seeking behaviors", dated 05/20/14, revealed interventions which included for staff to monitor with increased anxiety, wandering and exit seeking behaviors and for staff to provide one on one or diversional activities as needed and every thirty (30) minute checks. Review of a Nursing Note entry, dated 08/24/14 at 8:15 AM, revealed "Resident becoming agitated, exit seeking and stating I'm a truck driver and I need to start my route. Very hard to redirect". The Nursing Note also revealed, "This nurse notified of resident being outside Church Hill doors (West End dining room). This nurse walked resident back down sidewalk to front entrance". Review of the Event Report, dated 08/24/14 at 8:30 AM, revealed Resident #1 was found on the sidewalk by Certified Nurse Aide (CNA) #3. 2. Record review revealed the facility admitted Resident #2 on 10/08/12 with [DIAGNOSES REDACTED]. Review of the Elopement Risk Assessment revealed on 06/25/14, the facility assessed Resident #2 to be at risk. Review of the Comprehensive Care Plan, "Need for Supervision due to wandering and exit seeking behaviors", dated 07/15/14, revealed interventions which included for staff to monitor with increased anxiety, wandering and exit seeking behaviors and for staff to provide one on one or diversional activities as needed and every thirty (30) minute checks. Review of a Nursing Note, dated 08/24/14 at 8:15 AM revealed, "This nurse informed resident was outside Churchill doors. CNA pushed resident in wheel chair back into facility. Review of an Event Report, dated 08/24/14 at 8:15 AM, revealed Resident #2 was outside Churchill doors and a CNA brought him/her back into the facility via wheel chair". Interview with CNA #3 on 09/03/14 at 7:00 AM revealed she had clocked out at 8:10 AM on Sunday, August 24th and was in her car leaving the parking lot when she noticed Resident #1 walking at the end of the sidewalk away from the end of the building by the West End dining room. She stated the resident and was at the edge of the parking lot, and she did not hear the alarm sounding. CNA #3 stated Resident #2 coming along behind Resident #1 propelling his/herself in a wheel chair. The CNA stated she beat on the main entrance doors to get someone's attention. Resident #1 told her at the time, "I've been trying for hours to get out of this place". She had no idea how long Resident #1 and Resident #2 were in the West End dining room before exiting the facility. CNA #3 stated Resident #1 had rested throughout the night and had gotten up after the day shift arrived (6:00 AM). Resident #2 did not say anything about his/her whereabouts and CNA #3 did not recall seeing Resident #2 before leaving at the end of her shift. She stated her shift ends at 8:00 AM and she didn't leave until the breakfast meal was completed. CNA #3 stated the residents were served breakfast per room service and the West End dining room had not been utilized that morning. Interview with CNA #1, on 08/29/14 at 1:50 PM revealed she was just finishing feeding a resident when she heard CNA #3 banging on the entrance door at the front of the building to get her attention on the morning of 08/24/14. CNA #1 ran to the nursing desk to inform Registered Nurse #1 that two (2) residents were outside. CNA #1 stated the residents who normally ate in the West End dining room were provided room service for their breakfast on 08/24/14 due to a staff call in. She stated room service was usually completed by 8:30 AM; she recalled the CNAs were still passing trays when CNA #3 banged on the door to get her attention. CNA #1 stated she did not hear an alarm. Further interview revealed CNA #1 stated Resident #1 was always talking about leaving and went to all the doors frequently and caused the alarms to sound. She stated it took convincing to get Resident #1 back into the building as he/she did not want to come back into the building and had stated that he/she did not want to come back inside. She revealed Resident #2 went all over the building in a wheel chair and would make statements of going home. He/she would sit by the doors talking to people as they came and went. Review of the clinical records revealed no documented evidence the facility provided diversional activities or one to one supervision for these residents prior to the elopement. Interview on 08/29/14 at 1:15 PM with Registered Nurse (RN) #1, revealed on 08/24/14 a little after 8:00 AM, one of the CNAs came to the nursing station and notified her Residents #1 and #2 were found outside by Certified Nurse Aide (CNA) #3. The residents were escorted back into the facility and assessed for injury with none found. A head count was conducted to determine if any other resident was missing and all were there. RN #1 asked Resident #1 to show her how he/she left the building. RN #1 went to the West End dining room and found the entry door from the hall was unlocked. She pushed the exit door and exit door alarms did not sound, it "just opened like there was no connection". The key code alarm did not sound. Additionally, the pull away alarm also failed to sound. All other facility doors were checked for functionality and no other problems were identified. She stated the entrance door from the hall should have been locked and she could not explain why the door was unlocked as she and another nurse, RN #2, and the housekeeper were the only ones with a key. She revealed when the resident becomes agitated and starts talking about his/her truck he/she would go to the exit doors and push on them and cause the alarm to sound. She stated she would take him/her down to get a pop or something to eat. Interview with the Maintenance Director, on 08/29/14 at 4:40 PM, revealed he was notified on Sunday, August 24th about 8:30 AM that a door alarm had failed. He went to the facility and checked the door alarms of the West End dining room which worked at that time. He stated he thought the magnetic part of the alarm may have failed and the storms the night before might have affected it. Further interview revealed an electrician was called and did some type of repair on the key code alarm. He stated weekly checks were performed to verify functionality of the alarms and the security contractor had just completed a quarterly inspection of the alarmed doors on 08/19/14 with no issues identified. Further interview with the DON, on 09/02/14 at 11:45 AM and 3:35 PM, revealed she was notified about 8:30 AM on 08/24/14 that Resident #1 and Resident #2 had exited the building without staff knowledge. She stated she instructed the nurse to complete an incident report and body audits. She said the staff had checked the doors and the exit door was not functioning and the entrance door had not been secured by locking. Further interview revealed the DON came to the facility along with the Social Service Director, the Administrator and the Maintenance Director. An electrician was called to repair the malfunctioning door. The DON stated her part of the investigation of the elopement incident was to ensure everything had been completed. She further stated she did not personally check to see if the West End dining room had been utilized that morning. Additionally, the DON stated nobody was "going to own up to unlocking or not locking the entrance door". She revealed the nurses unlock the door and CNAs go into that dining room to obtain milk and ice for residents. She further stated no one had an answer to why the entrance door was unlocked allowing residents access, so she "could not determine" who left the door unlocked, it could have been any CNA. The DON stated she "could not explain how the residents were supervised" when they had entered the unsupervised dining room on the West End of the building and exited the facility through the exit door without staff knowledge. She stated she did not determine when the residents were last seen prior to being found outside of the building without staff knowledge. Additionally, the DON additionally stated the entrance door lock was going to be changed to an automatic lock; however, she "did not know if they did". Further interview with the DON, revealed a message was left via a phone recording system (all call system) to the nurses to make sure the door was locked. The DON stated there was no re-education provided to staff specific to the actual elopement event per the facility's policy and procedure. Interview with the Social Service Director (SSD), on 08/29/14 at 12:45 PM and 3:50 PM, revealed she had been notified on 08/24/14 sometime in the morning that there had been an elopement. She stated the residents had exited the West End dining room and staff had not observed them exiting. The SSD revealed she went to the facility and when she checked the exit door the alarms sounded but when RN #1 had checked it, the alarms did not sound. She stated she talked with Resident #1 who told her he/she went out the door and Resident #2 followed. The SSD revealed Resident #1 was agitated when she spoke with him/her and the resident exit seeks, walks around, asks where his/her truck is and says he/she has to make pay load and goes door to door and occasionally sets the alarms off. She stated when she asked staff what time the residents were last observed she was told Resident #1 was seen on the hall prior to exiting the building and had been agitated and exit seeking at the time. Interview with the In-service Coordinator, on 09/03/14 at 8:50 AM, revealed she had not provided any in-service or re-education to staff related to the actual elopement that had occurred on 08/24/14. She revealed she just started to in-service staff that morning (09/03/14) because she had not been instructed to do so until this date. Interview with the Administrator, on 08/29/14 at 11:00 AM, revealed he was notified of Resident #1 and Resident #2 exiting the facility without staff knowledge on 08/24/14 about 8:30 AM. He stated the residents had exited the facility through the exit door in the dining room off the West End of the building. The Administrator stated during interview on 09/03/14 at 2:45 PM , "At that moment the residents were not supervised, what else can I say". The facility implemented the following actions to remove the Immediate Jeopardy: 1. Resident (#1 and #2) were put on every thirty (30) minute watches for twenty four (24) hours per facility policy with no further attempts to exit the facility. RN #1 and RN #2 performed head to toe assessments on Residents #1 and #2 with no injuries identified. The entry door to the West End dining room door lock was replaced with an automatic lock mechanism on 08/24/14. A licensed electrician was called to the facility on [DATE] and corrected a mechanical failure. All exit doors from the facility on 08/24/14 were checked by the Maintenance Director and Social Services Director and determined to be functioning. 2. The Administrator was inservicerd by an outside consultant RN on 09/03/24 on the elopement policy statement and Risk Elopement Policy procedures and assessments. The Administrator was required to take a post test with 100% accuracy. 3. The Inservice Coordinator was inserviced on the Elopement Policy Statement and Risk Elopement Policy procedures and assessments by the Administrator on 09/03/14 and was required to complete a post test with 100% accuracy. 4. The DON, Restorative Nurse, Business Office Manager, Human Resources Manager, Laundry Manager, Activities Director, Environmental Director, Maintenance Director, RAI Nurses, Dietary Manager, Medical Records Manager, PC Coordinator, Social Services Director was inserviced on 09/03/14 by the Inservice Coordinator on the Elopement Policy Statement and Risk Elopement Policy procedures and assessments. A post test was required and completed with 100% accuracy. 5. A mandatory on-site inservice on the Elopement Policy Statement and Risk Elopement Policy Procedures and assessments was completed on 09/03/14 and 09/04/14 for all other staff by the Inservice Coordinator. The inservice also included the training of all staff that the hallway door leading into the West End dining room was locked at all times when not in use and can only be opened by a Charge Nurse for meal times and/or a Janitor in order to be cleaned. All staff was required to take a post test with 100% accuracy. Any staff who has not attended the Elopement Policy Statement and Risk Elopement Policy procedures and assessments inservice was taken off the schedule until it is completed. They will not work until they have attended the inservice and passed the post test with 100% accuracy. This included Nurses, CMAs, Ward Clerks, Business Office personnel, Nurse Aides, Activities, Maintenance Department, Social Services, Receptionist, Environmental Services, Laundry Department, Maintenance Department, Dietary Department and Therapy Department. Orientation program will include inservice on the Elopement Policy Statement and Risk Elopement procedures and assessments by the Inservice Coordinator for all new employees before they are allowed to work. This includes any new hires or contract labor should they employ them. They must complete a post test with 100% accuracy before being allowed to work. 6. All residents at risk for elopement were re-assessed by the DON on 08/25/14. The West End dining room exit door to the outside was checked for functioning of the locking mechanism by the Restorative Nurse on 09/03/14. All Janitors employed by the facility were trained by the Inservice Coordinator on 09/04/14 on proper procedure for checking door functioning and logging findings. A log was initiated and the door will be checked for functioning and effectiveness of the locking mechanism daily by the Janitor on duty and findings documented on the log. If any malfunctions are observed maintenance will be notified immediately and the Janitor will stay at the door until maintenance arrives. An audit of the log will be done by the Housekeeping Supervisor daily for fourteen (14) days of 100% compliance. Then weekly for four weeks until 100% compliance is met for four (4) consecutive weeks. Then monthly for three (3) months, then quarterly if 100% compliance is maintained. All logs and audits will be brought to the QAA meeting by the Housekeeping Supervisor and reviewed for any areas of concern. 7. The hallway entry door into the West end dining room was checked for functioning and effectiveness of the automatic locking system by the Restorative Nurse on 09/03/14. A log will be kept related to the effectiveness and functioning of the automatic lock and will be documented on the same log as the exit door in the West End dining room. Any malfunctions observed will be reported to Maintenance immediately and the Janitor will stay at the door until Maintenance arrives. An audit of the log will be done by the Housekeeping Supervisor daily for fourteen (14) days of 100% compliance, then weekly for four (4) weeks until 100% compliance is met for four (4) consecutive weeks, then every month for three (3)months, then quarterly if 100% compliance is maintained. All logs and audits will be brought to the quarterly QAA meeting by the Housekeeping Supervisor and addressed for areas of concern. The State Survey Agency validated the corrective actions taken by the facility as follows: 1. Observation on 09/11/14 at 10:45 AM, revealed the entrance door to the West End dining room was locked. A log book located in the dining room revealed signatures from Maintenance and Housekeeping staff that verified monitoring of the entrance and exit doors of the room. The log indicated the doors were being checked three (3) times daily for functioning of the exit door and the entrance door. The log gave indicators to include Maintenance being notified if a door was not functioning properly and if not was a staff member posted at the door to monitor any malfunctioning. The log was current and no malfunction had been identified. An audit form also verified the checks were being completed and documented on the log. 4. and 5. On 09/11/14, inservice training was verified completed on 09/03/14 and 09/04/14. The inservices had been completed by all facility staff, except four (4) who were on Family Medical Leave Act (FMLA). The Inservice Coordinator was responsible to ensure the four (4) staff that had not received the inservice would have the inservice prior to being allowed to work and would have to take a post test. The Orientation Program will include the inservice on the Elopement Policy Statement and Risk Elopement Policy Procedures and Assessments by the Inservice Coordinator for any new employees before they are allowed to work. 2. Interview with the Administrator on 09/03/14 at 10:45 AM revealed he had received inservicing on 09/03/14 by an outside consultant on the Elopement Policy Statement and Risk Elopement Policy Procedures and Assessments. He was required to take a post test with 100% accuracy. 