Every finding on record at Green Acres Healthcare

Based on record review, interview, and facility policy review, the facility failed to inform the resident representative when there was a significant change a resident's status for 1 of 4 residents sampled for notification, out of 6 total sampled residents (Resident (R)1). The findings include:Review of the facility policy titled, Notification of Changes, reviewed [DATE], revealed when there was a change in a resident's condition requiring notification, the facility was to promptly inform the resident, consult the resident's physician, and notify the resident's representative (ex. new treatment or significant change in the resident's physical condition).Review of the closed record Facesheet for R1 revealed the facility admitted the resident on [DATE], with diagnoses to include: pressure-induced deep tissue damage of sacral region, traumatic subdural hemorrhage, and malnutrition. Review further revealed R1 was discharged to the hospital on [DATE], where he expired on [DATE].Review of the admission Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of [DATE], revealed the facility assessed R1 to have a Brief Interview for Mental Status (BIMS) score of a seven out of 15, indicating the resident was severely cognitively impaired.Review of the progress note dated [DATE] at 10:55 AM, revealed the wound care Advanced Practice Registered Nurse (APRN) gave a new order for skin prep to the tissue surrounding R1's sacrum wound, apply medical grade honey to the wound bed, cover daily and as needed. Continued review revealed additional orders which included Triad cream (cream utilized to treat wounds) to the left gluteal fold twice a day and as needed. Review revealed R1 was noted to have a new Deep Tissue Injury (DTI) to the left heel and orders given to paint the DTI with betadine and leave open to air. Additional review revealed the APRN recommended an x-ray of R1's right heel to rule out osteomyelitis. Further review revealed however, no documented evidence the resident's Power of Attorney (POA) was notified of R1's change in condition (new DTI) or the APRN's new orders.Review of the physician's orders revealed the left heel X-ray order per a verbal order which had been entered. Record review revealed however, the left heel x-ray was not obtained until [DATE], seven days after the APRN's order. During interview with the DON on [DATE] at 1:50 PM, she stated the x-ray findings were that of osteomyelitis. During interview with R1's POA on [DATE] at 11:15 AM, he stated there had been no communication from the facility regarding the resident's condition. He stated he was unaware R1's wounds were as bad as they were. The POA reported when the family visited, R1's wounds were wrapped and the staff would describe the resident's wounds as a bad bruise. He said he was never informed R1 had a bone infection or had been prescribed antibiotics for the infection. The POA further stated if family had known the wounds were that bad, they would have had something done about them sooner.During interview with Licensed Practical Nurse (LPN) 3 on [DATE] at 3:55 PM, she stated on [DATE], she performed wound rounds with the APRN. LPN 3 reported she could not recall if she notified R1's POA of the new orders the APRN had given for R1; however, she should have done that. She stated if she had done that, she would have documented the notification in a progress note. The LPN further stated she did not have access to the system to enter radiology orders and so, she notified the Director of Nursing (DON) that R1 needed an x-ray order entered. She additionally stated the POA should have been notified as soon as possible.During interview with the DON on [DATE] at 1:50 PM, she stated the wound care nurse rounding with the APRN had been responsible for notifying the resident's family and obtaining and entering any new orders. She reported the nurse should have contacted the physician to obtain the x-ray order and then should have placed the order into the radiology system. The DON said she would have expected to see documentation of notification of the POA in the progress notes. During interview with the Administrator on [DATE] at 10:55 AM, she stated staff should follow the facility's policy and procedures when making any notifications.

Based on record review, interview, and facility policy review, the facility failed to develop and implement a baseline care plan with instructions to provide effective and person-centered care for 1 of 6 sampled residents, (Resident (R)1). The findings include: Review of the facility policy titled, Baseline Care Plan, reviewed [DATE], revealed the facility was to develop and implement a baseline care plan for each resident that included the instructions needed to provided effective and person-centered care of the resident to meet professional standards of quality of care. Review further revealed the baseline care plan was to be developed within 48 hours of a resident's admission. Review of the closed record revealed the Facesheet noted the facility admitted R1 on [DATE], with diagnoses to include: pressure-induced deep tissue damage of sacral region, traumatic subdural hemorrhage, and malnutrition. Review of the closed record further revealed R1 was discharged to the hospital on [DATE] and expired on [DATE]. Review of the admission Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of [DATE], revealed the facility assessed R1 as having a Brief Interview for Mental Status (BIMS) score of a seven out of 15, indicating severe cognitive impairment. Review of the baseline care plan the facility developed for risk of skin impairment revealed a start date of [DATE], seven days after R1's admission. Review of the wound care progress note dated [DATE], revealed R1 had been admitted with a Deep Tissue Injury (DTI) to the sacrum. Continued review revealed further assessment of R1 revealed since admission the resident had acquired an additional DTI to the right heel and a Stage 2 pressure injury to the right elbow. In interview on [DATE] at 1:36 PM, Licensed Practical Nurse (LPN) 2 stated she had been the admitting nurse for R1 on [DATE]. LPN 2 reported she did not know who was typically responsible for developing a resident's baseline care plan. She said she had been new at the time of R1's admission, and the Director of Nursing (DON) assisted her with the resident's admission. The LPN stated she would expect a resident assessed to have a risk for skin breakdown to have a care plan addressing that problem. She further stated the baseline care plan was to be done on a resident's admission, so other nurses would know how to care for that resident. In interview on [DATE] at 1:50 PM, the DON stated the facility process for initiating a new resident's baseline care plan was for the admitting nurse to initiate the care plan upon admission. The DON said she had assisted LPN 2 with R1's admission. The DON reported R1 should have had a baseline care plan developed for being at risk for impaired skin integrity on admission. She stated it was important to have the baseline care plan so staff would know R1 had impaired skin integrity on admission, had an area to watch for worsening. The DON further stated by not having a baseline care plan developed, R1 could have had a delay in care, harm, or staff caring for her might not have been aware of the resident's care needs. She additionally said R1 should have had a baseline care plan developed upon admission. The DON reported she was not sure what the breakdown had been or why the baseline care plan was not done; however, she or the nurse had been responsible for the baseline care plan. In interview on [DATE] at 10:55 AM, the Administrator stated she expected staff to follow the facility policies and procedures. She said if staff did not do that, residents might not get the care they needed. The Administrator reported a baseline care plan should have been implemented within 48 hours of R1's admission. She stated the purpose of the baseline care plan was to dictate the resident's care and what was going on with the resident. The Administrator further stated if the baseline care plan was completed, the resident would not receive the care they needed. She additionally stated R1's wounds might have been caught sooner if the facility had put a care plan in place.