1 and 4. On 09/11/14 at 11:00 AM, the DON verified through interview that the door entering into the West End dining room was secured on 08/24/14 by replacing the existing lock with one that locks automatically. Repair was made to the exit door by an electrician. Inservicing was completed by the Inservice Coordinator on 09/03/14. Inservice training was on the Elopement Policy Procedures and Assessments which included residents identified at risk would have a plan of care developed and implemented to ensure their safety. She was inserviced on the Elopement Policy and the door checks implemented 09/03/14. She was required to pass a post test with 100% accuracy. The inservice also included that the entrance door from the hall into the West End dining room would remain locked at all times when not in use for meals or church services and only be opened by a Charge Nurse and/or a Janitor in order to be cleaned. A log was placed in the West End dining room and the door will be checked for functioning and effectiveness of the locking mechanism daily by the Janitor on duty and finding documented. 4 and 7. Interview on 09/11/14 with the Restorative Nurse at 11:05 AM revealed she checked the doors on 09/03/14 and a log was initiated for daily checking for functioning of the automatic lock placed by the Janitor. She was inserviced on the Elopement Policy Statement and Risk Elopement Policy procedures and assessments and was required to pass a post test with 100% accuracy. The Charge Nurses, Janitor and Housekeeping are the only staff with a key to the West End dining room. 5 and 6. The Housekeeping Supervisor verified through interview on 09/11/14 at 11:10 AM that she had inservice training related to keeping the West End dining room locked at all times except when being used for meals or Church. Housekeeping, Maintenance and the Charge Nurses were the only staff with a key to unlock the entrance door to the dining room. She was inserviced on the facility's Elopement Policy to include reporting to the nurse if she saw any resident displaying exit seeking behaviors. She stated she was trained to check the door to ensure it was locked every day after meals and a log was used for documenting. After fourteen (14) days, then weekly for four (4) weeks, then every month for three (3) months, then quarterly. All logs and audits will be taken to the QAA meeting by the Housekeeping Supervisor. 5 and 6. On 09/11/14 at 11:20 AM Maintenance Staff #1, revealed he had received inservice training on the facility's Elopement Policy Statement and Risk Elopement Policy procedures and assessments and had to pass a post test with 100% accuracy. The doors will be checked daily by the Janitor and documented on a log. Housekeeping, Maintenance and Charge Nurses were the only staff that could unlock the entrance door to the West End dining room. If a malfunction was noted when checked, Maintenance would be notified immediately and the Janitor would stay with at the door until Maintenance arrived. Audits were also being done by Housekeeping. 4. Interview with the Social Service Director on 09/11/14 at 11:25 AM revealed she had received inservicing from the Inservice Coordinator on 09/03/14 and was required to take a post test with 100% accuracy. The inservice included keeping the entrance door to the West End dining room locked except when in use and only Charge Nurses, Maintenance and Housekeeping had a key to unlock it. Monitors were in place to ensure the doors were locked daily and will continue for a few months. The facility Elopement Policy and Elopement Risk Assessment policy and Procedures Assessment were included in the inservice. 3. On 09/11/14 at 11:30 AM LPN #3 revealed in interview that she had been provided inservice training on 09/03/14 by the Inservice Coordinator. The inservice included the Elopement Policy and the Elopement Risk Assessment Procedures. She stated only nurses, janitors and housekeeping had a key to unlock the door to the West End dining room and it was to remain locked all times when not in use for meals. She stated the Elopement Risk Assessment was completed when a resident exhibited exit seeking behaviors. The doors were being checked daily and documented on a log and the log was being audited by Housekeeping. 5. Housekeeping Staff #1 revealed in interview on 09/11/14 that she had received inservicing by the Inservice Coordinator last week. She stated the inservice covered keeping the door to the West End dining room locked except when in use for meals. The Nurse, Maintenance and Housekeeping had a key to unlock it. Housekeepers work one night a week and after the evening meal, they were to ensure the entrance door was locked after the room was cleaned. 5. Interview on 09/11/14 at 11:35 AM with the Social Service Assistant revealed she had received inservice training by the Inservice Coordinator on 09/03/14. The inservice covered the facility's Elopement Policy and the Elopement Risk Assessment Procedures. Residents at risk had care plan interventions implemented. The entrance door into the West End dining room from the hall was to be locked unless it was being utilized for meals or a church group. Maintenance was checking the doors in the room daily and Housekeeping was also checking to ensure the entrance door was locked. A log was being utilized to ensure verification documentation the doors were being checked. 5. LPN #3 revealed in interview on 09/11/14 at 11:40 AM that she had received inservice training by the Inservice Coordinator. The inservice included how the entrance and exit doors of the West End dining room were being monitored daily to ensure the locks and alarms were functional. A log was being kept to ensure documentation of the monitoring and an audit of the log was also being conducted. The West End dining room entrance door was to be locked at all times when not in use. Residents at risk for elopement behaviors were to have care plan interventions implemented to assure their safety. 5. On 09/11/14 a 11:45 AM, Nurse Aide Student #1, revealed she had been provided inservice training by the Inservice Coordinator. The inservice covered keeping the West End dining room locked when not in use and checking to ensure the doors remained locked. Maintenance and Housekeeping were monitoring the doors daily and only Charge Nurses, Maintenance and Housekeeping had a key to unlock the dining room. Resident behaviors of exit seeking was to be reported to the nurse immediately. 5. CNA #2 revealed in interview on 09/11/14 at 11:50 AM that she had been provided training in an inservice by the Inservice Coordinator. The facility's Elopement Policy and a risk assessment was covered in the inservice as well as keeping the door locked to the West End dining room. The doors were being monitored for functionality by Maintenance and Housekeeping. Charge Nurses, Maintenance and Housekeeping were the only staff that had keys to unlock the door to the dining room. Additionally, resident behaviors were to be reported to the nurse. CNA #2 took a post test to confirm competency. 5. An interview on 09/11/14 at 11:55 AM was conducted with CNA #4. She revealed the Inservice Coordinator provided inservicing on keeping the entrance door to the West End dining room locked at all times when not in use for meals and Maintenance, Housekeeping and the Charge Nurse had the only keys. Maintenance and Housekeeping were monitoring the doors daily to make sure alarms and locks were functioning. Residents with wandering behaviors were monitored and behaviors reported to the nurse. 5. Interview with a Laundry Aide on 09/11/14 at 12:00 PM revealed the Inservice Coordinator gave an inservice on 09/03/14 about keeping the West End dining room locked when not being used for meals. Maintenance and Housekeeping was monitoring the doors and keeping a log. A post test had to be completed with 100% accuracy. Maintenance, Housekeeping and the Charge Nurses had the only keys to the dining room. Residents were monitored for exit seeking and the nurse was to be informed of any of those type of behaviors. 5. An interview conducted on 09/11/14 at 12:05 PM with CNA #5 revealed she had completed a post test with 100% after inservicing given on 09/03/14. The Inservice Coordinator provided the inservice which included monitoring residents when displaying exit seeking and reporting to the nurse. Maintenance and Housekeeping was monitoring the doors to the West End dining room and noting it on a log. The doors were to remain locked at all times when the dining room was not in use and the keys to the dining room were kept by the Charge Nurse, Maintenance and Housekeeping. 5. CNA #6 revealed in interview conducted on 09/11/14 at 12:10 PM, that she had received recent inservicing related to the doors of the West End dining room. She stated the doors remain locked at all times when not in use. The Charge Nurse, Maintenance and Housekeeping had the only keys to the entrance door which was changed to an automatic locking system. A log was being used to verify when Maintenance and Housekeeping checked the doors on a daily basis. Resident behaviors of wandering and exit seeking was to be reported to the nurse and interventions to address those behaviors was discussed. The inservice covered the Elopement Policy and Risk Assessment Policy. CNA #6 was required to pass a post test with 100% after the inservice.

Based on record review, interview, and review of the Centers for Medicare and Medicaid (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual, it was determined the facility failed to ensure care and services were provided in accordance with the written plans of care for two (2) of six (6) sampled residents (Resident #1 and Resident #2). Resident #1 and Resident #2 were care planned for the "Need for supervision due to wandering and exit seeking behaviors", with interventions for staff to monitor when the resident exhibited increased anxiety, wandering and exit seeking behaviors and to provide one on one or diversional activities, as needed and every thirty (30) minute checks. On 08/24/14 at 8:15 AM, Resident #1 and Resident #2 exited the facility without staff knowledge and were found outside the facility, away from the building by the parking lot. The residents had entered an unsecured, unsupervised dining room from the hall and exited the facility without staff knowledge. Certified Nurse Aide (CNA) #3 found the residents as she was leaving for home after the night shift. The facility's failure to ensure the plan of care was followed for residents has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 09/03/14 and determined to exist on 08/24/14. An acceptable Allegation of Compliance (AoC) was received on 09/09/14, and the State Survey Agency validated the Immediate Jeopardy was removed on 09/05/14, as alleged. The Scope and Severity was lowered to a "D" at CFR 483.20 Resident Assessment at F282, CFR 483.25 Quality of Care at F323 and CFR 483.75 Administration at F490, while the facility develops and implements the Plan of Correction (POC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Interview with the Director of Nursing (DON), on 09/02/14 at 3:35 PM, revealed there was no specific facility policy related to implementing care plan interventions and the facility followed CMS's RAI Version 3.0 Manual. Review of the information provided by the facility, titled CMS's RAI Version 3.0 Manual, last revised October/November 2012, in the 4.7 RAI and Care Planning section, revealed the care plan must be reviewed and revised periodically, and the services provided or arranged must be consistent with each resident's written plan of care. 1. Record review revealed the facility admitted Resident #1 on 03/31/13 with [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set (MDS) assessment, dated 08/29/14, revealed the facility assessed the resident's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of three (3) which indicated the resident was not interviewable. Review of the Comprehensive Care Plan, dated 05/20/14, "Need for supervision due to wandering and exit seeking behaviors", revealed interventions which included for staff to monitor when the resident had increased anxiety, wandering and exit seeking behaviors and for staff to provide one on one or diversional activities as needed and every thirty (30) minute checks. Review of a Nursing Note, dated 08/24/14 at 8:15 AM, revealed "Resident becoming agitated, exit seeking and stating I'm a truck driver and I need to start my route. Very hard to redirect". The Nursing Note also revealed, "This nurse notified of resident being outside Church Hill doors (West end dining room). This nurse walked resident back down sidewalk to front entrance". There was no evidence in the record to reveal thirty (30) minute checks were being conducted, or that one on one or diversional activities was provided. Review of the Event Report, dated 08/24/14 at 8:30 AM, revealed Resident #1 was found on the sidewalk by Certified Nurse Aide (CNA) #3. Interview with the Social Service Director (SSD), on 08/29/14 at 3:50 PM, revealed when she asked staff what time the residents were last observed she was told Resident #1 was seen on the hall prior to exiting the building and had been agitated and exit seeking at the time. 2. Record review revealed the facility admitted Resident #2 on 10/08/12 with [DIAGNOSES REDACTED]. Review of the Annual MDS assessment, dated 08/29/14, revealed the facility assessed Resident #2's cognition as severely impaired with a Brief Interview for Mental Status score (BIMS) of six (6) which indicated the resident was not interviewable. Review of the Comprehensive Care Plan for Need for Supervision due to wandering and exit seeking behaviors, dated 07/15/14, revealed interventions which included for staff to monitor with increased anxiety, wandering and exit seeking behaviors and for staff to provide one on one or diversional activities as needed and every thirty (30) minute checks. Review of a Nursing Note, dated 08/24/14 at 8:15 AM, revealed "This nurse informed resident was outside Churchill doors. CNA pushed resident in wheel chair back into facility. Review of an Event Report, dated 08/24/14 at 8:15 AM, revealed Resident #2 was outside Churchill doors and a CNA brought him/her back into the facility via wheel chair. Record review revealed no documented evidence the facility provided one on one diversional activities or thirty (30) minute checks. Interview with CNA #3, on 09/03/14 at 7:00 AM, revealed she clocked out at 8:10 AM on Sunday, August 24th and was in her car leaving the parking lot when she noticed Resident #1 walking at the end of the sidewalk away from the end of the building by the West End dining room. She stated the resident was at the edge of the parking lot and Resident #2 was behind Resident #1 propelling his/herself in a wheel chair. She stated she beat on the main entrance doors to get someone's attention. CNA #3 revealed she did not hear an alarm sounding. She stated her shift ended at 8:00 AM and she did not leave until the breakfast meal was completed and the residents were served breakfast in their room so the West End dining room had not been utilized that morning. Interview with CNA #1, on 08/29/14 1:50 PM, revealed she was just finishing feeding a resident when she heard CNA #3 banging on the entrance door at the front of the building to get her attention on the morning of 08/24/14. CNA #1 ran to the nursing desk to inform RN #1 that two (2) residents were outside. CNA #1 revealed residents who normally ate in the West End dining room were provided room service for their breakfast on 08/24/14 due to a staff call in. She stated room service was usually completed by 8:30 AM and she recalled the CNAs were still passing trays when CNA #3 banged on the door to get her attention. CNA #1 stated Resident #1 was always talking about leaving and went to all doors frequently and caused alarms to sound. She stated it took convincing to get Resident #1 back into the building as he/she stated he/she did not want to come back inside. CNA #1 revealed Resident #2 went all over the building in a wheel chair and would make statements of going home. He/she would sit by the doors talking to people as they came and went. Interview with Registered Nurse (RN) #1, on 08/29/14 at 1:15 PM, revealed on 08/24/14 a little after 8:00 AM, one of the CNAs came to the nursing station and notified her Resident #1 and #2 were found outside by CNA #3. RN #1 stated the West End dining room was to be locked when not in use and no there was no staff person present for supervision. She stated that door was not locked and no staff had been present there and she gave no explanation why the door was not locked. She revealed Resident #1 has periods of agitation and always wanted to go out. The agitation would get worse when he/she was talking about his/her truck and looking for the log. She stated sometimes when he/she gets so agitated there was no helping him/her and she has given the resident intra-muscular injections of [MEDICATION NAME]. She stated she had talked to the staff on the morning of 08/24/14 and was told they did not see Resident #1 or #2 as they were feeding residents that required assistance with eating and it took about an hour to get everyone fed. She stated the "feeder" trays come out at 7:30 AM. Further interview with the DON, on 09/02/14 at 11:45 AM and 3:35 PM, revealed she was notified about 8:30 AM on 08/24/14 that Resident #1 and Resident #2 had exited the building without staff knowledge. The DON stated "nobody was going to own up to unlocking or not locking the entrance door". She revealed the nurses unlock the door and CNAs go into that dining room to obtain milk and ice for residents and no one had an answer as to why the entrance door was unlocked allowing access by residents so she "could not determine" who left the door unlocked, it could have been any CNA. The DON stated she "could not explain how the residents were supervised" when they had entered the unsupervised dining room on the West End of the building and exited the facility through the exit door without staff knowledge. She stated she did not determine when the residents were last seen prior to being found outside of the building without staff knowledge The facility implemented the following actions to remove the Immediate Jeopardy: 1. Resident (#1 and #2) were put on every thirty (30) minute watches for twenty four (24) hours per facility policy with no further attempts to exit the facility. RN #1 and RN #2 performed head to toe assessments on Residents #1 and #2 with no injuries identified. The entry door to the West End dining room door lock was replaced with an automatic lock mechanism on 08/24/14. A licensed electrician was called to the facility on [DATE] and corrected a mechanical failure. All exit doors from the facility on 08/24/14 were checked by the Maintenance Director and Social Services Director and determined to be functioning. 