Based on interview, record review, and facility policy review, the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 4 sampled residents (Resident (R)1). The findings include:Review of the facility policy titled, Pressure Injury Prevention and Management, reviewed [DATE], revealed the facility was committed to the prevention of avoidable pressure injuries unless clinically unavoidable. Per review, revealed the facility was also committed to providing treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries. Review of the closed record for R1 revealed the Facesheet documented the facility admitted the resident on [DATE], with diagnoses including: malnutrition, pressure-induced deep tissue damage of sacral region, and traumatic subdural hemorrhage. Per review of the closed record, R1 was discharged to the hospital on [DATE] and noted to have expired on [DATE]. Review of the admission Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of [DATE], revealed the facility assessed R1 to have a Brief Interview for Mental Status (BIMS) score of a seven out of 15, which indicated severe cognitive impairment. Review of the facility's baseline care plan for risk of skin impairment revealed a start date of [DATE], seven days after R1's admission. Review of the medical record revealed that the facility had early knowledge of skin integrity problems with the resident including notation from a document entitled, Observation Detail List Report from [DATE] at 2:17 AM which disclosed ulcer with open area to the buttocks. In interview with the DON on [DATE] at 1:50 PM, she stated she had done part of R1's admission assessment, the head-to-toe skin assessment. She stated R1 had an open area on her sacrum/coccyx, with no open areas on her heels at that time. Review of the wound care progress note dated [DATE], revealed it was noted R1 had been admitted with a Deep Tissue Injury (DTI) to the sacrum. Continued review revealed in additional assessment of R1 since admission the resident acquired a DTI to the right heel and a Stage 2 pressure injury to the right elbow. Review of the progress note dated [DATE] timed 10:55 AM, revealed the wound care Advanced Practice Registered Nurse (APRN) had given new orders, one of which was for R1's sacrum. Per review, the sacrum order was to apply skin prep to the surrounding tissue, apply medical grade honey to the wound bed, cover daily and as needed. Continued review revealed additional orders included to apply Triad cream to R1's left gluteal fold twice a day and as needed. Review of the progress note revealed documentation noting R1 had a new Deep Tissue Injury (DTI) to the left heel and the orders given were to paint that area with betadine and leave open to air. Further review revealed the APRN changed the orders for R1's right heel wound to betadine soaked gauze, apply an abdominal (ABD) pad, and wrap in Kerlix daily. In addition, review of the progress note revealed the APRN recommended an X-ray of R1's right heel to rule out osteomyelitis, a Low Air Loss (LAL) mattress and to off load bilateral heels in heel boots. Review of the left heel x-ray order revealed a verbal order entered, and the x-ray obtained on [DATE], seven days after the APRN's recommendation on [DATE]. Review of the left heel x-ray result report dated [DATE], revealed the findings were suspicious for calcaneal (heel) osteomyelitis (a serious bone infection). In interview on [DATE] at 11:15 AM, R1's POA stated the facility had not communicated with him regarding the resident's condition. The POA said he had not been aware R1's wounds were as bad as they were. He reported when the family visited R1 the wounds were wrapped, and the staff would describe the resident's wounds as a bad bruise. The POA stated he had never been informed R1 had a bone infection or had been prescribed antibiotics to treat the infection. He further stated if the family had known R1's wounds were that bad, they would have had something done about them sooner. In interview on [DATE] at 1:36 PM, Licensed Practical Nurse (LPN) 2 stated she had been the nurse who admitted R1 on [DATE]. LPN 2 reported she had been new at the time of R1's admission, so the Director of Nursing (DON) assisted her with the admission. She stated the DON had performed R1's admission skin assessment. LPN 2 said she would expect a resident who was at risk for skin breakdown to have a care plan to address that. She further stated a baseline care plan should be completed on a new resident's admission so other nurses would know how to care for that resident. In interview on [DATE] at 1:36PM, LPN 2 stated we do the baseline, care plan; however, I did not do one on R1 because I had not been working at the facility very long at that time. She said she had not finished R1's admission, so the DON completed it for her. In interview on [DATE] at 1:50 PM, the DON stated baseline care plans were to be developed and implemented on admission. She said R1 should have had one for skin integrity on admission, so everyone taking care of her would know she had an area to watch for worsening and that the resident was at risk for skin breakdown. The DON further stated however, she had not completed one for R1. During interview with LPN 3 on [DATE] at 3:55 PM, she stated on [DATE], she did wound rounds with the APRN. LPN 3 said she recalled R1 having several wounds that day. She reported R1 had a wound on her heels, her bottom and maybe a new one on the gluteal fold. The LPN reported she could not recall if she notified R1's POA of the new orders for the resident received that day; however, she should have done that and documented the notification in a progress note. She stated she did not have access to the facility's system to enter radiology orders and so she notified the DON that R1 needed an x-ray order entered. She further stated R1's POA should have been notified as soon as possible. In interview with the DON on [DATE] at 1:50 PM, she stated she had performed R1's admission skin assessment. The DON said R1 had an open area to her sacrum/coccyx at that time, with no open areas on the heels at that time. She explained the facility's process for initiating a new resident's baseline care plan was for the admitting nurse to initiate the care plan upon the new resident's admission. The DON stated R1 should have had a baseline care plan developed for being at risk for impaired skin integrity on admission. She said the baseline care plan was important so staff would know R1 had an area to watch for worsening and so they would know the resident was at risk for skin breakdown. The DON reported by not having a baseline care plan developed for R1's risk for skin breakdown, the resident could have experienced a delay in care, harm, or staff caring for her might not be aware of R1's care needs. She further stated she was not sure what the breakdown had been with R1 not having a baseline care plan developed for being at risk for skin breakdown and did not know why the baseline care plan had not been done. During interview with the Administrator on [DATE] at 10:55 AM, she stated her expectations were for staff to follow the facility's policy and procedures when providing resident care. She explained the facility's policies and procedures lined out with how resident's skin or wounds were to be assessed. The Administrator stated she expected staff to report any skin abnormalities to the DON or herself immediately. She reported R1 should have had a baseline care plan developed within 48 hours of admission. The Administrator said otherwise, R1 could have experienced a delay in care or not receive the care the resident would have needed. She further stated R1's new skin breakdown could potentially have been caught sooner if the resident had a baseline care plan in place. The Administrator additionally stated by staff not following the facility's policy, the resident's wound could have worsened.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure resident(s)had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for three of 12 sampled residents (Resident (R) 11, 12, and R38).The findings include: Review of the facility's policy titled Resident Rights, dated 06/2025, revealed that residents had the right to receive services in the facility with reasonable accommodation of resident needs and preferences, except when to do so would endanger the health or safety of the resident or other residents. Further review of the policy revealed that the resident had a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Review of the facility's policy titled Call Lights: Accessibility and Timely Response, reviewed 06/2025, revealed that staff should ensure the call lights were within reach of the resident and secured, as needed. Further, the call system should be accessible to residents while in their bed or other sleeping accommodations within the resident's room.1. Review of R11's face-sheet revealed the facility admitted R11 on 01/28/2022 with diagnoses which included chronic obstructive pulmonary disease, Alzheimer's disease, and essential hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed that R11 had a Brief Interview of Mental Status (BIMS) score of 3 out of 15, indicating severe cognitive impairment. Further review of the MDS Assessment revealed that R11 was dependent on staff for all activities of daily living, toileting, and mobility.Observations of R11 on 08/12/2025 at 10:27 AM, in room [ROOM NUMBER]-A, revealed R11 was sitting in wheelchair and the resident's call light was clipped to the privacy curtain, not within reach of the resident.2. Review of R38's face-sheet revealed the facility admitted the resident on 10/24/2018 with diagnoses which included unspecified dementia, unspecified convulsions, and unspecified intellectual disabilities. Review of the quarterly MDS assessment dated [DATE], revealed R38 was rarely/never understood. Further review of the MDS assessment revealed that R38 was dependent on staff for activities of daily living, toileting, and mobility. Observations of R38 on 08/12/2025 at 10:28 AM, revealed she was lying in bed asleep. Further observation revealed that R38 had a touch pad call light at the foot of her bed and not within her reach.3. Review of R12's face-sheet revealed the facility admitted the resident on 02/05/2021 with diagnoses which included acute pulmonary edema, type 2 diabetes, and heart failure. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 8 out of 15, indicating R12 had moderate cognitive impairment. Further review of the MDS assessment revealed that R12 was dependent on staff for activities of daily living and using wheelchair. Observations of R12 on 08/12/2025 at 12:13 PM, revealed he was sitting in his wheelchair with his arms crossed over his chest. Further observation revealed his call light was under his bed linens and not within his reach. During an interview with R12 on 08/12/2025 at 12:15 PM, he stated that he did not know where his call light was and he was not able to roll himself in his wheelchair.Observations of R12 on 08/13/2025 at 8:44 AM, revealed he was sitting in his wheelchair facing the television and away from the bed. Further observation revealed the call light cord and button were located under his bedding.During an interview with Registered Nurse (RN)2 on 08/13/2025 at 3:16 PM, she stated to ensure the resident's safety before exiting their room, staff should make sure their bed was in the proper position, call light was in a position where they could reach it. She further stated if the resident was sitting in a wheelchair in their room, staff should ensure they can reach the call light. RN2 stated that there could be negative outcomes if a resident were to fall and not able to reach their call light to call for assistance. During an interview with Licensed Practical Nurse (LPN)1 on 08/14/2025 at 8:55 AM, she stated that before exiting a resident's room, staff were to make sure their floor is dry and not cluttered and make sure their call light was within reach. She stated that if the resident was sitting in a wheelchair in their room, she would make sure they could reach their call light. LPN1 stated that some residents want the call lights clipped to them so they can get to it. During an interview with Certified Nurse Aide (CNA)4 on 08/15/2025 at 9:50 AM, she stated that before exiting a resident's room, to ensure the resident's safety she would make sure there was nothing the resident could trip on, and make sure their call light was within reach. She stated that if the resident was not mobile, she would make sure their call light was within reach. CNA4 stated that for a resident that was not mobile, the call light being placed at the foot of the bed would not be considered to be within reach and she did not know why R38's call light was placed at the foot of her bed. She stated that for residents who are sitting in their wheelchair, she would make sure the call light was clipped to their side. CNA4 further stated that bed linens should not be placed over the call light. She stated she was unsure how or why the bed linens were placed over R12's call light. During an interview with CNA5 on 08/15/2025 at 9:57 AM, she stated that before leaving a resident's room she would make sure she put the bed down, make sure the resident was not near the edge of the bed, make sure the call light was within reach if they are in bed. She stated that if the resident were up in the wheelchair, she would clip their call light to their shirt or somewhere where they can reach it. She stated that she was unsure how the call light got clipped to R11's privacy curtain and should not have been, because it was out of reach. She stated that if the resident is in bed, the call light being placed at the foot of the bed would not be considered in reach. She stated that the bed linens should not be made over the call light. She stated that possible negative outcomes of the resident not being able to reach their call light could be that the resident could not get help and die, the resident could be unconscious or be sitting in a wet or dirty brief for an extended period of time, and the resident could fall if trying to get up and reach the call light.During an interview with the Director of Nursing (DON) on 08/15/2025 at 11:50 AM, she stated that she expected nursing staff to follow the facility's policy and procedures regarding call light placement and keeping resident's safe. She stated that the call light would not be in the resident's reach if it was placed at the foot of the resident's bed. The DON further stated the call light was essentially the resident's lifeline to staff. She stated that negative outcomes could be they would need something and not be able to contact staff and other safety concern. During an interview with the facility's Administrator on 08/15/2025 at 11:58 AM, she stated that her expectations of staff for keeping residents safe was keeping their call light within reach. She stated that if the resident was in bed, the call light should be within their reach. She stated that if they were in a wheelchair, it would need to be in the wheelchair with them. The Administrator further stated that if a resident needed to call for help and their call light was not within reach, there could be a negative outcome.