2. The Administrator was inservicerd by an outside consultant RN on 09/03/24 on the elopement policy statement and Risk Elopement Policy procedures and assessments. The Administrator was required to take a post test with 100% accuracy. 3. The Inservice Coordinator was inserviced on the Elopement Policy Statement and Risk Elopement Policy procedures and assessments by the Administrator on 09/03/14 and was required to complete a post test with 100% accuracy. 4. The DON, Restorative Nurse, Business Office Manager, Human Resources Manager, Laundry Manager, Activities Director, Environmental Director, Maintenance Director, RAI Nurses, Dietary Manager, Medical Records Manager, PC Coordinator, Social Services Director was inserviced on 09/03/14 by the Inservice Coordinator on the Elopement Policy Statement and Risk Elopement Policy procedures and assessments. A post test was required and completed with 100% accuracy. 5. A mandatory on-site inservice on the Elopement Policy Statement and Risk Elopement Policy Procedures and assessments was completed on 09/03/14 and 09/04/14 for all other staff by the Inservice Coordinator. The inservice also included the training of all staff that the hallway door leading into the West End dining room was locked at all times when not in use and can only be opened by a Charge Nurse for meal times and/or a Janitor in order to be cleaned. All staff was required to take a post test with 100% accuracy. Any staff who has not attended the Elopement Policy Statement and Risk Elopement Policy procedures and assessments inservice was taken off the schedule until it is completed. They will not work until they have attended the inservice and passed the post test with 100% accuracy. This included Nurses, CMAs, Ward Clerks, Business Office personnel, Nurse Aides, Activities, Maintenance Department, Social Services, Receptionist, Environmental Services, Laundry Department, Maintenance Department, Dietary Department and Therapy Department. Orientation program will include inservice on the Elopement Policy Statement and Risk Elopement procedures and assessments by the Inservice Coordinator for all new employees before they are allowed to work. This includes any new hires or contract labor should they employ them. They must complete a post test with 100% accuracy before being allowed to work. 6. All residents at risk for elopement were re-assessed by the DON on 08/25/14. The West End dining room exit door to the outside was checked for functioning of the locking mechanism by the Restorative Nurse on 09/03/14. All Janitors employed by the facility were trained by the Inservice Coordinator on 09/04/14 on proper procedure for checking door functioning and logging findings. A log was initiated and the door will be checked for functioning and effectiveness of the locking mechanism daily by the Janitor on duty and findings documented on the log. If any malfunctions are observed maintenance will be notified immediately and the Janitor will stay at the door until maintenance arrives. An audit of the log will be done by the Housekeeping Supervisor daily for fourteen (14) days of 100% compliance. Then weekly for four weeks until 100% compliance is met for four (4) consecutive weeks. Then monthly for three (3) months, then quarterly if 100% compliance is maintained. All logs and audits will be brought to the QAA meeting by the Housekeeping Supervisor and reviewed for any areas of concern. 7. The hallway entry door into the West end dining room was checked for functioning and effectiveness of the automatic locking system by the Restorative Nurse on 09/03/14. A log will be kept related to the effectiveness and functioning of the automatic lock and will be documented on the same log as the exit door in the West End dining room. Any malfunctions observed will be reported to Maintenance immediately and the Janitor will stay at the door until Maintenance arrives. An audit of the log will be done by the Housekeeping Supervisor daily for fourteen (14) days of 100% compliance, then weekly for four (4) weeks until 100% compliance is met for four (4) consecutive weeks, then every month for three (3)months, then quarterly if 100% compliance is maintained. All logs and audits will be brought to the quarterly QAA meeting by the Housekeeping Supervisor and addressed for areas of concern. The State Survey Agency validated the corrective actions taken by the facility as follows: 1. Observation on 09/11/14 at 10:45 AM, revealed the entrance door to the West End dining room was locked. A log book located in the dining room revealed signatures from Maintenance and Housekeeping staff that verified monitoring of the entrance and exit doors of the room. The log indicated the doors were being checked three (3) times daily for functioning of the exit door and the entrance door. The log gave indicators to include Maintenance being notified if a door was not functioning properly and if not was a staff member posted at the door to monitor any malfunctioning. The log was current and no malfunction had been identified. An audit form also verified the checks were being completed and documented on the log. 4. and 5. On 09/11/14, inservice training was verified completed on 09/03/14 and 09/04/14. The inservices had been completed by all facility staff, except four (4) who were on Family Medical Leave Act (FMLA). The Inservice Coordinator was responsible to ensure the four (4) staff that had not received the inservice would have the inservice prior to being allowed to work and would have to take a post test. The Orientation Program will include the inservice on the Elopement Policy Statement and Risk Elopement Policy Procedures and Assessments by the Inservice Coordinator for any new employees before they are allowed to work. 2. Interview with the Administrator on 09/03/14 at 10:45 AM revealed he had received inservicing on 09/03/14 by an outside consultant on the Elopement Policy Statement and Risk Elopement Policy Procedures and Assessments. He was required to take a post test with 100% accuracy. 1 and 4. On 09/11/14 at 11:00 AM, the DON verified through interview that the door entering into the West End dining room was secured on 08/24/14 by replacing the existing lock with one that locks automatically. Repair was made to the exit door by an electrician. Inservicing was completed by the Inservice Coordinator on 09/03/14. Inservice training was on the Elopement Policy Procedures and Assessments which included residents identified at risk would have a plan of care developed and implemented to ensure their safety. She was inserviced on the Elopement Policy and the door checks implemented 09/03/14. She was required to pass a post test with 100% accuracy. The inservice also included that the entrance door from the hall into the West End dining room would remain locked at all times when not in use for meals or church services and only be opened by a Charge Nurse and/or a Janitor in order to be cleaned. A log was placed in the West End dining room and the door will be checked for functioning and effectiveness of the locking mechanism daily by the Janitor on duty and finding documented. 4 and 7. Interview on 09/11/14 with the Restorative Nurse at 11:05 AM revealed she checked the doors on 09/03/14 and a log was initiated for daily checking for functioning of the automatic lock placed by the Janitor. She was inserviced on the Elopement Policy Statement and Risk Elopement Policy procedures and assessments and was required to pass a post test with 100% accuracy. The Charge Nurses, Janitor and Housekeeping are the only staff with a key to the West End dining room. 5 and 6. The Housekeeping Supervisor verified through interview on 09/11/14 at 11:10 AM that she had inservice training related to keeping the West End dining room locked at all times except when being used for meals or Church. Housekeeping, Maintenance and the Charge Nurses were the only staff with a key to unlock the entrance door to the dining room. She was inserviced on the facility's Elopement Policy to include reporting to the nurse if she saw any resident displaying exit seeking behaviors. She stated she was trained to check the door to ensure it was locked every day after meals and a log was used for documenting. After fourteen (14) days, then weekly for four (4) weeks, then every month for three (3) months, then quarterly. All logs and audits will be taken to the QAA meeting by the Housekeeping Supervisor. 5 and 6. On 09/11/14 at 11:20 AM Maintenance Staff #1, revealed he had received inservice training on the facility's Elopement Policy Statement and Risk Elopement Policy procedures and assessments and had to pass a post test with 100% accuracy. The doors will be checked daily by the Janitor and documented on a log. Housekeeping, Maintenance and Charge Nurses were the only staff that could unlock the entrance door to the West End dining room. If a malfunction was noted when checked, Maintenance would be notified immediately and the Janitor would stay with at the door until Maintenance arrived. Audits were also being done by Housekeeping. 4. Interview with the Social Service Director on 09/11/14 at 11:25 AM revealed she had received inservicing from the Inservice Coordinator on 09/03/14 and was required to take a post test with 100% accuracy. The inservice included keeping the entrance door to the West End dining room locked except when in use and only Charge Nurses, Maintenance and Housekeeping had a key to unlock it. Monitors were in place to ensure the doors were locked daily and will continue for a few months. The facility Elopement Policy and Elopement Risk Assessment policy and Procedures Assessment were included in the inservice. 3. On 09/11/14 at 11:30 AM LPN #3 revealed in interview that she had been provided inservice training on 09/03/14 by the Inservice Coordinator. The inservice included the Elopement Policy and the Elopement Risk Assessment Procedures. She stated only nurses, janitors and housekeeping had a key to unlock the door to the West End dining room and it was to remain locked all times when not in use for meals. She stated the Elopement Risk Assessment was completed when a resident exhibited exit seeking behaviors. The doors were being checked daily and documented on a log and the log was being audited by Housekeeping. 5. Housekeeping Staff #1 revealed in interview on 09/11/14 that she had received inservicing by the Inservice Coordinator last week. She stated the inservice covered keeping the door to the West End dining room locked except when in use for meals. The Nurse, Maintenance and Housekeeping had a key to unlock it. Housekeepers work one night a week and after the evening meal, they were to ensure the entrance door was locked after the room was cleaned. 5. Interview on 09/11/14 at 11:35 AM with the Social Service Assistant revealed she had received inservice training by the Inservice Coordinator on 09/03/14. The inservice covered the facility's Elopement Policy and the Elopement Risk Assessment Procedures. Residents at risk had care plan interventions implemented. The entrance door into the West End dining room from the hall was to be locked unless it was being utilized for meals or a church group. Maintenance was checking the doors in the room daily and Housekeeping was also checking to ensure the entrance door was locked. A log was being utilized to ensure verification documentation the doors were being checked. 5. LPN #3 revealed in interview on 09/11/14 at 11:40 AM that she had received inservice training by the Inservice Coordinator. The inservice included how the entrance and exit doors of the West End dining room were being monitored daily to ensure the locks and alarms were functional. A log was being kept to ensure documentation of the monitoring and an audit of the log was also being conducted. The West End dining room entrance door was to be locked at all times when not in use. Residents at risk for elopement behaviors were to have care plan interventions implemented to assure their safety. 5. On 09/11/14 a 11:45 AM, Nurse Aide Student #1, revealed she had been provided inservice training by the Inservice Coordinator. The inservice covered keeping the West End dining room locked when not in use and checking to ensure the doors remained locked. Maintenance and Housekeeping were monitoring the doors daily and only Charge Nurses, Maintenance and Housekeeping had a key to unlock the dining room. Resident behaviors of exit seeking was to be reported to the nurse immediately. 5. CNA #2 revealed in interview on 09/11/14 at 11:50 AM that she had been provided training in an inservice by the Inservice Coordinator. The facility's Elopement Policy and a risk assessment was covered in the inservice as well as keeping the door locked to the West End dining room. The doors were being monitored for functionality by Maintenance and Housekeeping. Charge Nurses, Maintenance and Housekeeping were the only staff that had keys to unlock the door to the dining room. Additionally, resident behaviors were to be reported to the nurse. CNA #2 took a post test to confirm competency. 5. An interview on 09/11/14 at 11:55 AM was conducted with CNA #4. She revealed the Inservice Coordinator provided inservicing on keeping the entrance door to the West End dining room locked at all times when not in use for meals and Maintenance, Housekeeping and the Charge Nurse had the only keys. Maintenance and Housekeeping were monitoring the doors daily to make sure alarms and locks were functioning. Residents with wandering behaviors were monitored and behaviors reported to the nurse. 5. Interview with a Laundry Aide on 09/11/14 at 12:00 PM revealed the Inservice Coordinator gave an inservice on 09/03/14 about keeping the West End dining room locked when not being used for meals. Maintenance and Housekeeping was monitoring the doors and keeping a log. A post test had to be completed with 100% accuracy. Maintenance, Housekeeping and the Charge Nurses had the only keys to the dining room. Residents were monitored for exit seeking and the nurse was to be informed of any of those type of behaviors. 5. An interview conducted on 09/11/14 at 12:05 PM with CNA #5 revealed she had completed a post test with 100% after inservicing given on 09/03/14. The Inservice Coordinator provided the inservice which included monitoring residents when displaying exit seeking and reporting to the nurse. Maintenance and Housekeeping was monitoring the doors to the West End dining room and noting it on a log. The doors were to remain locked at all times when the dining room was not in use and the keys to the dining room were kept by the Charge Nurse, Maintenance and Housekeeping. 5. CNA #6 revealed in interview conducted on 09/11/14 at 12:10 PM, that she had received recent inservicing related to the doors of the West End dining room. She stated the doors remain locked at all times when not in use. The Charge Nurse, Maintenance and Housekeeping had the only keys to the entrance door which was changed to an automatic locking system. A log was being used to verify when Maintenance and Housekeeping checked the doors on a daily basis. Resident behaviors of wandering and exit seeking was to be reported to the nurse and interventions to address those behaviors was discussed. The inservice covered the Elopement Policy and Risk Assessment Policy. CNA #6 was required to pass a post test with 100% after the inservice.