Based on interview, record review, and facility policy, it was determined the facility failed to ensure that the required care plan meetings were conducted quarterly for reviewing and revising care plans by the interdisciplinary team after each quarterly review assessments for two of twelve sampled residents (Resident (R) 11 and R33). The findings include: Review of the facility's policy titled, Comprehensive Care Plans, revised 03/03/2025, revealed the facility was to develop and implement a comprehensive person-centered care plan for each resident to meet a resident's medical, physical, mental, and psychosocial needs. Further review revealed the comprehensive care plan would be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly Minimum Data Set (MDS) assessment. Review of facility's job description titled, Social Service Director, dated 10/2022, revealed essential duties and responsibilities included to provide timely and accurate completion of the social services portion of the MDS, resident assessment protocols, resident care plan, and progress notes. 1.Review of R33's Electronic Health Record (EHR) revealed the facility admitted the resident on 11/02/2021 with diagnoses which included vascular dementia, psychotic disturbance, mood disturbance, and anxiety. Review of R33's EHR revealed the last care plan meetings was conducted 02/13/2025. Further review revealed a quarterly care plan meeting should have been conducted in 05/2025, and the next quarterly care plan meeting would have been due 08/2025. Review of R33's Quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) date of 05/06/2025, revealed the facility assessed the resident with the Brief Interview of Mental Status (BIMS) of 05, which indicated severely impaired. Review of Resident (R)33's, Care Conference Report, dated 06/13/2024 through 06/10/2025, revealed missing quarterly assessments in 09/2024 and 05/2025, the notes on 06/10/2025 were added after the initial review of the resident's EHRs on 08/14/2025. In an interview with Family Member (F)1, on 08/13/2025 at 2:37 PM, he stated the facility had generally called him about care plan meetings, but he had not recalled hearing anything from them in a long while. He stated he lived out of state with spouse of R33 but had participated with the care planning via phone. 2. Review of R11's face sheet revealed the facility admitted the resident on 01/28/2022 with diagnoses which included chronic obstructive pulmonary disease, Alzheimer's disease, and essential hypertension. Review of the quarterly Minimum Data Set (MDS) assessment with an ARD date of 08/10/2025, revealed that R11 had a Brief Interview of Mental Status (BIMS) score of 3 out of 15, indicating severe cognitive impairment. Review of R11's EHR revealed the last care plan meeting was conducted on 10/22/2024. Further review revealed quarterly care plan meetings should have been conducted on 01/2025, 04/2025, and 07/2025. Review of R11's Care Conference Report, dated 06/29/2023 through 10/22/2024, revealed missing quarterly care conferences in 01/2024, 04/2025, and 07/2025. During an interview with F2 on 8/12/2025 at 3:54 PM, she stated that the only care conference that the facility had discussed was when the resident was declining and they were discussing the residents code status. She stated that she could not remember the exact date, but it was not this year. In an interview with the Social Services Director (SSD), on 08/14/2025 at 3:34 PM, she stated she had worked as the SSD for a year. She stated all care conferences were conducted quarterly, and she had been responsible to ensure that the residents and representative were contacted. She stated contacts were made via phone and if that was unsuccessful a letter would be sent. The SDC stated if a representative was unable to be in the facility they had participated by phone. She further stated that all call conference meeting notes should be entered right after the meeting had occurred. She stated it was her responsibility to ensure that the required care conference meetings were being conducted quarterly and documented. She could not recall any specific reason as to why R33 or R11 had missing care plan meetings. In an interview with the Director of Nursing (DON), on 08/15/2025 at 11:55 AM, she stated based on the facility's policy and procedures the care meetings were conducted quarterly. She stated if the resident or representative were notified of the care plan conference it would be documented in the progress notes. The DON further stated residents could be affected if care plan meeting were not conducted as required regarding their care. In an interview with the Administrator, on 08/15/2025 at 12:05 AM, she stated the SSD was responsible for ensuring the quarterly care plan meetings were conducted and the resident and representative were notified. She stated those meetings were important and reviewed areas of communication, medications, care plan revisions, behaviors, therapy, and goals. Additionally, the Administrator stated there were potentially negative outcomes for residents regarding the best quality of care if the care plan meetings were not conducted timely and as required and updated as necessary.

Based on interviews, record review, and facility policy review, it was determined the facility failed to ensure a resident's medical record reflected the desired code status (the type of emergent treatment a person would or would not want to receive if their heart or breathing were to stop) of a resident and/or a resident's power of attorney (POA) for one (1) of three (3) residents sampled for advanced directives (Resident #43) of a total sample of sixteen (16) residents. Record review revealed Resident #43's signed advanced directive documents reflected a code status of do not resuscitate (DNR), but the resident's face sheet/medical record reflected a code status of full code. Therefore, documents in the medical record were conflicting and could lead to the resident receiving treatment they did not wish to receive. The findings included: Review of the facility's policy titled, Residents' Rights Regarding Treatment and Advance Directives, revised [DATE], revealed, the facility would support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an advanced directive. Definitions: Advance directive was a written instruction, such as a living will or durable power of attorney for health care, recognized under State law (whether statutory or as recognized by the courts of the State), related to the provision of health care when the individual is incapacitated. The policy further revealed during the care planning process, the facility would identify, clarify, and review with the resident or legal representative whether they desired to make any changes related to any advance directives. Decisions regarding advance directives and treatment would be periodically reviewed as part of the comprehensive care planning process, the existing care instructions and whether the resident wished to change or continue these instructions. Any decision making regarding the resident's choices would be documented in the resident's medical record and communicated to the interdisciplinary team and staff responsible for the resident's care. Review of Resident #43's medical record revealed the facility admitted the resident on [DATE] and readmitted him/her on [DATE] with diagnoses which included Parkinson's Disease, Atrial Fibrillation, Dementia, Anxiety, and Acute Embolism and Thrombosis of Right Peroneal Vein. Further review of the record revealed the resident's code status was Full Code, and indicated a copy was on file. Review of the Significant Change in Status Minimum Data Set (MDS) Assessment, dated [DATE], revealed the facility assessed Resident #43 to have a Brief Interview for Mental Status (BIMS) score of ten (10), which indicated the resident had moderate cognitive impairment. Review of Resident #43's Progress Notes revealed a Health Status Note, dated [DATE] and signed by the Advanced Practice Registered Nurse (APRN), revealed Resident #43 had a Code Status: DNR (do not resuscitate). Review of Resident #43's Advance Directives/Medical Treatment Decisions, dated [DATE], revealed the resident had chosen to formulate and issued the following Advance Directives. Further review revealed Resident #43 initialed Do Not Resuscitate [DNR] as received on [DATE]. The form was signed by Resident #43's Power of Attorney (POA) on [DATE]. Review of Resident #43's Medical Orders for Scope of Treatment [MOST] form, dated [DATE], revealed Section A for, Cardiopulmonary Resuscitation (CPR): Person has no pulse and is not breathing that the box next to Do Not Attempt Resuscitation was checked. The form was signed by Resident #43's POA on [DATE]. Review of Resident #43's medical record revealed there were no other advance directive documents, other than the documents signed on [DATE] indicating Resident #43 was a DNR. A review of Progress Notes for the timeframe from [DATE] through [DATE] revealed a note, dated [DATE], that indicated the resident returned from the hospital and Resident remains Full Code. Another note, dated [DATE], revealed Resident remains Full Code. There were no other Progress Notes which reflected the resident's code status or if/when there was a change to the resident's code status after the resident was initially a DNR on [DATE], except for a Progress Note dated [DATE] (during the survey process). The Progress Note indicated that on [DATE] at 8:16 AM, the facility had a conversation with the resident's POA, who indicated the resident's code status was a DNR. The note indicated the resident's care plan had been revised and the physician's orders had been updated to reflect the DNR status. Review of Resident #43's Comprehensive Care Plan, revealed the care plan was not updated on [DATE] but was updated on [DATE]. Review of Resident #46's care plan revealed the care plan had been initiated on [DATE], with a problem area of advance directives. An approach was initiated on [DATE] that directed staff to withhold CPR in the event that the resident is found without pulse or respirations. In an interview and observation, on [DATE] at 10:19 AM, with State Registered Nurse Assistant (SRNA) #1, she was observed to log into the electronic health record and stated Resident #43's code status was a full code. In an interview on [DATE] at 10:23 AM, with Licensed Practical Nurse (LPN) #2, she stated a resident's code status would be on the face sheet in the electronic medical record. LPN #2 opened the record for Resident #43 and reported the resident was listed as a full code on the face sheet and the physician's orders. In an interview on [DATE] at 10:26 AM, with the Social Service Director (SSD), she stated that when residents were admitted to the facility, the code status was determined. The SSD reviewed Resident #43's electronic record and reported the resident was a full code. The SSD was shown the advanced directive document, dated [DATE], that reflected the resident desired to be a DNR. She stated she would have to check on that form. Further on [DATE] at 10:58 AM, the SSD reported she had contacted the POA, and the resident was supposed to be an DNR. In an interview with the Director of Nursing (DON), on [DATE] at 2:52 PM, she stated the resident's physician orders and the advance directive should all match up. She stated she was not at the facility at the time Resident #43 was interviewed and was not sure how the change in status had been missed.