Based on interview, record review and review of the Administrator Position Description and the facility's policy and procedures, it was determined the facility failed to be administered in a manner that enabled it to use it's resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well being for two (2) of six (6) sampled residents (Resident #1 and Resident #2). The facility failed to ensure staff were reeducated after Resident #1 and Resident #2 eloped from the facility per the facility's policy and procedure. Resident #1 and Resident #2, who were assessed and care planned as elopement risks, exited the building without staff knowledge on 08/24/14 at approximately 8:15 AM. Resident #1 and Resident #2 entered the dining room at the West End of the building through an unlocked door, then proceeded to exit through the exit door to the outside without the two (2) alarms on the door sounding. The residents were found outside by Certified Nurse Aide (CNA) #3 who was leaving work. The facility's policy, to re-educate staff after the elopement, was not implemented until 09/03/14, ten (10) days later. The facility's failure to ensure the facility was administered in a manner that enabled it to use its resources effectively and efficiently caused or was likely to cause serious injury, harm, impairment or death of a resident. Immediate Jeopardy was identified 09/03/14 and determined to exist on 08/24/14. An acceptable Allegation of Compliance (AoC) was received on 09/09/14, and the State Survey Agency validated the Immediate Jeopardy was removed on 09/05/14, as alleged. The Scope and Severity was lowered to a "D" at CFR 483.20 Resident Assessment at F282, CFR 483.25 Quality of Care at F323 and CFR 483.75 Administration at F490, while the facility develops and implements the Plan of Correction (POC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the Administrator's job description and performance standards revealed: Purpose of this position; "The purpose of this position is to establish and maintain systems that are effective and efficient to operate the facility in a manner to safely meet residents' needs in compliance with Federal, State and local requirements. To establish and maintain systems that are effective and efficient to operate the facility in a financially sound manner". Review of the facility policy titled "Elopement", not dated, revealed "Residents are comprehensively assessed for wandering/elopement risk in order to minimize the potential for eloping from the facility". The policy additionally revealed, "Re-education of staff is conducted following any actual elopement event to critique staff performance and to assure that any improvements to the facility protocol are known to all staff". 1. Record review revealed the facility admitted Resident #1 on 03/31/13 with [DIAGNOSES REDACTED]. Review of a Nursing Note, dated 08/24/14 at 8:15 AM, revealed "Resident becoming agitated, exit seeking and stating I'm a truck driver and I need to start my route. Very hard to redirect". The Nursing Note also revealed "This nurse notified of resident being outside Church Hill doors (West end dining room). 2. Record review revealed the facility admitted Resident #2 on 10/08/12 with [DIAGNOSES REDACTED]. Review of a Nurse's Note, dated 08/24/14 at 8:15 AM revealed, "This nurse informed resident was outside Churchill doors. CNA pushed resident in wheel chair back into facility". Interview with the In-service Coordinator, on 09/03/14 at 8:50 AM, revealed there had been no reeducation of staff related to the elopement on 08/24/14. She stated she started reeducating the staff this morning (09/03/14) because she had not been instructed to do so until this date. Interview with the Administrator on 08/29/14 at 11:00 AM revealed he was notified of Resident #1 and Resident #2 exiting the facility without staff knowledge on 08/24/14 about 8:30 AM. The Administrator stated the door entering the West End dining room was not locked and should have been. Resident #1 and #2 had entered the unsupervised dining room from the hall and exited out of the facility through the exit door and the key code alarm and the pull away alarm failed. A Post Survey Interview, on 09/15/14 at 4:45 PM, revealed he had no system in place to ensure the staff was educated after an elopement per the facility's policy and procedure. The facility implemented the following actions to remove the Immediate Jeopardy: 1. Resident (#1 and #2) were put on every thirty (30) minute watches for twenty four (24) hours per facility policy with no further attempts to exit the facility. RN #1 and RN #2 performed head to toe assessments on Residents #1 and #2 with no injuries identified. The entry door to the West End dining room door lock was replaced with an automatic lock mechanism on 08/24/14. A licensed electrician was called to the facility on [DATE] and corrected a mechanical failure. All exit doors from the facility on 08/24/14 were checked by the Maintenance Director and Social Services Director and determined to be functioning. 2. The Administrator was inservicerd by an outside consultant RN on 09/03/24 on the elopement policy statement and Risk Elopement Policy procedures and assessments. The Administrator was required to take a post test with 100% accuracy. 3. The Inservice Coordinator was inserviced on the Elopement Policy Statement and Risk Elopement Policy procedures and assessments by the Administrator on 09/03/14 and was required to complete a post test with 100% accuracy. 4. The DON, Restorative Nurse, Business Office Manager, Human Resources Manager, Laundry Manager, Activities Director, Environmental Director, Maintenance Director, RAI Nurses, Dietary Manager, Medical Records Manager, PC Coordinator, Social Services Director was inserviced on 09/03/14 by the Inservice Coordinator on the Elopement Policy Statement and Risk Elopement Policy procedures and assessments. A post test was required and completed with 100% accuracy. 5. A mandatory on-site inservice on the Elopement Policy Statement and Risk Elopement Policy Procedures and assessments was completed on 09/03/14 and 09/04/14 for all other staff by the Inservice Coordinator. The inservice also included the training of all staff that the hallway door leading into the West End dining room was locked at all times when not in use and can only be opened by a Charge Nurse for meal times and/or a Janitor in order to be cleaned. All staff was required to take a post test with 100% accuracy. Any staff who has not attended the Elopement Policy Statement and Risk Elopement Policy procedures and assessments inservice was taken off the schedule until it is completed. They will not work until they have attended the inservice and passed the post test with 100% accuracy. This included Nurses, CMAs, Ward Clerks, Business Office personnel, Nurse Aides, Activities, Maintenance Department, Social Services, Receptionist, Environmental Services, Laundry Department, Maintenance Department, Dietary Department and Therapy Department. Orientation program will include inservice on the Elopement Policy Statement and Risk Elopement procedures and assessments by the Inservice Coordinator for all new employees before they are allowed to work. This includes any new hires or contract labor should they employ them. They must complete a post test with 100% accuracy before being allowed to work. 6. All residents at risk for elopement were re-assessed by the DON on 08/25/14. The West End dining room exit door to the outside was checked for functioning of the locking mechanism by the Restorative Nurse on 09/03/14. All Janitors employed by the facility were trained by the Inservice Coordinator on 09/04/14 on proper procedure for checking door functioning and logging findings. A log was initiated and the door will be checked for functioning and effectiveness of the locking mechanism daily by the Janitor on duty and findings documented on the log. If any malfunctions are observed maintenance will be notified immediately and the Janitor will stay at the door until maintenance arrives. An audit of the log will be done by the Housekeeping Supervisor daily for fourteen (14) days of 100% compliance. Then weekly for four weeks until 100% compliance is met for four (4) consecutive weeks. Then monthly for three (3) months, then quarterly if 100% compliance is maintained. All logs and audits will be brought to the QAA meeting by the Housekeeping Supervisor and reviewed for any areas of concern. 7. The hallway entry door into the West end dining room was checked for functioning and effectiveness of the automatic locking system by the Restorative Nurse on 09/03/14. A log will be kept related to the effectiveness and functioning of the automatic lock and will be documented on the same log as the exit door in the West End dining room. Any malfunctions observed will be reported to Maintenance immediately and the Janitor will stay at the door until Maintenance arrives. An audit of the log will be done by the Housekeeping Supervisor daily for fourteen (14) days of 100% compliance, then weekly for four (4) weeks until 100% compliance is met for four (4) consecutive weeks, then every month for three (3)months, then quarterly if 100% compliance is maintained. All logs and audits will be brought to the quarterly QAA meeting by the Housekeeping Supervisor and addressed for areas of concern. The State Survey Agency validated the corrective actions taken by the facility as follows: 1. Observation on 09/11/14 at 10:45 AM, revealed the entrance door to the West End dining room was locked. A log book located in the dining room revealed signatures from Maintenance and Housekeeping staff that verified monitoring of the entrance and exit doors of the room. The log indicated the doors were being checked three (3) times daily for functioning of the exit door and the entrance door. The log gave indicators to include Maintenance being notified if a door was not functioning properly and if not was a staff member posted at the door to monitor any malfunctioning. The log was current and no malfunction had been identified. An audit form also verified the checks were being completed and documented on the log. 4. and 5. On 09/11/14, inservice training was verified completed on 09/03/14 and 09/04/14. The inservices had been completed by all facility staff, except four (4) who were on Family Medical Leave Act (FMLA). The Inservice Coordinator was responsible to ensure the four (4) staff that had not received the inservice would have the inservice prior to being allowed to work and would have to take a post test. The Orientation Program will include the inservice on the Elopement Policy Statement and Risk Elopement Policy Procedures and Assessments by the Inservice Coordinator for any new employees before they are allowed to work. 2. Interview with the Administrator on 09/03/14 at 10:45 AM revealed he had received inservicing on 09/03/14 by an outside consultant on the Elopement Policy Statement and Risk Elopement Policy Procedures and Assessments. He was required to take a post test with 100% accuracy. 1 and 4. On 09/11/14 at 11:00 AM, the DON verified through interview that the door entering into the West End dining room was secured on 08/24/14 by replacing the existing lock with one that locks automatically. Repair was made to the exit door by an electrician. Inservicing was completed by the Inservice Coordinator on 09/03/14. Inservice training was on the Elopement Policy Procedures and Assessments which included residents identified at risk would have a plan of care developed and implemented to ensure their safety. She was inserviced on the Elopement Policy and the door checks implemented 09/03/14. She was required to pass a post test with 100% accuracy. The inservice also included that the entrance door from the hall into the West End dining room would remain locked at all times when not in use for meals or church services and only be opened by a Charge Nurse and/or a Janitor in order to be cleaned. A log was placed in the West End dining room and the door will be checked for functioning and effectiveness of the locking mechanism daily by the Janitor on duty and finding documented. 4 and 7. Interview on 09/11/14 with the Restorative Nurse at 11:05 AM revealed she checked the doors on 09/03/14 and a log was initiated for daily checking for functioning of the automatic lock placed by the Janitor. She was inserviced on the Elopement Policy Statement and Risk Elopement Policy procedures and assessments and was required to pass a post test with 100% accuracy. The Charge Nurses, Janitor and Housekeeping are the only staff with a key to the West End dining room. 5 and 6. The Housekeeping Supervisor verified through interview on 09/11/14 at 11:10 AM that she had inservice training related to keeping the West End dining room locked at all times except when being used for meals or Church. Housekeeping, Maintenance and the Charge Nurses were the only staff with a key to unlock the entrance door to the dining room. She was inserviced on the facility's Elopement Policy to include reporting to the nurse if she saw any resident displaying exit seeking behaviors. She stated she was trained to check the door to ensure it was locked every day after meals and a log was used for documenting. After fourteen (14) days, then weekly for four (4) weeks, then every month for three (3) months, then quarterly. All logs and audits will be taken to the QAA meeting by the Housekeeping Supervisor. 5 and 6. On 09/11/14 at 11:20 AM Maintenance Staff #1, revealed he had received inservice training on the facility's Elopement Policy Statement and Risk Elopement Policy procedures and assessments and had to pass a post test with 100% accuracy. The doors will be checked daily by the Janitor and documented on a log. Housekeeping, Maintenance and Charge Nurses were the only staff that could unlock the entrance door to the West End dining room. If a malfunction was noted when checked, Maintenance would be notified immediately and the Janitor would stay with at the door until Maintenance arrived. Audits were also being done by Housekeeping. 4. Interview with the Social Service Director on 09/11/14 at 11:25 AM revealed she had received inservicing from the Inservice Coordinator on 09/03/14 and was required to take a post test with 100% accuracy. The inservice included keeping the entrance door to the West End dining room locked except when in use and only Charge Nurses, Maintenance and Housekeeping had a key to unlock it. Monitors were in place to ensure the doors were locked daily and will continue for a few months. The facility Elopement Policy and Elopement Risk Assessment policy and Procedures Assessment were included in the inservice. 3. On 09/11/14 at 11:30 AM LPN #3 revealed in interview that she had been provided inservice training on 09/03/14 by the Inservice Coordinator. The inservice included the Elopement Policy and the Elopement Risk Assessment Procedures. She stated only nurses, janitors and housekeeping had a key to unlock the door to the West End dining room and it was to remain locked all times when not in use for meals. She stated the Elopement Risk Assessment was completed when a resident exhibited exit seeking behaviors. The doors were being checked daily and documented on a log and the log was being audited by Housekeeping. 