Based on interviews, record review, and facility policy review, it was determined the facility failed to address each resident's discharge goals and needs as well as develop and implement a care plan addressing a goal to discharge back to the community for one (1) of three (3) residents sampled for discharge planning (Resident #22) of a total sample of sixteen (16) residents. The findings included: Review of the facility's policy titled, Transfer and Discharge, dated 2022, revealed the comprehensive, person-centered care plan should contain the resident's goals for admission and desired outcomes and should be in alignment with the discharge. The policy further revealed supporting documentation should include evidence of the resident's or resident representative's verbal or written notice of intent to leave the facility, a discharge plan, and documented discussions with the resident and/or resident representative. Review of the medical record revealed the facility admitted Resident #22 on 03/15/2023 with diagnoses which included Myasthenia Gravis, Chronic Pain Syndrome, Visual Loss in the Left Eye, and Fracture of the Lower End of the Right Tibia. Review of the Admission Minimum Data Set (MDS) Assessment, dated 03/19/2023, revealed the facility had assessed Resident #22 to have a Brief Interview for Mental Status (BIMS) score of thirteen (13), which indicated Resident #22 was cognitively intact. The MDS further revealed the resident participated in the assessment, and his/her overall goal included the expectation to return to the community. The MDS indicated that active discharge planning had not occurred for the resident to return to the community. Review of the Observation Detail List Report for Resident #22 revealed an Admission Observation, completed 03/16/2023, revealed there was no documented information related to the resident's goals for discharge. Further review of the Observation Detail List Report for Resident #22 revealed a Social History Initial Assessment, dated 03/17/2023. This assessment indicated the resident had lived alone with the support of home care services prior to admission, but contained no information related to the resident's goal to discharge back to the community. Review of Resident #22's Comprehensive Care Plan, with a start date of 03/16/2023, revealed no information addressing the resident's goal to discharge back to the community. Review of all Resident Progress Notes, for the timeframe from 03/15/2023 through 05/24/2023, revealed no documented evidence of discussions with Resident #22 regarding his/her goal to return to the community. During an interview on 05/23/2023 at 12:13 PM, Resident #22 stated the facility had not had any conversations with him/her regarding their goal to discharge home. During an interview with the Social Services Director (SSD), on 05/26/2023 at 8:35 AM, she stated discharge planning started during the post-admission conference. The SSD stated Resident #22's goal was to return home and she had continued to check on the resident to see when the resident was ready for discharge. She stated she typically documented discharge discussions with residents in the progress notes. The SSD reviewed the progress notes, social history, and care plan for Resident #22 and verified there were no plans for Resident #22's discharge. The SSD stated she was unaware there had to be a discharge care plan. In an interview with the Administrator, on 05/26/2023 at 2:30 PM, he stated he expected discharge planning to begin as soon as the resident walked in the door of the facility. He stated he expected a discharge care plan to be formulated and for any discussions with the family and/or resident about discharge to be documented in the resident's medical record. In an interview with the Director of Nursing (DON), on 05/26/2023 at 2:54 PM, she stated she expected discharge planning to start soon after admission and should be included on the comprehensive care plan.

Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to provide supervision to ensure an environment free from accidents and hazards for two (2) of eighteen (18) sampled residents (Residents #3 and #5). The facility assessed Resident #3 and Resident #5 to be at high risk for falls. Review of Resident #3's Electronic Medical Record (EMR), revealed for seven (7) of the fourteen (14) falls the resident experienced between January 2021 through June 2022, the facility failed to ensure appropriate interventions were implemented to reduce or prevent additional falls and possible injuries. Resident #3 experienced a fall on 10/27/2021 at 3:05 AM, which resulted in serious injuries which included fractures of the resident's nasal bone, nasal septum, right maxillary fractures, left comminuted displaced distal radial fracture, a comminuted intra-articular fracture of the distal radius, and displaced distal ulnar metaphysis. The wrist fractures required hospitalization and surgical repair on 10/27/2021. Review of Resident #5's closed EMR revealed for six (6) of the twenty (20) unwitnessed falls the resident experienced between 01/30/2021 to 05/05/2021, the facility failed to ensure interventions were implemented to reduce or prevent additional falls and possible injuries. Resident #5 experienced a fall on 04/15/2021 which resulted in a laceration to the back of the resident's head. This fall resulted in the facility transferring Resident #5 to the hospital emergency room (ER) for staples to close the laceration. The findings include: Review of the facility's policy titled, Accidents and Supervision, revised 03/23/2022, revealed the residents' environment would remain as free of accident hazards as possible. Per review of the policy, each resident would receive adequate supervision and assistive devices to prevent accidents that included: identifying, evaluating and analyzing hazards and risks; and implementing interventions to reduce hazards and risks. Further review revealed the facility would ensure residents received monitoring for the effectiveness of the interventions implemented and would modify the interventions when necessary. Review of the facility's policy titled, Falls, revised 03/22/2022, revealed the facility would strive to maintain a hazard free environment, mitigate fall risk factors, and implement preventative measures. Continued review of the policy revealed the facility would provide a fall risk assessment for residents as part of the admission process, quarterly and when a fall occurred. Further review revealed the identified risk factors were to be evaluated for their contribution in the likelihood of a resident falling, and care plan interventions were to be implemented that addressed the resident's identified risk factors. 1. Record review revealed the facility admitted Resident #3 on 12/14/2020, with diagnoses which included [CONDITION(S)] Without Behavioral Disturbance, Muscle Weakness, and Abnormalities of Gait and Mobility. Review of Resident #3's Quarterly Minimum Data Set (MDS) Assessment, dated 03/18/2022, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of eleven (11), which indicated moderate cognitive impairment. Review of Resident #3's fall risk assessment revealed the facility assessed the resident to be at high risk for falls on admission and with each fall. Review of Resident #3's Comprehensive Falls Care Plan, dated 06/07/2022, revealed interventions which included staff to visualize the resident every hour. However, this intervention was initiated on 05/17/2018, and revised on 07/26/2021. Review of the facility's Post Fall Review, for Resident #3's fall, dated 01/30/2021 at 8:05 PM, revealed the resident had experienced an unwitnessed fall from the bed, with no injury noted. Continued review revealed Resident #3 was found laying on his/her back on the floor mat beside his/her bed. Further review revealed Resident #3 stated he/she had been reaching for a magazine and slid off the bed. Record review revealed the facility's immediate fall intervention was instructed the resident to ask for assistance when needing an item. Review of the Post Fall Review, dated 01/30/2021, revealed the Interdisciplinary Team (IDT) performed a root cause analysis of Resident #3's fall on 01/30/2021. Further review revealed the IDT recommended a referral to Occupational therapy. Review of Resident #3's facility Post Fall Review, dated 04/29/2021 at 6:50 AM, revealed the resident had an unwitnessed fall from his/her bed, and was found by a Certified Nurse Aide (CNA) on the floor of his/her room. Continued review revealed Resident #3 was able to get up and ambulate without assistance; however, he/she had lacerations noted to his/her left lower extremity and left elbow. Further review revealed an immediate intervention noted to remind Resident #3 to always call for assistance when wanting to get up. Review of the facility's Post Fall Review, dated 04/29/2021, revealed the IDT's review of Resident #3's fall for that date revealed a root cause analysis was performed. Continued review revealed the IDT noted Resident #3 had a BIMS' score of fourteen (14), was alert and oriented, and ambulated with the assistance of a walker, accompanied by staff. Per review, Resident #3's gait was unsteady and he/she lacked safety awareness of his/her limitations. Further review of the Post Fall Review revealed Resident #3 stated he/she had gotten up to get a Pepsi from the other side of his/her room and had used the bedside table to aid in his/her ambulation. Continued review revealed Resident #3 reported the bedside tablet slipped out from his/her grasp and he/she fell to the floor. The bedside table caught his/her left leg and caused the skin tear. Additional review revealed the IDT's root cause for Resident #3's fall and subsequent skin tear to the left leg was noted as poor judgement and safety awareness on the part of the resident. Further review revealed the IDT's recommendation was to add a soft touch call light for Resident #3's use, and encourage the resident to use it to call staff before getting up and ambulating. Review of the facility's Post Fall Review, dated 07/22/2022 at 1:00 PM, revealed the resident had experienced an unwitnessed fall from his/her bed. Per review, a Personal Care Assistant (PCA) heard Resident #3 yell and went to the resident's room and found him/her lying on the floor mat on the right side of his/her bed. Further review revealed Resident #3 had complaints of right shoulder pain, with no obvious injury. Continued review revealed orders were received to obtain an x-ray of Resident #3's right shoulder, and an immediate intervention was noted to remind the resident to call for help when he/she needed something. Review of the facility's, Post Fall Review, dated 07/22/2021, revealed the IDT's review of Resident #3's fall for that date revealed a root cause analysis was performed. Per review, the IDT's root cause analysis included the following information: Resident #3's BIMS' score was fourteen (14); he/she was alert and oriented; the resident preferred to lay in bed on his/her right side on the edge of the bed. Continued review revealed Resident #3 had been encouraged to lay in the middle of his/her bed. Further review revealed Resident #3 stated he/she had been reaching for his/her television remote that had fallen to the floor and he/she rolled off the bed while reaching. Record review revealed an intervention was noted to educate Resident #3 and remind him/her to use the call light for assistance. Review of the facility's Post Fall Review, dated 10/27/2021 at 3:05 AM, revealed Resident #3 had a unwitnessed fall. Continued review revealed Resident #3 had previously been in bed, and had tried to self ambulate to the bathroom, when he/she fell and hit his/her head on the floor and possibly had a left wrist fracture. Further review revealed the immediate intervention was noted to send Resident #3 out to the hospital emergency room . Review of the hospital discharge record, dated 10/29/2021, revealed Resident #3 had been diagnosed with acute fractures of his/her nasal bone, nasal septum, and right maxillary facial bones. Further review of the hospital discharge records revealed Resident #3 had also been diagnosed with a left comminuted displaced distal radial fracture, a comminuted intra-articular fracture of the distal radius, and displaced distal ulnar metaphysis, which had been surgically repaired at the hospital. Review of Resident #3's Post Fall Review, dated 10/27/2021, revealed the resident's fall required hospitalization . The intervention to be implemented upon the resident's return to the facility was to place signs to remind Resident #3 to ask for assistance from staff. Continued review of the facility's Post Fall Review, dated 10/27/2021, revealed the IDT performed a root cause analysis which noted: Resident #3's BIMS' score was fifteen (15); the resident was alert and oriented; he/she was very impulsive; and preferred to stay in bed most of the time. Further review revealed Resident #3 reported he/she had wanted to go to the bathroom, got up out of bed and fell to the floor. The IDT identified the root cause of Resident #3's fall on 10/27/2021, as the resident's impulsiveness and that he/she transferred unassisted. Continued review revealed the facility's immediate intervention was to send Resident #3 to the emergency room . Upon the resident's return to the facility, staff were to place signs to remind the resident to ask for assistance from staff. Review of Resident #3's Comprehensive Care Plan revealed the facility implemented an intervention on 10/29/2021, after the resident's return from the hospital. The intervention noted was for staff to place signs to remind the resident to ask for assistance. Review of the care plan, revealed the facility also implemented an intervention on 11/04/2021, to change Resident #3's hi/low bed to a manual bed. Review of the facility's fall's report for Resident #3's fall, dated 11/26/2021 at 11:15 AM, revealed the resident had experienced an unwitnessed fall in his/her room from his/her wheelchair with no injury noted. Continued review revealed Resident #3 had tried to transfer himself/herself from the wheelchair to bed. Further review revealed the facility's immediate intervention was for Resident #3 to be in the common area with staff present while up in his/her wheelchair in order to prevent future falls. Review of the care plan revealed the resident was to be in the common area with staff present. However, observation of Resident #3, on 06/08/2022 at 3:00 PM, revealed the resident was sitting up in a wheelchair watching television in his/her room, without staff present. Review of the facility's Post Fall Review information, dated 11/26/2021, for Resident #3's fall on that date revealed IDT reviewed and performed a root cause analysis of the fall. Continued review revealed documentation noting Resident #3 had a BIMS' score of nine (9), was alert and oriented, and very impulsive. Per review of the Post Fall Review information, Resident #3 refused to use his/her call light despite staff's encouragement and education, and continued to ambulate unassisted. Further review revealed the IDT determined the root cause of Resident #3's fall was the resident's impulsiveness, and recommended an intervention for Resident #3 not to be left unattended in his/her wheelchair while in his/her room. Additional review of the medical record revealed the intervention for Resident #3 not to be left alone in his/her room was discontinued due to not being feasible. Continued review of Resident #3's Comprehensive Care Plan revealed on 12/20/2021, an intervention was implemented to return the resident to bed after breakfast, if he/she agreed to get out of bed. Additional review of Resident #3's Comprehensive Care Plan for Falls revealed on 01/05/2022, the facility implemented interventions for Resident #3 to have Dycem (material used to stabilize objects) for his/her meal trays. Per review, the interventions added to the care plan included for staff to ensure Resident #3's head of his/her bed was elevated to facilitate good visibility of his/her food as well as to prevent aspiration. Review of the care plan revealed another intervention was added to ensure Resident #3's food tray was set up so that the food and drink items were in reach to prevent him/her from dropping things and prevent him/her from falling. Review of the facility's information for Resident #3's fall, dated 03/06/2022 at 3:00 PM, revealed the resident had experienced an unwitnessed fall from the bed in his/her room. Continued review revealed Resident #3 had stated he/she rolled out of bed trying to sit up straight in the bed. Further review revealed Resident #3 denied hitting his/her head, and the facility's immediate intervention was for his/her manual bed to be replaced with an electric low bed. Review of the facility's Post Fall Review information dated 03/06/2022, for Resident #3's fall revealed the IDT reviewed the fall and performed a root cause analysis. Continued review revealed the documentation noted Resident #3 reported he/she rolled off the bed trying to reposition himself/herself on the bed. Per review, no injury had been noted to Resident #3. Further review revealed the IDT's recommended intervention was for the resident's manual bed to be replaced with an electric low bed, with the remote placed near the foot of the bed in order for the resident not to place the bed too high. Review of Resident #3's Comprehensive Care Plan for Falls further revealed on 03/07/2022, an intervention was implemented for a soft mat at bedside and an electric low bed with the remote at the foot of the bed to replace his/her manual bed. Review of the facility's information for Resident #3's fall, dated 04/26/2022 at 5:53 PM, revealed the resident had experienced an unwitnessed fall from the wheelchair while in his/her room. Per review, Resident #3 had completed his/her meal and wheeled himself/herself back to his/her room and attempted to self transfer onto the bed. Further review revealed the facility's immediate interventions included: signs to be posted to use the call light to call for help; place gripper socks when getting the resident up out of bed; and place the call light close to the resident when he/she was out of bed. Review of the facility's Post Fall Review information, dated 04/26/2022, for Resident #3's fall on that date revealed the IDT reviewed the fall and performed a root cause analysis of the fall. Per review of the documentation, Resident #3 was alert with confusion and had decreased safety awareness; was up for all meals to promote oral consumption. Continued review revealed Resident #3 had completed his/her meal and wheeled himself/herself back to his/her room after the meal. Further review revealed Resident #3 attempted to transfer to his/her bed which resulted in the fall, with no injuries noted. Review further revealed Resident #3 had also been noted to have increased confusion on that date and a medication review was performed. Additional review revealed the IDT's recommended intervention was to place Resident #3 in bed after all meals, and complete a medication review. Further review of Resident #3's Comprehensive Care Plan for Falls revealed on 04/26/2022, the facility implemented an intervention to offer assistance to the resident to go to bed after meals. Additional care plan review revealed on 05/27/2022, the facility implemented an intervention to re-configure Resident #3's room and reposition the bed. Review of the facility's information for Resident #3's fall, dated 06/12/2022 at 12:50 PM, revealed the resident had an unwitnessed fall out of his/her bed, with no injury noted. Per review, staff observed Resident #3 lying on the floor beside his/her bed while delivering the resident's lunch meal tray. Further review revealed Resident #3 was unable to recall how the fall occurred. Continued review revealed the facility's immediate intervention was to turn Resident #3's bed against the wall. Review of the facility's Post Fall Review information revealed the IDT's recommendation was to increase repositioning of the resident with pillows when he/she was lying on the bed. Interview, on 06/15/2022 at 2:30 PM, with Certified Nursing Assistant (CNA) #2, revealed the CNA had provided care for Resident #3. CNA #2 stated residents were to be