5. Housekeeping Staff #1 revealed in interview on 09/11/14 that she had received inservicing by the Inservice Coordinator last week. She stated the inservice covered keeping the door to the West End dining room locked except when in use for meals. The Nurse, Maintenance and Housekeeping had a key to unlock it. Housekeepers work one night a week and after the evening meal, they were to ensure the entrance door was locked after the room was cleaned. 5. Interview on 09/11/14 at 11:35 AM with the Social Service Assistant revealed she had received inservice training by the Inservice Coordinator on 09/03/14. The inservice covered the facility's Elopement Policy and the Elopement Risk Assessment Procedures. Residents at risk had care plan interventions implemented. The entrance door into the West End dining room from the hall was to be locked unless it was being utilized for meals or a church group. Maintenance was checking the doors in the room daily and Housekeeping was also checking to ensure the entrance door was locked. A log was being utilized to ensure verification documentation the doors were being checked. 5. LPN #3 revealed in interview on 09/11/14 at 11:40 AM that she had received inservice training by the Inservice Coordinator. The inservice included how the entrance and exit doors of the West End dining room were being monitored daily to ensure the locks and alarms were functional. A log was being kept to ensure documentation of the monitoring and an audit of the log was also being conducted. The West End dining room entrance door was to be locked at all times when not in use. Residents at risk for elopement behaviors were to have care plan interventions implemented to assure their safety. 5. On 09/11/14 a 11:45 AM, Nurse Aide Student #1, revealed she had been provided inservice training by the Inservice Coordinator. The inservice covered keeping the West End dining room locked when not in use and checking to ensure the doors remained locked. Maintenance and Housekeeping were monitoring the doors daily and only Charge Nurses, Maintenance and Housekeeping had a key to unlock the dining room. Resident behaviors of exit seeking was to be reported to the nurse immediately. 5. CNA #2 revealed in interview on 09/11/14 at 11:50 AM that she had been provided training in an inservice by the Inservice Coordinator. The facility's Elopement Policy and a risk assessment was covered in the inservice as well as keeping the door locked to the West End dining room. The doors were being monitored for functionality by Maintenance and Housekeeping. Charge Nurses, Maintenance and Housekeeping were the only staff that had keys to unlock the door to the dining room. Additionally, resident behaviors were to be reported to the nurse. CNA #2 took a post test to confirm competency. 5. An interview on 09/11/14 at 11:55 AM was conducted with CNA #4. She revealed the Inservice Coordinator provided inservicing on keeping the entrance door to the West End dining room locked at all times when not in use for meals and Maintenance, Housekeeping and the Charge Nurse had the only keys. Maintenance and Housekeeping were monitoring the doors daily to make sure alarms and locks were functioning. Residents with wandering behaviors were monitored and behaviors reported to the nurse. 5. Interview with a Laundry Aide on 09/11/14 at 12:00 PM revealed the Inservice Coordinator gave an inservice on 09/03/14 about keeping the West End dining room locked when not being used for meals. Maintenance and Housekeeping was monitoring the doors and keeping a log. A post test had to be completed with 100% accuracy. Maintenance, Housekeeping and the Charge Nurses had the only keys to the dining room. Residents were monitored for exit seeking and the nurse was to be informed of any of those type of behaviors. 5. An interview conducted on 09/11/14 at 12:05 PM with CNA #5 revealed she had completed a post test with 100% after inservicing given on 09/03/14. The Inservice Coordinator provided the inservice which included monitoring residents when displaying exit seeking and reporting to the nurse. Maintenance and Housekeeping was monitoring the doors to the West End dining room and noting it on a log. The doors were to remain locked at all times when the dining room was not in use and the keys to the dining room were kept by the Charge Nurse, Maintenance and Housekeeping. 5. CNA #6 revealed in interview conducted on 09/11/14 at 12:10 PM, that she had received recent inservicing related to the doors of the West End dining room. She stated the doors remain locked at all times when not in use. The Charge Nurse, Maintenance and Housekeeping had the only keys to the entrance door which was changed to an automatic locking system. A log was being used to verify when Maintenance and Housekeeping checked the doors on a daily basis. Resident behaviors of wandering and exit seeking was to be reported to the nurse and interventions to address those behaviors was discussed. The inservice covered the Elopement Policy and Risk Assessment Policy. CNA #6 was required to pass a post test with 100% after the inservice.

Based on interview, record review and review of the facility's Administrator's job description, it was determined the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being for one (1) of eight (8) sampled residents (Resident #1). On 08/10/13, the facility noted Resident #1 had an injury of unknown source to his/her left hand. There was no documented evidence the facility conducted an investigation of this injury. On 08/20/13, Adult Protective Services (APS) notified the facility's Social Service Director (SSD), who is the Abuse/Neglect Coordinator, and responsible for investigating allegations of abuse, that they were investigating an allegation of abuse that a staff member injured Resident #1. It was alleged staff pulled the resident, by his/her wrist down the hall, causing an injury. There was no documented evidence the facility initiated an investigation of abuse, protected the residents from the alleged perpetrator or notified the State Survey Agency (SSA), after this notification. Furthermore, the Administrator was made aware of the allegation of abuse on 09/25/13 but the Certified Nurse Aide (CNA) was not suspended and an investigation was not initiated until 09/27/13. Refer to F225 and F226. The facility's failure to ensure the facility was administered in a manner that enabled it to use its resources effectively and efficiently to attain and maintain the highest practicable physical, mental and psychosocial well-being related to abuse allegations and an injury of unknown origin has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified, on 10/02/13, and determined to exist on 08/20/13, at 42 CFR 483.13 Resident Behavior and Facility Practice at F225 and F226, and 42 CFR 483.75 Administration at F490, at a scope and severity of a "J". Substandard Quality of Care was identified at 42 CFR 483.13 Resident Behavior and Facility Practice. The facility was notified of Immediate Jeopardy on 10/02/13. An acceptable Allegation of Compliance (AoC) was received on 10/08/13 alleging removal of the Immediate Jeopardy on 10/09/13. The State Survey Agency validated, on 10/09/13, the Immediate Jeopardy was removed on 10/09/13, as alleged. The scope and severity was lowered to a "D" at 42 CFR 483.13 Resident Behavior and Facility Practice with F225 and F226, and 42 CFR 483.75 Administration with F490 while the facility implements the Plan of Correction (PoC) and facility's Quality Assurance (QA) Audits are implemented and monitored for the effectiveness of system changes. The findings include: Review of the job description entitled, "Job Description and Performance Standards of the SSD", undated, revealed the SSD was responsible for the safety of residents under his/her supervision, and must observe all facility's policies and procedures. Review of the job description entitled, "Job Description and Performance Standards of the DON", undated, revealed the DON was responsible for directing, evaluating and supervising all resident care, to initiate corrective action as necessary, to assume responsibility for analysis of incident and accident investigation reports to determine cause(s) and implement corrective action(s), when appropriate. Review of the job description entitled, "Job Description and Performance Standards of the Administrator", undated, revealed the Administrator was responsible to operate the facility in accordance with the established policies and procedures of the governing body in compliance with federal, state and local regulations; establish systems to ensure compliance with all federal, state, and local regulations, observe all facility policies and procedures and observe all facility safety policies and procedures. Review of facility's policy entitled, Reporting & Investigation of Abuse, Neglect, Mistreatment, Exploitation and/or Misappropriation of Resident Property, last revised 07/21/10, revealed: If an injury is noted and the source of the injury cannot be identified, the abuse investigation is started as described below with the goal of determining what caused the injury and ruling out any instance of abuse. The facility's Injury of Unknown Etiology Investigation Form will be started by the Social Service Director (SSD) or his or her designee after he/she is notified by a staff member or family member noting the injury. It is imperative that the injury be reported to the SSD, the Director of Nursing (DON) and the Administrator immediately. In addition, the policy and procedure revealed all personnel must immediately report an incident or suspected incident of resident abuse, neglect or mistreatment including injuries of an unknown source or misappropriation of resident property. Observation of an incident or resident abuse or suspecting resident abuse must be reported to the charge nurse or supervisor and the DON/designee, SSD and Administrator should be notified immediately, with the investigation starting immediately. The resident should be removed from harm and examined and the examination recorded in the medical record. If the allegation of abuse is against a staff member, that person is to "leave the building immediately and will be denied unsupervised access to the residents", that staff is placed on administrative leave pending the outcome of the investigation. The Administrator or his/her designee is to immediately notify the State agency and the Adult Protective Services (APS) as required by state law. An immediate investigation will be made by the SSD and a copy of the findings will be provided to the Administrator or his/her designee per "Allegation of Abuse Investigation Form-Appendix E". The State agency is to be notified within five (5) working days of the occurrence. The Administrator or his/her designee will inform the resident and his/her legal representative of the results of the investigation and corrective action taken. Record review revealed the facility admitted Resident #1 on 05/13/13 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 08/16/13, revealed the facility assessed Resident #1's cognition as severely impaired and he/she required assistance with all activities of daily living. On 08/10/13, the facility noted Resident #1 had an injury of unknown source to his/her left hand. There was no documented evidence the facility conducted an investigation of this injury. On 08/20/13, Adult Protective Services (APS) notified the facility's Social Service Director (SSD), who is the Abuse/Neglect Coordinator, and responsible for investigating allegations of abuse, that they were investigating an allegation of abuse that a staff member injured Resident #1. It was alleged staff pulled the resident, by his/her wrist down the hall, causing an injury. There was no documented evidence the facility initiated an investigation of abuse, protected the residents from the alleged perpetrator or notified the State Survey Agency (SSA), after this notification. Interview with the SSD who is also the Abuse/Neglect Coordinator, on 09/30/13 at 12:50 PM, revealed she was aware of the bruise on Resident #1's hand because she had read about the bruise in the Nursing Notes. The SSD stated the facility's policy and procedure for abuse was staff should complete the Injury of Unknown Etiology Investigation form, an investigation should have been conducted to try to determine the cause of the injury and rule out abuse and the Administrator should have been notified. The SSD revealed the facility's policy and procedure was not followed. Further interview with the SSD, on 09/25/13 at 6:00 PM, on 09/27/13 at 11:00 AM and 2:15 PM, on 09/30/13 at 12:50 PM, and on 10/01/13 at 10:25 AM, revealed APS had made her aware on 08/20/13 that there was an allegation that a CNA had dragged Resident #1 down the hall by the resident's wrist. The SSD stated the facility's policy and procedure for an allegation of abuse was if an allegation was received against a staff member it was the facility's policy to have the staff member go to the conference room to take their statement and then send him/her home until the investigation was completed. The Administrator and DON should be notified and an investigation should be initiated immediately. The SSD stated the SSA and APS should be notified within twenty-four hours and the final investigation results should have been reported within five (5) days to the SSA. The SSD revealed an initial allegation form and allegation of Abuse Investigation form should be completed for the abuse allegation. The SSD revealed the facility's policy and procedure was not followed because staff failed to complete the forms. The SSD stated according to the facility's policy she should have notified the DON, Administrator and the SSA immediately, conducted a thorough investigation and determined if the allegation was or was not substantiated. The SSD stated APS unsubstantiated the allegation so she unsubstantiated it because "they are the experts". Interview with the DON, on 09/27/13 at 11:45 AM and 1:45 PM, and 09/30/13 at 2:39 PM revealed it was the facility's policy that the Administrator, SSD, and DON should be notified immediately if an allegation is made. The DON stated the resident should be removed from any suspected harm, the staff member should be suspended and walked out of the building by staff, an investigation should be initiated and the SSA should be notified immediately. The DON stated she was made aware of the allegation on 08/20/13 by the SSD who informed her an allegation had been made that a staff member had roughly handled Resident #1. The DON revealed the facility's policy and procedure was not followed related to notification of the SSA and completing a thorough investigation. The DON stated she, the Administrator and SSD were responsible to ensure an investigation was completed. Review of CNA #1's Employee Daily Activity Report revealed the facility allowed her to work twenty-six (26) days from 08/20/13 through 09/26/13. Interview with CNA #1, on 09/26/13 at 6:45 PM, revealed she was aware an allegation of abuse was made