checked on every two (2) hours, but the CNA checked on Resident #3 more often because the resident scoots around in the bed. However, according to Resident #3's care plan, an intervention was for staff to visualize the resident every hour. Continued interview revealed when staff got Resident #3 up out of bed he/she wanted to lay right back down. CNA #2 stated Resident #3 pulled his/her feet up toward his/her buttocks, and was a determined individual. Interview revealed when the CNAs provided care for Resident #3 he/she would yell and curse at them, and then laugh about it. CNA #2 stated they always used two (2) staff for Resident #3's transfers because he/she became even more fidgety when being transferred. Further interview revealed Resident #3 knew how to use his/her call light; however, he/she chose not to use it. Interview on 06/15/2022 at 2:45 PM, with CNA #9, revealed she had provided care for Resident #3 in the past. CNA #9 stated Resident #3 could transfer with assistance of one (1) staff person. Continued interview revealed staff had to watch Resident #3 because he/she thought he/she was able to walk, but he/she could not walk. Further interview revealed when CNA #9 cared for Resident #3 she rounded on the resident every two (2) hours as per the care plan. Review of Resident #3's care plan revealed an intervention for staff to visualize the resident every hour. Interview, on 06/15/2022 at 3:20 PM, with CNA #8, revealed she checked on Resident #3 as often as I can, it's supposed to be every two (2) hours with rounds. Per CNA #8, she looked in on Resident #3 more often because I know how (the resident) is According to the CNA, she looked in on Resident #3 every time she went down the hall, and also did that for all the residents in her care. Further interview revealed when CNA #8 transferred Resident #3 she always got another staff member to help her because the resident got busy fidgeting. Interview on 06/15/2022 at 3:45 PM, with Licensed Practical Nurse (LPN) #3, revealed we check on Resident #3 often because the resident squirms in bed. LPN #3 stated, every time I walk down the hall I look into (Resident #3's) room. Further interview revealed Resident #3's bed had been placed against the wall so the resident was facing the door in order for staff to easily visualize him/her. Interview on 06/16/2022 at 9:35 AM, with Physical Therapy Assistant (PTA) #17, revealed Resident #3 was a minimum to moderate assistance of one (1) staff with transfers and with side stepping. She stated performing Resident #3's therapy depended on the resident's mood as to what he/she would do for therapy staff. PTA #17 stated there were days when Resident #3 would complete therapy in one (1) session and on other days therapy staff would have to work with the resident for half a session and then go back later to complete his/her therapy session. Interview, on 06/16/2022 at 10:30 AM, with CNA #4, revealed she had not cared for the resident on 10/27/2021, the night of the fall. CNA #4 stated Resident #3 was care planned to be checked on every two (2) hours. Per CNA #4, at the time of the 10/27/2021 fall, Resident #3 had transferred with assist of one (1) staff person. However, record review revealed the facility assessed Resident #3 to require the extensive assistance of two (2) for transfers. Interview, on 06/16/2022 at 1:00 PM, with Certified Nursing Assistant (CNA) #6, related to Resident #3's fall on 06/12/2022, revealed she had walked into the resident's room and found him/her lying on the floor. Continued interview revealed CNA #6 got the nurse on duty and another CNA. Staff assessed Resident #3 and got him/her back on to his/her bed. According to CNA #6, Resident #3 would not tell staff what he/she had been trying to do when the fall occurred. Further interview revealed as a team decision they decided to move the left side of the bed against the wall because Resident #3 leaned towards the left side of the bed. Interview on 06/22/2022 at 3:30 PM, with the Director of Nursing (DON) and Assistant Director of Nursing (ADON), revealed most of the interventions for Resident #3 were put in place when the resident's BIMS' scores were at fifteen (15) and fourteen (14), and the facility was trying very hard to move away from interventions such as educating the resident or reminding the resident. Per interview, when Resident #3's BIMS score had been at eleven (11) the resident had continued to be impulsive, and had not believed he/she required staff's assistance. Interview further revealed the facility would be re-evaluating Resident #3's perimeter mattress, and would try to find another perimeter mattress that better fit the resident's needs. 2. Review of the closed medical record for Resident #5 revealed the facility admitted the resident on 01/29/2021, with the following diagnoses: Unspecified Fracture of the Second Lumbar Vertebra, Subsequent Encounter for Fracture With Routine Healing; and Other Accident with Motorized Mobility Scooter, [CONDITION(S)] Without Behavioral Disturbance. Review of Resident #5's Quarterly MDS, dated [DATE], revealed the facility assessed the resident to have a BIMS' score of three (3) indicating he/she was severely cognitively impaired and non-interviewable. Continued review of Resident #5's closed medical record revealed documentation of Resident #5 experiencing twenty (20) unwitnessed falls from 01/30/2021 to 05/05/2021. Additional review revealed Resident #5 experienced an injury on 04/15/2021, which required transfer to the hospital for treatment. Resident #5 required staples to the laceration on the back of his/her head. Review of Resident #5 Baseline Care Plan, dated 01/29/2021, revealed the facility had care planned the resident as at risk for falls related to his/her impaired cognitive function, decreased safety awareness, history of falls, impulsive behavior and [CONDITION(S)]. Review of Resident #5's Comprehensive Care Plan revealed: on 02/05/2021, an intervention was added for the resident to wear non-skid footwear; on 02/06/2021, an intervention for floor mats to be placed beside his/her bed; on 02/07/2021, an intervention was added to place the resident in high traffic areas when he/she was up in the wheelchair; on 03/01/2021, an intervention noting signage to be placed in his/her room to use call light; on 03/06/2021, an intervention for fall mats was added; on 03/07/2021, an intervention was noted for Dycem to be placed in the resident's wheelchair; on 04/21/2021, an intervention was added for a lap buddy (a device fitted over a resident sitting in a wheelchair that acts as a reminder for the resident to ask for assistance before getting up); on 05/03/2021, an intervention was added for a self-release belt to the resident's wheelchair; and on 05/05/2021, an intervention was added for the resident to have one to one (1:1) supervision twenty-four (24) hours seven (7) days a week. Review of the facility's information for Resident #5's fall dated 01/31/2021 at 2:55 PM, revealed the resident was found lying on the floor in the doorway to his/her room, with no injury noted. Continued review revealed the facility's intervention was for a sensor pad alarm to his/her bed. Review of the facility's Post Fall Review information, dated 01/31/2021, revealed the IDT's review of Resident #5's fall for that date; a root cause analysis was performed. Continued review revealed the IDT noted Resident #5 had poor cognition as indicated by his/her BIMS' score of three (3). Record review revealed the IDT noted Resident #5 was unable to be reeducated, was impulsive and had no safety awareness. Further review revealed the IDT identified the root cause for Resident #5's fall, on 01/31/2021, was due to his/her advanced [CONDITION(S)] with poor safety awareness. Review further revealed the IDT's recommended intervention was for a sensor pad to be placed on Resident #5's bed. However, the sensor pad had already been implemented for Resident #3 on 01/30/2021. Review of Resident #5's Care Plan revealed interventions implemented, dated 01/31/2021, for a sensor pad alarm to the resident's bed, and for staff to reassure and redirect the resident when needed. Review of the facility's information for Resident #5's fall, dated 02/26/2021, revealed the resident had fallen to the floor from his/her bed. Continued review revealed the facility's intervention was for signage in Resident #5's room for him/her to use the call light. Record review revealed this had been an ineffective intervention for Resident #5, whom the facility had assessed as severely cognitively impaired. Review of the facility's Post Fall Review information, dated 02/26/2021, revealed the IDT performed a root cause analysis. Continued review of the IDT's root cause analysis revealed Resident #5 had: a BIMS's score of three (3); a history of brain injury and [CONDITION(S)]; and, he/she was impulsive with no safety awareness. Further review revealed the IDT identified the root cause for Resident #5's 02/26/2021 fall as advanced Dementia. Additional review revealed the IDT's recommended intervention was for signage in Resident #5's room for direction. However, the facility had assessed the resident to be severely cognitively impaired. Review of the facility's information for Resident #5's fall, dated 03/08/2021, revealed the resident was found on the floor after trying to self transfer to the bathroom, with no injury noted. Review of the facility's Post Fall Review information, dated 03/08/2021, of the IDT's review of Resident #5's fall revealed a root cause analysis was performed. Per review, the IDT's analysis noted Resident #5 had: a BIMS' score of six (6) which indicated severe cognitive impairment; was very impulsive with no safety awareness despite redirection and interventions; and did not respond to education or encouragement. Further review revealed the IDT was in agreement that Resident #5 was confused and the root cause identified for the fall was impulsiveness related to progressing dementia. Additional review revealed the IDT's recommended intervention was for Resident #5's urine to be obtained for a urinalysis with culture and sensitivity. Review of Resident #5's Care Plan, revealed interventions, dated 03/08/2021, to obtain urine for a urinalysis with culture and sensitivity, and to encourage the resident to wear gripper socks. Further record review revealed Resident #5's urine was collected and the resident was diagnosed with a urinary tract infection ([CONDITION(S)]) with an antibiotic ordered to treat the [CONDITION(S)]. Review of the facility's information for Resident #5's fall, dated 03/19/2021, revealed the resident was found sitting on the floor beside his/her bed with no injuries noted. Continued review revealed the facility's intervention was for staff to anticipate and meet Resident #5's needs. Review of the facility's Post Fall Review information, dated 03/19/2021, of the IDT's review of Resident #5's fall for that date revealed a root cause analysis was performed. Record review revealed the IDT's analysis included information noting Resident #5 had a BIMS' score of three (3); a history of brain injury and [CONDITION(S)]; was impulsive and had no safety awareness; and did not realize he/she could not stand or transfer alone. Further review revealed the IDT's root cause identified for the resident's fall was his/her advanced dementia. Review further revealed the IDT's recommended intervention was for staff to anticipate and meet Resident #5's needs. Additional care plan review revealed an interventions dated 03/19/2021; for staff to anticipate and meet Resident #5's needs; for every thirty (30) minute behavior checks for twenty-four (24) hours related to his/her self safety deficit. Review of the facility's information for Resident #5's fall, dated 04/01/2021, revealed the resident had been assisted by a CNA to be lowered to the floor with no injury noted. Further review revealed the facility's intervention was for the Advanced Practice Registered Nurse (APRN) to evaluate Resident #5. Review of the facility's Post Fall Review information, dated 04/01/2021, related to the IDT's review of Resident #5's fall, revealed a root cause analysis was performed. Continued review revealed Resident #5 had: a low BIMS' score; self transferred often; and was impulsive and had decreased safety awareness. Review further revealed the IDT identified the root cause for Resident #5's fall as his/her advanced dementia. Record review revealed the IDT recommended an intervention for alternative placement at another facility for Resident #5. Continued review of Resident #5's care plan revealed an intervention, dated 04/01/2021, for alternate placement at another facility for the resident, and the APRN (Advanced Practice Registered Nurse) to evaluate him/her. Review of the facility's information for Resident #5's fall, dated 04/03/2021, revealed the resident was found on the floor beside his/her bed. Review of the facility's Post Fall Review information, dated 04/03/2021, of the IDT's review of Resident #5's fall revealed a root cause analysis was performed. Per review, the IDT's analysis information included Resident #5 had: a low BIMS' score; a history of falls; was impulsive; performed unassisted self transfers; spilled his/her drinks; and was incontinent of bowel and bladder with some control. Record review revealed the IDT identified the root cause for the resident's fall as his/her advanced dementia and impulsiveness. Additional review revealed the IDT's recommended intervention was to educate staff to ensure Resident #5's alarm was on and working due to the alarm not working, and not being positioned properly when the resident experienced the fall on 04/03/2021. Further review of Resident #5's care plan revealed an intervention, dated 04/03/2021, to educate staff that the resident's alarm was on and functioning. Review of the facility's information for Resident #5's fall, dated 04/15/2021 at 1:00 PM, revealed a CNA found the resident lying on the floor next to his/her wheelchair in his/her room. Continued review revealed Resident #5 had hit his/her head on a corner of a wall and had a six (6) centimeter laceration observed to the back of the resident's head. Review of the facility's Post Fall Review information revealed staff were to send Resident #5 to the emergency room for evaluation of the laceration to the back of his/her head, and evaluate for possible urinary tract infection. Additional review of Resident #5's care plan revealed an intervention, dated 04/15/2021, to remind the resident not to stand or transfer without assist. Review of the Progress Note, dated 04/30/2021, and timed at 10:47 AM, documented by the former Social Services Director (SSD), revealed a care plan meeting had been held with Resident #5, his/her daughter, nursing staff, the former DON, the former ADON, the former MDS Coordinator, the former Social Services Director (SSD), and therapy staff. Continued review revealed the former DON noted Resident #5 had experienced nineteen (19) falls since his/her admission on 01/29/2021. Per review, with each fall Resident #5 had declined a little more and had alarms and floor mats in place. Record review revealed the facility had attempted the use of a lap buddy. However, Resident #5 had refused that intervention. Review of the 04/30/2021 [TRUNCATED]

Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to develop and implement a Comprehensive Care Plan which ensured residents received the necessary adequate supervision and assistance for one (1) of eighteen (18) sampled residents (Resident #3). The facility assessed Resident #3 to be at high risk for falls on admission, quarterly; and, with falls he/she sustained. However, the facility failed to implement the necessary assistive devices and supervision to reduce/prevent further falls. Resident #3 experienced fourteen (14) unwitnessed falls from January 2021 through June 2022, with the resident experiencing serious injuries as a result of the fall on 10/27/2021. Resident #3's injuries included nasal and facial fractures, and fractures of his/her left arm and wrist. The resident's wrist injuries required surgical repair. The findings include: Review of the facility's Comprehensive Care Plan Policy, revised on 03/23/2022, revealed the facility would develop and implement a Comprehensive Person-Centered Care Plan for each resident. Per review, the Comprehensive Person-Centered Care Plan developed and implemented for each resident was to be consistent with residents' rights, and include measurable objectives and timeframes to meet the resident's medical, nursing, mental and psychosocial needs as identified in each resident's comprehensive assessment. Record review revealed the facility admitted Resident #3, on 12/22/2017, with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #3's fall risk assessments revealed the facility assessed the resident as a high risk for falls. Review of Resident #3's Quarterly Minimum Data Set (MDS) Assessment, dated 03/18/2022, revealed the facility assessed the resident with the Brief Interview for Mental Status (BIMS) score of eleven (11). This score indicated the resident was moderately cognitively impaired. Further review revealed the facility assessed Resident #3 to require the extensive assistance of two (2) for transfers and the extensive assistance of one (1) staff for bathing due to the resident's unsteady balance. Continued review of the MDS revealed the facility assessed Resident #3 to not ambulate and as having a history of two (2) or more falls. Continued review of Resident #3's medical record revealed fourteen (14) unwitnessed falls were noted between January 2021 and June 2022. Per review, the fall noted on 10/27/2021 resulted in Resident #3 experiencing fractures of his/her right maxillary facial area, nasal septum, and nasal bone. Further review, of the 10/27/2021 documentation, revealed Resident #3 also sustained a left comminuted intra-articular fracture of the distal radius, left comminuted displaced distal radial fracture, and displaced distal ulnar metaphysis. Continued review revealed Resident #3 required hospitalization for the wrist fractures to be surgically repaired. The facility readmitted Resident #3 on 10/29/2021. Review of Resident #3's Comprehensive Care Plan, dated 06/07/2022, revealed the facility had developed a falls' care plan for the resident with interventions dated 12/22/2017. The interventions included: anticipating and meeting the resident's needs; being sure his/her call light was within reach and encouraging the resident to use it for assistance, as needed; removing or redirecting the resident if he/she placed self in a situation for possible fall injury; reviewing information on past falls for the resident and attempting to determine the cause of the fall, recording the possible root causes, and educating the resident, family, caregivers, Interdisciplinary Team (IDT) as to the root causes. Continued review revealed other interventions which included: on 01/09/2020, anti-rollbacks to the resident's wheelchair; on 05/17/2018, to not leave him/her in the bathroom/shower unattended; on 04/30/2021, to keep his/her personal items on the bedside table within reach; on 07/26/2021, to ensure he/she was wearing appropriate footwear during transfers and when in his/her wheelchair, and remind the resident to ask for assistance, using visual cues, if needed. Review of the Nursing Progress Notes for Resident #3 revealed on 01/16/2021 at 3:45 PM, the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Per review of the Note, staff found Resident #3 lying on the mat beside his/her bed. The resident had complaints of a headache, and neurological (neuro) checks were implemented. Continued review revealed Resident #3 refused to be sent out to the hospital. Review of the facility's information regarding the fall revealed the root cause of the fall was noted as Resident #3 wanted to go to the bathroom. Review of Resident #3's Comprehensive Care Plan revealed it had been revised to include interventions for staff to check on the resident every two (2) hours, and provide education for him/her on transfers without assistance. However, record review revealed documentation that noted Resident #3 was noncompliant when being provided education on asking for staff's assistance. Review of the