against her but she had not been placed on administrative leave. Interview with the Administrator, on 10/01/13 at 9:25 AM and 10/02/13 at 3:22 PM, revealed according to the abuse/neglect policy and procedure the SSD, Administrator, and DON should be notified of an allegation once a resident has been made safe; the suspected staff, witnesses and resident should be interviewed, and the suspected staff should be placed on administrative leave until the investigation was complete. The Administrator stated he was not aware of the allegation of abuse involving CNA #1 to Resident #1 until 09/25/13, and the SSD should have made him aware of the allegation. The Administrator further revealed CNA #1 was not placed on administrative leave and an investigation had not been initiated until 09/27/13. The Administrator stated he was 100% responsible for what goes on in the facility, and the SSD does not make the determination of the allegation on her own it is a joint effort. The facility implemented the following actions to remove the Immediate Jeopardy: On 09/27/13, the alleged perpetrator was put on administrative leave and not allowed to work with residents and an investigation was initiated by the Social Services Director (SSD) related to the allegation of abuse involving Resident #1 and CNA #1. In addition, an investigation was initiated related to Resident #1's injury of unknown injury by a Restorative Nurse. The investigations involved staff interviews, record reviews, and review of electronic documentation. Subsequently, the alleged perpetrator was terminated on 10/04/13 for failure to get along with other staff. The SSD was trained on investigations of alleged abuse, mistreatment, neglect and misappropriation of funds by the Nurse Consultant on 10/08/13. The Administrative Staff (Administrator, DON, Restorative Nurse, Business Office Manager, Human Resources Manager, Laundry Manager, Activities Director, Environmental Director, Maintenance Director, RAI Nurses, Dietary Manager, Medical Record Manager, Social Service Director, and QA Inservice Coordinator) was inserviced by the RN Consultant on the Abuse, Neglect, Mistreatment and Misappropriation of Funds policy which include the seven components of the Abuse Prevention Protocol on 10/08/13. The staff was required to take a post test and receive 100% accuracy. All staff was inserviced on the Abuse Neglect, Mistreatment and Misappropriation of Funds policy including the seven (7) components of the Abuse Prevention Protocol on 10/02-10/04/13 by the QA/Inservice Coordinator/Nurse Aide Instructor. The staff was required to take a post test and pass with 100% accuracy. Staff involved in the policy inservice training included: nurses, certified medical assistants (CMA), CNAs, ward clerks, business office, nurse aides, activity workers, maintenance department, social services, receptionist, environmental services department, laundry department, maintenance department, dietary department, and therapy. The orientation program will include an inservice on the Abuse Policy and the seven (7) criteria by the Inservice Director for all new employees before they were allowed to give direct care. This includes new hires, contract labor and agency staff if used. The new employees will be given a post test and must pass with 100% accuracy. On 10/03/13, the DON and SSD conducted audits with twenty-seven (27) interviewable residents (those with BIMs score of eight (8) and above) asking if they had been abused or mistreated with all residents denying abuse with no concerns noted. Non-interviewable residents were observed for signs and symptoms of abuse using observation of skin assessments, and family interviews to detect changes or concerns, with no concerns noted. A Quality Assurance (QA) audit was conducted on interviewable residents by the SSD asking if they have been mistreated or abused once a week for eight (8) weeks of 100% compliance and continued for at least six (6) months, with the QA audit being brought to and reviewed at quarterly and interim QA meetings by the Social Service Director. The audit will also include the thirty-eight (38) non-interviewable residents. They will be observed for signs and symptoms of abuse during weekly skin assessments and family interviews. This audit will be done once a week for eight weeks of 100 % compliance. This audit will be continued for at least three (3) months. If any issues are identified they will be immediately investigated. The QA audit will be brought to and reviewed at quarterly and interim QA meetings by the Social Service Director. On 10/03/13, the DON audited one-hundred four (104) incident reports for the past three (3) months to assess for suspected abuse, mistreatment, neglect and source of injury unknown origin. The audit consisted of review of incident reports, medical records and staff/resident interviews if needed. If issues were identified they were investigated. This audit will continue at least monthly for three (3) months with 100% compliance with random audits continued quarterly. The QA nurse reviewed twenty four (24) grievances on 10/03/13 which consisted of review of grievance forms, grievance log and staff interviews to see if any would have been suggestive of abuse with no abuse noted. This audit will be done by the QA nurse once a week for eight (8) weeks of 100% compliance and be continued for at least six (6) months, with the audit being brought to and reviewed at quarterly and interim QA meetings by the QA nurse. The QA nurse will conduct an audit once a week for eight (8) weeks to establish the staff understands the seven (7) components of the abuse prevention protocol. The audit consist of interviewing staff on screening, training, prevention, identification, investigation protection, reporting and responding; with the audit being done once a week for eight (8) weeks of 100% compliance for at least six (6) months. The State Survey Agency validated the corrective action by the facility as follows: Review on 10/08/13 of the activity audits of all departments revealed CNA #1 was not working in the facility from 09/27/13 through 10/05/13. Interview with the DON, on 10/09/13 at 9:00 AM, revealed CNA #1 had not worked at the facility since being put on administrative leave on 09/27/13. Review of the facility's inservices, dated 10/02/13 through 10/04/13 and 10/08/13, revealed all staff which included the Administrative staff was inserviced on the seven (7) components of the abuse prevention policy and an abuse test was given afterward with test scores of 100%. The Administrative staff also received an additional inservice by an Registered Nurse (RN) Consultant on the seven (7) components of the abuse prevention policy and an abuse test was given afterward with test scores of 100%. Interviews on 10/09/13 from 11:00 PM to 5:55 PM with fourteen (14) CNAs, six (6) nurses, three (3) Certified Medicine Aids (CMA), two (2) Therapy Aides, three (3) Dietary Aides, a Receptionist, a Ward Clerk/Medical Records, two (2) Minimum Data Set/Resident Assessment Instrument nurses, one (1) Maintenance, two (2) laundry aides, and six (6) Housekeeping Aides revealed they had received an inservice on the seven (7) components of abuse and had made 100 % on required test given by the Quality Assurance (QA)/Inservice Coordinator/Nurse Aide Instructor nurse from 10/02/13 through 10/04/13. Interviews on 10/09/13 at 1:00 PM through 5:00 PM with Administrative staff, to include the Administrator, DON, Restorative Nurse, Dietary Supervisor, Activity Director, SSD, Maintenance Director, Laundry Supervisor, Housekeeping Supervisor, and Business Office Manager revealed they had been inserviced on the seven (7) components of abuse and had made 100% on the required test. In addition the Administrative staff revealed they had received an additional inservice by an outside Nurse Consultant on 10/08/13 on the seven (7) components of abuse and had made 100% on the required test. Interview with the QA/Inservice Coordinator/Nurse Aide Instructor, on 10/09/13 at 2:00 PM revealed she will inservice new hires on the seven (7) components of abuse and the new hires will be required to take the test and make 100% before they will be allowed to work on the floor. Interview on 10/09/13 at 11:00 AM with the DON and QA/Inservice Coordinator/Nurse Aide Instructor revealed all staff had been inserviced on the seven (7) components of abuse and had made 100% on the required test. The DON and QA/Inservice Coordinator/Nurse Aide Instructor further revealed Administrative staff had received an additional inservice by an outside Nurse Consultant on 10/08/13 on the seven (7) components of abuse and had made 100% on the required test afterward. Review of QA Audits dated 10/09/13 revealed interviewable residents were interviewed by the SSD and she asked them if they had been mistreated or abused. The QA audit also included the thirty-eight (38) non-interviewable residents observed for signs and symptoms of abuse during weekly skin assessments and family interviews. Interview on 10/08/13 at 10:00 AM and on 10/09/13 at 12:20 PM with the SSD and DON revealed they completed the resident interviews with interviewable residents and family interview with non-inviewable residents' family. The SSD and DON stated they observed the residents to determine if there were any signs or symptoms of abuse. A review of the Incident Log Audit, on 10/09/13, revealed the audit had been completed. Interview on 10/09/13 at 12:45 PM with the DON revealed she had audited the incident log and would now be using the CQI form designated for review of event reports to adequately identify, investigate, screen, and follow up on potential abuse for future events and if issues were identified they would be investigated. This audit will continue at least monthly for three (3) months with 100% compliance with random audits continued quarterly with summarization being taken to QA meetings. Review of the CQI form for grievances, the Grievance Log and interview with the QA/Inservice Coordinator/Nurse Aide Instructor, on 10/09/13 at 3:00 PM revealed she utilized the CQI review to ensure grievances were resolved promptly and to ensure screening and follow up on suspected abuse. The audit will be completed by the QA nurse once a week for eight (8) weeks of 100% compliance and be continued for at least six (6) months, with the audit being brought to and reviewed at quarterly and interim QA meetings by the QA nurse. In addition, the CQI review form was completed to ensure staff had an understanding and are compliant with the abuse policy related to screening, training, prevention, identifying, investigating, protection and reporting will be utilized at the facility. Record review for Residents #9, #10 and #11 revealed a bruise of unknown origin was identified on Resident #10 with the facility initiating an investigation and notification sent to the State agency. Record reviews for Resident #9 and Resident #11 revealed no concerns. Review of the audits and monitoring tools initiated for tracking the effectiveness of the implemented policy, revealed no concerns. Interviews with the DON, QA/Inservice Coordinator/Nurse Aide Instructor, and SSD on 10/09/13 revealed they would ensure the audits and monitoring would continue as stated in the Allegation of Compliance.

Based on interview, record review, and facility policy and procedure review, it was determined the facility failed to have an effective system in place to ensure all alleged violations involving abuse to include injuries of unknown origin were immediately reported to the Administrator and appropriate State agencies; thorough investigations were conducted and actions were taken to protect the residents from further potential abuse for one (1) of eight (8) sampled residents (Resident #1). On 08/10/13, the facility identified Resident #1 had an injury of unknown source (bruising) to his/her left hand. There was no documented evidence the facility conducted an investigation of this injury. On 08/20/13, Adult Protective Services (APS) notified the facility's Social Service Director (SSD), who is the Abuse/Neglect Coordinator, and responsible for investigating allegations of abuse, that they were investigating an allegation of abuse that a staff member injured Resident #1. It was alleged staff pulled the resident, by his/her wrist down the hall, causing an injury. There was no documented evidence the facility initiated an investigation of abuse, protected the residents from the alleged perpetrator or notified the State Survey Agency (SSA), after this notification. The facility's failure to have an effective system in place to ensure allegations of abuse and injuries of unknown origin were investigated; action was taken to prevent further potential abuse during an investigation; and allegations of abuse and injuries of unknown origin were reported to the SSA has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified, on 10/02/13, and determined to exist on 08/20/13, at 42 CFR 483.13 Resident Behavior and Facility Practice at F225 & F226; and, 42 CFR 483.75 Administration at F490, at a scope and severity of a "J". Substandard Quality of Care was identified at 42 CFR 483.13 Resident Behavior and Facility Practice. The facility was notified of Immediate Jeopardy on 10/02/13. An acceptable Allegation of Compliance (AoC) was received on 10/08/13 alleging removal of the Immediate Jeopardy on 10/09/13. The State Survey Agency validated, on 10/09/13, the Immediate Jeopardy was removed on 10/09/13, as alleged. The Scope and Severity was lowered to a "D" at 42 CFR 483.13 Resident Behavior and Facility Practice with F225 and F226; and, 42 CFR 483.75 Administration with F490, while the facility implements the Plan of Correction (PoC) and the facility's Quality Assurance (QA) monitors for the effectiveness of system changes. The findings include: Review of the facility's policy entitled, "Reporting & Investigation of Abuse, Neglect, Mistreatment, Exploitation and/or Misappropriation of Resident Property", last revised 07/21/10, revealed: If an injury is noted and the source of the injury cannot be identified, the abuse investigation is started as described below with the goal of determining what caused the injury and ruling out any instance of abuse. The facility's Injury of Unknown Etiology Investigation Form will be started by the Social Service Director (SSD) or his or her designee after he/she is notified by a staff member or family member noting the injury. It is imperative that the injury be reported to the SSD, the Director of Nursing (DON) and the Administrator immediately. In addition, the policy and procedure revealed all personnel must immediately report an incident or suspected incident of resident abuse, neglect or mistreatment including injuries of an unknown source or misappropriation of resident property. Observation of an incident of resident abuse or suspecting resident abuse must be reported to the charge nurse or supervisor and the DON/designee, SSD and Administrator should be notified immediately, with the investigation starting immediately. The resident should be removed from harm and examined and the examination recorded in the medical record. If the allegation of abuse is against a staff member, that person is to "leave the building immediately and will be denied unsupervised access to the residents", that staff is placed on administrative leave pending the outcome of the investigation. The Administrator or his/her designee is to immediately notify the State agency and the Adult Protective Services (APS) as required by state law. An immediate investigation will be made by the SSD and a copy of the findings will be provided to the Administrator or his/her designee per "Allegation of Abuse Investigation Form-Appendix E". The State agency is to be notified within five (5) working days of the occurrence. The Administrator or his/her designee will inform the resident and his/her legal representative of the results of the investigation and corrective action taken. Record review revealed the facility admitted Resident #1 on 05/13/13 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 08/16/13, revealed the facility assessed Resident #1's cognition as severely impaired and he/she required assistance with all activities of daily living. Review of a Nursing Note, dated 08/10/13, and a skin assessment, dated 08/11/13, revealed the facility identified Resident #1 had a bruise covering the top of his/her left hand. Further record review revealed there was no evidence of the cause of the bruise or of a facility investigation to determine the cause of the bruise. Interview with Licensed Practical Nurse (LPN) #3 who obtained an order for [REDACTED]. LPN #3 stated she did not know what caused the bruise and she did not check to see if a report had been made. Interview with the SSD who is also the Abuse/Neglect Coordinator, on 09/30/13 at 12:50 PM, revealed she was aware of the bruise on Resident #1's hand because she had read about the bruise in the Nursing Notes. The SSD stated the Injury of Unknown Etiology Investigation form should have been completed and an investigation conducted to try to determine the cause of the injury and rule out abuse. The SSD revealed the form was not completed and investigation of the injury was not initiated. Further interview with the SSD, on 09/25/13 at 6:00 PM, on 09/27/13 at 11 AM and 2:15 PM, on 09/30/13 at 12:50 PM, and on 10/01/13 at 10:25 AM, revealed APS had made her aware on 08/20/13 that there was an allegation that a CNA had dragged Resident #1 down the hall by the resident's wrist. The SSD stated when an allegation is received against a staff member it was the facility's policy to have the staff member go to the conference room to take their statement and then send him/her home until the investigation was completed. The Administrator and DON should be notified and an investigation should be initiated immediately. The SSD stated the SSA and APS should be notified within twenty-four (24)hours and the final investigation results should have been reported within five (5) days to the SSA. The SSD revealed an initial allegation form and allegation of Abuse Investigation form should be completed for the abuse allegation. The SSD revealed these forms were not completed and staff did not conduct a head to toe skin assessment of Resident #1. The SSD stated she should have notified the DON, Administrator and the SSA immediately, conducted a thorough investigation and determined if the allegation was or was not substantiated. The SSD stated APS unsubstantiated the allegation so she unsubstantiated it because "they are the experts". Review of CNA #1's Employee Daily Activity Report revealed she had worked twenty-six (26) days from 08/20/13 through 09/26/13. Interview with CNA #1, on 09/26/13 at 6:45 PM, revealed she was aware an allegation of abuse was made against her but she had not been placed on administrative leave. Interview with the DON, on 09/27/13 at 11:45 AM and 1:45 PM, and on 09/30/13 at 2:39 PM revealed the Administrator, SSD, and she should be notified immediately if an allegation is made. The DON stated the resident should be removed from any suspected harm, the staff member should be suspended and walked out of the building by staff, and an investigation should be initiated and the SSA should be notified immediately. The DON stated she was made aware of the allegation on 08/20/13 by the SSD, who informed her an allegation had been made that a staff member had roughly handled Resident #1. The DON further revealed a skin assessment had not been done on Resident #1 following the allegation, and the SSA was not made aware of the allegation. The DON stated it was the Administrator's, SSD and her responsibility to ensure an investigation was completed. Interview with the Administrator, on 10/01/13 at 9:25 AM; and, on 10/02/13 at 3:22 PM revealed he was not made aware of the allegation of abuse that involved Resident #1 until 09/25/13. He stated CNA #1 continued to work and was not placed on administrative leave and an investigation was not initiated until 09/27/13. The facility implemented the following actions to remove the Immediate Jeopardy: On 09/27/13, the alleged perpetrator was put on administrative leave and not allowed to work with residents and an investigation was initiated by the Social Services Director (SSD) related to the allegation of abuse involving Resident #1 and CNA #1. In addition, an investigation was initiated related to Resident #1's injury of unknown injury by a Restorative Nurse. The investigations involved staff interviews, record reviews, and review of electronic documentation. Subsequently, the alleged perpetrator was terminated on 10/04/13 for failure to get along with other staff. The SSD was trained on investigations of alleged abuse, mistreatment, neglect and misappropriation of funds by the Nurse Consultant on 10/08/13. The Administrative Staff (Administrator, DON, Restorative Nurse, Business Office Manager, Human Resources Manager, Laundry Manager, Activities Director, Environmental Director, Maintenance Director, RAI Nurses, Dietary Manager, Medical Record Manager, Social Service Director, and QA Inservice Coordinator) was inserviced by the RN Consultant on the Abuse, Neglect, Mistreatment and Misappropriation of Funds policy which include the seven components of the Abuse Prevention Protocol on 10/08/13. The staff was required to take a post test and receive 100% accuracy. All staff was inserviced on the Abuse Neglect, Mistreatment and Misappropriation of Funds policy including the seven (7) components of the Abuse Prevention Protocol on 10/02-10/04/13 by the QA/Inservice Coordinator/Nurse Aide Instructor. The staff was required to take a post test and pass with 100% accuracy. Staff involved in the policy inservice training included: nurses, certified medical assistants (CMA), CNAs, ward clerks, business office, nurse aides, activity workers, maintenance department, social services, receptionist, environmental services department, laundry department, maintenance department, dietary department, and therapy. The orientation program will include an inservice on the Abuse Policy and the seven (7) criteria by the Inservice Director for all new employees before they were allowed to give direct care. This includes new hires, contract labor and agency staff if used. The new employees will be given a post test and must pass with 100% accuracy. On 10/03/13, the DON and SSD conducted audits with twenty-seven (27) interviewable residents (those with BIMs score of eight (8) and above) asking if they had been abused or mistreated with all residents denying abuse with no concerns noted. Non-interviewable residents were observed for signs and symptoms of abuse using observation of skin assessments, and family interviews to detect changes or concerns, with no concerns noted. A Quality Assurance (QA) audit was conducted on interviewable residents by the SSD asking if they have been mistreated or abused once a week for eight (8) weeks of 100% compliance and continued for at least six (6) months, with the QA audit being brought to and reviewed at quarterly and interim QA meetings by the Social Service Director. The audit will also include the thirty-eight (38) non-interviewable residents. They will be observed for signs and symptoms of abuse during weekly skin assessments and family interviews. This audit will be done once a week for eight weeks of 100 % compliance. This audit will be continued for at least three (3) months. If any issues are identified they will be immediately investigated. The QA audit will be brought to and reviewed at quarterly and interim QA meetings by the Social Service Director. On 10/03/13, the DON audited one-hundred four (104) incident reports for the past three (3) months to assess for suspected abuse, mistreatment, neglect and source of injury unknown origin. The audit consisted of review of incident reports, medical records and staff/resident interviews if needed. If issues were identified they were investigated. This audit will continue at least monthly for three (3) months with 100% compliance with random audits continued quarterly. The QA nurse reviewed twenty four (24) grievances on 10/03/13 which consisted of review of grievance forms, grievance log and staff interviews to see if any would have been suggestive of abuse with no abuse noted. This audit will be done by the QA nurse once a week for eight (8) weeks of 100% compliance and be continued for at least six (6) months, with the audit being brought to and reviewed at quarterly and interim QA meetings by the QA nurse. The QA nurse will conduct an audit once a week for eight (8) weeks to establish the staff understands the seven (7) components of the abuse prevention protocol. The audit consist of interviewing staff on screening, training, prevention, identification, investigation protection, reporting and responding; with the audit being done once a week for eight (8) weeks of 100% compliance for at least six (6) months. The State Survey Agency validated the corrective action by the facility as follows: Review on 10/08/13 of the activity audits of all departments revealed CNA #1 was not working in the facility from 09/27/13 through 10/05/13. Interview with the DON, on 10/09/13 at 9:00 AM, revealed CNA #1 had not worked at the facility since being put on administrative leave on 09/27/13. Review of the facility's inservices, dated 10/02/13 through 10/04/13 and 10/08/13, revealed all staff which included the Administrative staff was inserviced on the seven (7) components of the abuse prevention policy. Review of the abuse tests revealed staff scored 100%. The Administrative staff also received an additional inservice by a Registered Nurse (RN) Consultant on the seven (7) components of the abuse prevention policy. Review of the abuse test results revealed staff scored of 100%. Interviews on 10/09/13 from 11:00 PM to 5:55 PM with fourteen (14) CNAs, six (6) nurses, three (3) Certified Medicine Aids (CMA), two (2) Therapy Aides, three (3) Dietary Aides, a Receptionist, a Ward Clerk/Medical Records, two (2) Minimum Data Set/Resident Assessment Instrument nurses, one (1) Maintenance, two (2) laundry aides, and six (6) Housekeeping Aides revealed they had received an inservice on the seven (7) components of abuse and had made 100 % on required test given by the Quality Assurance (QA)/Inservice Coordinator/Nurse Aide Instructor nurse from 10/02/13 through 10/04/13. Interviews on 10/09/13 at 1:00 PM through 5:00 PM with Administrative staff, to include the Administrator, DON, Restorative Nurse, Dietary Supervisor, Activity Director, SSD, Maintenance Director, Laundry Supervisor, Housekeeping Supervisor, and Business Office Manager revealed they had been inserviced on the seven (7) components of abuse and had made 100% on the required test. In addition the Administrative staff revealed they had received an additional inservice by an outside Nurse Consultant on 10/08/13 on the seven (7) components of abuse and had made 100% on the required test. Interview with the QA/Inservice Coordinator/Nurse Aide Instructor, on 10/09/13 at 2:00 PM revealed she will inservice new hires on the seven (7) components of abuse and the new hires will be required to take the test and make 100% before they will be allowed to work on the floor. Interview on 10/09/13 at 11:00 AM with the DON and QA/Inservice Coordinator/Nurse Aide Instructor revealed all staff had been inserviced on the seven (7) components of abuse and had made 100% on the required test. The DON and QA/Inservice Coordinator/Nurse Aide Instructor further revealed Administrative staff had received an additional inservice by an outside Nurse Consultant on 10/08/13 on the seven (7) components of abuse and had made 100% on the required test afterward. Review of QA Audits dated 10/09/13 revealed interviewable residents were interviewed by the SSD and she asked them if they had been mistreated or abused. The QA audit also included the thirty-eight (38) non-interviewable residents observed for signs and symptoms of abuse during weekly skin assessments and family interviews. Interview on 10/08/13 at 10:00 AM and on 10/09/13 at 12:20 PM with the SSD and DON revealed they completed the resident interviews with interviewable residents and family interview with non-inviewable residents' family. The SSD and DON stated they observed the residents to determine if there were any signs or symptoms of abuse. A review of the Incident Log Audit, on 10/09/13, revealed the audit had been completed. Interview on 10/09/13 at 12:45 PM with the DON revealed she had audited the incident log and would now be using the CQI form designated for review of event reports to adequately identify, investigate, screen, and follow up on potential abuse for future events and if issues were identified they would be investigated. This audit will continue at least monthly for three (3) months with 100% compliance with random audits continued quarterly with summarization being taken to QA meetings. Review of the CQI form for grievances, the Grievance Log and interview with the QA/Inservice Coordinator/Nurse Aide Instructor, on 10/09/13 at 3:00 PM revealed she utilized the CQI review to ensure grievances were resolved promptly and to ensure screening and follow up on suspected abuse. The audit will be completed by the QA nurse once a week for eight (8) weeks of 100% compliance and be continued for at least six (6) months, with the audit being brought to and reviewed at quarterly and interim QA meetings by the QA nurse. In addition, the CQI review form was completed to ensure staff had an understanding and are compliant with the abuse policy related to screening, training, prevention, identifying, investigating, protection and reporting will be utilized at the facility. Record review for Residents #9, #10 and #11 revealed a bruise of unknown origin was identified on Resident #10 with the facility initiating an investigation and notification sent to the State agency. Record reviews for Resident #9 and Resident #11 revealed no concerns. Review of the audits and monitoring tools initiated for tracking the effectiveness of the implemented policy, revealed no concerns. Interviews with the DON, QA/Inservice Coordinator/Nurse Aide Instructor, and SSD on 10/09/13 revealed they would ensure the audits and monitoring would continue as stated in the Allegation of Compliance.

Based on interview, record review and facility policy and procedure review it was determined the facility failed to implement it's policy and procedure related to abuse and injury of unknown origin for one (1) of eight (8) sampled residents (Resident #1). On 08/10/13, the facility noted Resident #1 had an injury of unknown source to his/her left hand. There was no documented evidence the facility followed its policy and procedure related to conducting an investigation of this injury. On 08/20/13, Adult Protective Services (APS) notified the facility's Social Service Director (SSD), who is the Abuse/Neglect Coordinator, and responsible for investigating allegations of abuse, that they were investigating an allegation of abuse that a staff member injured Resident #1. It was alleged staff pulled the resident, by his/her wrist down the hall, causing an injury. There was no documented evidence the facility followed its policy and procedure related to initiating an investigation of abuse, protecting the residents from the alleged perpetrator or notifying the State Survey Agency (SSA), after this notification. The facility's failure to follow its policy and procedure to ensure allegations of abuse and injuries of unknown origin were investigated, action was taken to prevent further potential abuse during an investigation, and allegations of abuse and injuries of unknown origin were reported to the SSA has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified, on 10/02/13, and determined to exist on 08/20/13, at 42 CFR 483.13 Resident Behavior and Facility Practice at F225 & F226, and 42 CFR 483.75 Administration at F490, at a scope and severity of a "J". Substandard Quality of Care was identified at 42 CFR 483.13 Resident Behavior and Facility Practice. The facility was notified of Immediate Jeopardy on 10/02/13. An acceptable Allegation of Compliance (AoC) was received on 10/08/13 alleging removal of the Immediate Jeopardy on 10/09/13. The State Survey Agency validated, on 10/09/13, the Immediate Jeopardy was removed on 10/09/13, as alleged. The scope and severity was lowered to a "D" at 42 CFR 483.13 Resident Behavior and Facility Practice with F225 & F226, and 42 CFR 483.75 Administration with F490, while the facility implements the Plan of Correction (PoC) and the facility's Quality Assurance (QA) monitors for the effectiveness of system changes. The findings include: Review of facility's policy entitled, Reporting & Investigation of Abuse, Neglect, Mistreatment, Exploitation and /or Misappropriation of Resident Property", last revised 07/21/10, revealed: If an injury is noted and the source of the injury cannot be identified, the abuse investigation is started as described below with the goal of determining what caused the injury and ruling out any instance of abuse. The facility's Injury of Unknown Etiology Investigation Form will be started by the Social Service Director (SSD) or his or her designee after he/she is notified by a staff member or family member noting the injury. It is imperative that the injury be reported to the SSD, the Director of Nursing (DON) and the Administrator immediately. In addition, the policy and procedure revealed all personnel must immediately report an incident or suspected incident of resident abuse, neglect or mistreatment including injuries of an unknown source or misappropriation of resident property. Observation of an incident or resident abuse or suspecting resident abuse must be reported to the charge nurse or supervisor and the DON/designee, SSD and Administrator should be notified immediately, with the investigation starting immediately. The resident should be removed from harm and examined and the examination recorded in the medical record. If the allegation of abuse is against a staff member, that person is to "leave the building immediately and will be denied unsupervised access to the residents", that staff is placed on administrative leave pending the outcome of the investigation. The Administrator or his/her designee is to immediately notify the State agency and the Adult Protective Services (APS) as required by state law. An immediate investigation will be made by the SSD and a copy of the findings will be provided to the Administrator or his/her designee per "Allegation of Abuse Investigation Form-Appendix E". The State agency is to be notified within five (5) working days of the occurrence. The Administrator or his/her designee will inform the resident and his/her legal representative of the results of the investigation and corrective action taken. Record review revealed the facility admitted Resident #1 on 05/13/13 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 08/16/13, revealed the facility assessed Resident #1's cognition as severely impaired and he/she required assistance with all activities of daily living. Review of a Nursing Note, dated 08/10/13, and a skin assessment, dated 08/11/13, revealed the facility identified Resident #1 had a bruise covering the top of his/her left hand. Further record review revealed there was no evidence of what caused the bruise or if the facility conducted an investigation to determine the cause of the bruise. Interview with Licensed Practical Nurse (LPN) #3, on 10/01/13 at 11:53 AM, revealed she did not complete a form related to the bruise covering Resident #1's left hand. LPN #3 stated she did not know what caused the bruise and did not check to see if a report had been made. Interview with the SSD, who is also the Abuse/Neglect Coordinator, on 09/30/13 at 12:50 PM, revealed she was aware of the bruise on Resident #1's hand because she had read about the bruise in the Nursing Notes. The SSD stated the facility's policy and procedure for abuse was staff should complete the Injury of Unknown Etiology Investigation form, an investigation should have been conducted to try to determine the cause of the injury and rule out abuse and the Administrator should have been notified. The SSD revealed the facility's policy and procedure was not followed. Further interview with the SSD, on 09/25/13 at 6:00 PM, on 09/27/13 at 11 AM and 2:15 PM, on 09/30/13 at 12:50 PM, and on 10/01/13 at 10:25 AM, revealed APS had made her aware on 08/20/13 that there was an allegation that a CNA had dragged Resident #1 down the hall by the resident's wrist. The SSD stated the facility's policy and procedure for an allegation of abuse was if an allegation is received against a staff member it was the facility's policy to have the staff member go to the conference room to take their statement and then send him/her home until the investigation was completed. The Administrator and DON should be notified and an investigation should be initiated immediately. The SSD stated the SSA and APS should be notified within twenty-four hours and the final investigation results should have been reported within five (5) days to the SSA. The SSD revealed an initial allegation form and allegation of Abuse Investigation form should be completed for the abuse allegation. The SSD revealed the facility's policy and procedure was not followed because staff failed to complete the forms. The SSD stated according to the facility's policy she should have notified the DON, Administrator and the SSA immediately, conducted a thorough investigation and determined if the allegation was substantiated or not. The SSD stated APS unsubstantiated the allegation so she unsubstantiated it because "they are the experts". Review of CNA #1's Employee Daily Activity Report revealed she had worked twenty-six (26) days from 08/20/13 through 09/26/13. Interview with CNA #1, on 09/26/13 at 6:45 PM, revealed she was aware an allegation of abuse was made against her but she had not been placed on administrative leave. Interview with the DON, on 09/27/13 at 11:45 AM and 1:45 PM, and on 09/30/13 at 2:39 PM revealed it was the facility's policy that the Administrator, SSD, and she be notified immediately if an allegation is made. The DON stated the resident should be removed from any suspected harm, the staff member should be suspended and walked out of the building by staff, an investigation should be initiated and the SSA should be notified immediately. The DON stated she was made aware of the allegation on 08/20/13 by the SSD who informed her an allegation had been made that a staff member had roughly handled Resident #1. The DON revealed the facility's policy and procedure was not followed related to notification of the SSA and completing a thorough investigation. The DON stated it was the responsibility of her, the Administrator and SSD to ensure an investigation was completed. Interview with the Administrator, on 10/01/13 at 9:25 AM and on 10/02/13 at 3:22 PM revealed staff did not follow the facility's Abuse policy as he was not made aware of the allegation of abuse involving Resident #1 until 09/25/13. The Administrator stated the facility's policy was not followed when CNA #1 was not placed on administrative leave and an investigation was not initiated until 09/27/13. The facility implemented the following actions to remove the Immediate Jeopardy: On 09/27/13, the alleged perpetrator was put on administrative leave and not allowed to work with residents and an investigation was initiated by the Social Services Director (SSD) related to the allegation of abuse involving Resident #1 and CNA #1. In addition, an investigation was initiated related to Resident #1's injury of unknown injury by a Restorative Nurse. The investigations involved staff interviews, record reviews, and review of electronic documentation. Subsequently, the alleged perpetrator was terminated on 10/04/13 for failure to get along with other staff. The SSD was trained on investigations of alleged abuse, mistreatment, neglect and misappropriation of funds by the Nurse Consultant on 10/08/13. The Administrative Staff (Administrator, DON, Restorative Nurse, Business Office Manager, Human Resources Manager, Laundry Manager, Activities Director, Environmental Director, Maintenance Director, RAI Nurses, Dietary Manager, Medical Record Manager, Social Service Director, and QA Inservice Coordinator) was inserviced by the RN Consultant on the Abuse, Neglect, Mistreatment and Misappropriation of Funds policy which include the seven components of the Abuse Prevention Protocol on 10/08/13. The staff was required to take a post test and receive 100% accuracy. All staff was inserviced on the Abuse Neglect, Mistreatment and Misappropriation of Funds policy including the seven (7) components of the Abuse Prevention Protocol on 10/02-10/04/13 by the QA/Inservice Coordinator/Nurse Aide Instructor. The staff was required to take a post test and pass with 100% accuracy. Staff involved in the policy inservice training included: nurses, certified medical assistants (CMA), CNAs, ward clerks, business office, nurse aides, activity workers, maintenance department, social services, receptionist, environmental services department, laundry department, maintenance department, dietary department, and therapy. The orientation program will include an inservice on the Abuse Policy and the seven (7) criteria by the Inservice Director for all new employees before they were allowed to give direct care. This includes new hires, contract labor and agency staff if used. The new employees will be given a post test and must pass with 100% accuracy. On 10/03/13, the DON and SSD conducted audits with twenty-seven (27) interviewable residents (those with BIMs score of eight (8) and above) asking if they had been abused or mistreated with all residents denying abuse with no concerns noted. Non-interviewable residents were observed for signs and symptoms of abuse using observation of skin assessments, and family interviews to detect changes or concerns, with no concerns noted. A Quality Assurance (QA) audit was conducted on interviewable residents by the SSD asking if they have been mistreated or abused once a week for eight (8) weeks of 100% compliance and continued for at least six (6) months, with the QA audit being brought to and reviewed at quarterly and interim QA meetings by the Social Service Director. The audit will also include the thirty-eight (38) non-interviewable residents. They will be observed for signs and symptoms of abuse during weekly skin assessments and family interviews. This audit will be done once a week for eight weeks of 100 % compliance. This audit will be continued for at least three (3) months. If any issues are identified they will be immediately investigated. The QA audit will be brought to and reviewed at quarterly and interim QA meetings by the Social Service Director. On 10/03/13, the DON audited one-hundred four (104) incident reports for the past three (3) months to assess for suspected abuse, mistreatment, neglect and source of injury unknown origin. The audit consisted of review of incident reports, medical records and staff/resident interviews if needed. If issues were identified they were investigated. This audit will continue at least monthly for three (3) months with 100% compliance with random audits continued quarterly. The QA nurse reviewed twenty four (24) grievances on 10/03/13 which consisted of review of grievance forms, grievance log and staff interviews to see if any would have been suggestive of abuse with no abuse noted. This audit will be done by the QA nurse once a week for eight (8) weeks of 100% compliance and be continued for at least six (6) months, with the audit being brought to and reviewed at quarterly and interim QA meetings by the QA nurse. The QA nurse will conduct an audit once a week for eight (8) weeks to establish the staff understands the seven (7) components of the abuse prevention protocol. The audit consist of interviewing staff on screening, training, prevention, identification, investigation protection, reporting and responding; with the audit being done once a week for eight (8) weeks of 100% compliance for at least six (6) months. The State Survey Agency validated the corrective action by the facility as follows: Review on 10/08/13 of the activity audits of all departments revealed CNA #1 was not working in the facility from 09/27/13 through 10/05/13. Interview with the DON, on 10/09/13 at 9:00 AM, revealed CNA #1 had not worked at the facility since being put on administrative leave on 09/27/13. Review of the facility's inservices, dated 10/02/13 through 10/04/13 and 10/08/13, revealed all staff which included the Administrative staff was inserviced on the seven (7) components of the abuse prevention policy and an abuse test was given afterward with test scores of 100%. The Administrative staff also received an additional inservice by an Registered Nurse (RN) Consultant on the seven (7) components of the abuse prevention policy and an abuse test was given afterward with test scores of 100%. Interviews on 10/09/13 from 11:00 PM to 5:55 PM with fourteen (14) CNAs, six (6) nurses, three (3) Certified Medicine Aids (CMA), two (2) Therapy Aides, three (3) Dietary Aides, a Receptionist, a Ward Clerk/Medical Records, two (2) Minimum Data Set/Resident Assessment Instrument nurses, one (1) Maintenance, two (2) laundry aides, and six (6) Housekeeping Aides revealed they had received an inservice on the seven (7) components of abuse and had made 100 % on required test given by the Quality Assurance (QA)/Inservice Coordinator/Nurse Aide Instructor nurse from 10/02/13 through 10/04/13. Interviews on 10/09/13 at 1:00 PM through 5:00 PM with Administrative staff, to include the Administrator, DON, Restorative Nurse, Dietary Supervisor, Activity Director, SSD, Maintenance Director, Laundry Supervisor, Housekeeping Supervisor, and Business Office Manager revealed they had been inserviced on the seven (7) components of abuse and had made 100% on the required test. In addition the Administrative staff revealed they had received an additional inservice by an outside Nurse Consultant on 10/08/13 on the seven (7) components of abuse and had made 100% on the required test. Interview with the QA/Inservice Coordinator/Nurse Aide Instructor, on 10/09/13 at 2:00 PM revealed she will inservice new hires on the seven (7) components of abuse and the new hires will be required to take the test and make 100% before they will be allowed to work on the floor. Interview on 10/09/13 at 11:00 AM with the DON and QA/Inservice Coordinator/Nurse Aide Instructor revealed all staff had been inserviced on the seven (7) components of abuse and had made 100% on the required test. The DON and QA/Inservice Coordinator/Nurse Aide Instructor further revealed Administrative staff had received an additional inservice by an outside Nurse Consultant on 10/08/13 on the seven (7) components of abuse and had made 100% on the required test afterward. Review of QA Audits dated 10/09/13 revealed interviewable residents were interviewed by the SSD and she asked them if they had been mistreated or abused. The QA audit also included the thirty-eight (38) non-interviewable residents observed for signs and symptoms of abuse during weekly skin assessments and family interviews. Interview on 10/08/13 at 10:00 AM and on 10/09/13 at 12:20 PM with the SSD and DON revealed they completed the resident interviews with interviewable residents and family interview with non-inviewable residents' family. The SSD and DON stated they observed the residents to determine if there were any signs or symptoms of abuse. A review of the Incident Log Audit, on 10/09/13, revealed the audit had been completed. Interview on 10/09/13 at 12:45 PM with the DON revealed she had audited the incident log and would now be using the CQI form designated for review of event reports to adequately identify, investigate, screen, and follow up on potential abuse for future events and if issues were identified they would be investigated. This audit will continue at least monthly for three (3) months with 100% compliance with random audits continued quarterly with summarization being taken to QA meetings. Review of the CQI form for grievances, the Grievance Log and interview with the QA/Inservice Coordinator/Nurse Aide Instructor, on 10/09/13 at 3:00 PM revealed she utilized the CQI review to ensure grievances were resolved promptly and to ensure screening and follow up on suspected abuse. The audit will be completed by the QA nurse once a week for eight (8) weeks of 100% compliance and be continued for at least six (6) months, with the audit being brought to and reviewed at quarterly and interim QA meetings by the QA nurse. In addition, the CQI review form was completed to ensure staff had an understanding and are compliant with the abuse policy related to screening, training, prevention, identifying, investigating, protection and reporting will be utilized at the facility. Record review for Residents #9, #10 and #11 revealed a bruise of unknown origin was identified on Resident #10 with the facility initiating an investigation and notification sent to the State agency. Record reviews for Resident #9 and Resident #11 revealed no concerns. Review of the audits and monitoring tools initiated for tracking the effectiveness of the implemented policy, revealed no concerns. Interviews with the DON, QA/Inservice Coordinator/Nurse Aide Instructor, and SSD on 10/09/13 revealed they would ensure the audits and monitoring would continue as stated in the Allegation of Compliance.