Nursing Progress Note for Resident #3, dated 04/29/2021 at 6:50 AM, revealed the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review revealed Resident #3 had attempted ambulating without assistance. The facility assessed the resident with lacerations to his/her left lower extremity and left elbow. Review of Resident #3's Comprehensive Care Plan, dated 04/14/2020, revealed it had been revised with an intervention to remind Resident #3 to always call for assistance when wanting to get up out of bed. However, this was an intervention that was noted before and was not effective for Resident #3. Review of Resident #3's Nursing Progress Note, dated 07/22/2021 at 1:00 PM, revealed the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Per review, a Personal Care Assistant (PCA) heard Resident yell and went to Resident #3's room and found the resident lying on the floor mat on the right side of his/her bed. Continued review revealed Resident #3 had complaints of right shoulder pain, with no assessed obvious injury. Further review revealed physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #3's Comprehensive Care Plan, revealed it was revised on 04/14/2020, to remind to ask for assist-use visual cues if needed. Further review revealed on 07/22/2021, the facility revised the care plan again, with an intervention to remind Resident #3 to call for help when needing something. Record review revealed this intervention was also noted on the Post Fall Review for 07/22/2021. Review of Resident #3's Nursing Progress Note, dated 10/27/2021 at 3:05 AM, revealed the resident had an unwitnessed fall, trying to stand and self ambulate to the bathroom. Further review revealed Resident #3 fell and hit his/her head on the floor. Continued review revealed the facility assessed Resident #3 to have a head injury and possible left wrist fracture. The facility transferred Resident #3 to the hospital emergency room (ER). Review of Resident #3's hospital records, dated 10/29/2021, revealed the resident was assessed to have acute right maxillary fractures, and fractures of the nasal bone and septum. Continued review of the hospital records revealed Resident #3 was also diagnosed with a left comminuted intra-articular fracture of the distal radius, left comminuted displaced distal radial fracture, and displaced distal ulnar metaphysis (the neck portion of a long bone between the rounded end at its joint and the midsection/shaft). Review of Resident #3's Comprehensive Care Plan revealed it had been revised on 10/29/2021, when the resident returned to the facility from the hospital. Further review of the care plan revealed a previous intervention of signs to be placed in his/her room to remind Resident #3 to ask for assistance from staff. No further interventions were added. Review of the Nursing Progress Note for Resident #3, dated 11/05/2021 at 2:30 PM, revealed the resident had an unwitnessed fall from his/her wheelchair in the dining room. Per review, Resident #3 slid out of the wheelchair while waiting for a family visit, unattended. Review of Resident #3's Comprehensive Care Plan revealed, on 11/08/2021 the facility added the intervention that the resident would not be taken to the lobby for a visit with spouse prior to his/her arrival. Review of the care plan revealed an additional intervention listed on the Post Fall Review, dated 11/05/2021 with an intervention for placing the resident in the hallway where staff could observe him/her until family arrived, then taking him/her to the lobby. Review of Resident #3's Nursing Progress Note, dated 11/26/2021 at 11:15 AM, revealed the resident had sustained an unwitnessed fall from his/her wheelchair in his/her room with no injury assessed or noted. Continued review revealed Resident #3 attempted to transfer himself/herself from the wheelchair to the bed. Review of Resident #3's Post Fall Review, dated 11/29/2021, revealed an intervention for the resident to be placed in a common area with staff present while up in his/her wheelchair, and not be left unattended in his/her wheelchair in his/her room in order to prevent future falls. Review of the Nursing Progress Note for Resident #3, dated 04/26/2022 at 5:53 PM, revealed the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . However, review of the Care Plan revealed Resident #3 was not to be left sitting up in his/her wheelchair alone in his/her room. Per review, Resident #3 had consumed his/her dinner meal and wheeled himself/herself back to his/her room and attempted to transfer from the wheelchair to the bed without assistance. Review of Resident #3's Post Fall Review, dated 04/26/2022, revealed interventions: for signs to be posted in the resident's room for him/her to use the call light for help; for staff to place gripper (non-skid) socks on his/her feet when out of bed; and to place the call light close to the resident when he/she was up out of bed. Review of the Nursing Progress Note for Resident #3, dated 05/26/2022 at 11:30 PM, revealed the resident had sustained an unwitnessed fall from the bed in his/her room. Continued review revealed staff entered Resident #3's room and observed the resident lying on the floor on his/her left side with his/her feet towards the bed. Further review revealed Resident #3 was assessed and assisted back to bed. Additional review revealed Resident #3 informed staff he/she had just fell out of bed; however, he/she did not know why. Review of Resident #3's Comprehensive Care Plan revealed it had been revised on 05/17/2018, with an intervention for the resident to be visually observed every hour ( unless with visitor/ family): Night light in room at hour of sleep; assist to bed after meals and activities; advise visitors to notify staff when leaving. However, observation of and interview with Resident #3, on 06/08/2022 at 3:00 PM, revealed the resident was sitting up in his/her wheelchair in his/her room alone watching television. Review of Resident #3's Care Plan, revealed an intervention, dated 07/26/2021, for staff to assist him/her to bed after meals and activities. Interview, on 06/15/2022 at 2:45 PM, with CNA #9, revealed she had cared for Resident #3 in the past. CNA #9 stated Resident #3 had been able to transfer with assistance of one (1) staff when she provided care for the resident in the past. She stated staff had to watch Resident #3 because he/she thought he/she could walk, but was unable to walk. Further interview revealed she had rounded on Resident #3 every two (2) hours like the care plan said. Interview on 06/15/2022 at 3:20 PM, with CNA #8 revealed staff were supposed to check on Resident #3 every two (2) hours but, she looked in on the resident more often as she could because she knew how Resident #3 was. CNA #8 stated every time she went down the hall she looked in on Resident #3, and did the same thing for all the residents assigned to her care. Interview on 06/15/2022 at 3:45 PM, with Licensed Practical Nurse (LPN) #3, revealed staff checked on Resident #3 often because the resident squirmed in bed. Per LPN #3, she looked in Resident #3's room every time she walked down the hall. Further interview revealed Resident #3's bed had been moved against that wall, with the resident facing the door, so staff were able to visualize him/her when going by the room. During an interview, on 06/22/2022 at 3:30 PM, with the Director of Nursing (DON) and Assistant Director of Nursing (ADON), the DON stated that reminding residents to call for assistance was not an effective intervention. The DON stated the facility's goals were always for a resident's safety, and to find interventions that were the best fit for each resident. Continued interview with the DON and ADON revealed most of Resident #3's interventions had been implemented when the resident had a BIMS' score of fourteen (14) or fifteen (15) which indicated no cognitive impairment. Per the DON and ADON, the facility would be trying very hard to move away from the interventions to educate Resident #3 or for reminding the resident of things. Interview, on 06/23/2022 at 4:30 PM, with current MDS Coordinator #22, revealed she was new to her position. She stated she attended the facility's clinical meetings after residents' falls and updated the residents' care plans during the meetings. According to MDS Coordinator #22, she also attended the facility's Interdisciplinary Team (IDT) meetings where the staff present went over the residents' falls. She stated she checked the residents' care plans for interventions that were already in place, and determined what might need to be added or changed. She stated she be new to the position and moving forward the process would be to check the residents' care plans for interventions already in place, and determine what might need to be added or changed.

Based on observation, interview, record review and review of the facility's policies, it was determined the facility failed to ensure each resident's care plan was revised and updated; and, failed to provide the necessary supervision and assistive devices for each resident to prevent accidents for two (2) of eighteen (18) sampled residents (Resident #3 and Resident #5). The facility assessed Resident #3 as a high risk for falls on admission, quarterly and with any falls. However, the facility failed to review and revise Resident #3's care plan and failed to implement the necessary supervision and assistive devices to prevent accidents. The facility repeatedly care planned Resident #3 to ask for assistance when picking items up off the floor and with transfers. There were numerous documented episodes of Resident #3's non-compliance in asking for staff's assistance. However, the facility continued to care plan to remind the resident to ask for assistance as an intervention and to recommend previous interventions already in place. The facility also assessed Resident #5 as a high risk for falls on admission, quarterly and after fall events. However, the facility failed to review interventions already in place for Resident #5, and continued to add those same interventions to the resident's care plan after he/she experienced falls. The findings include: Review of the facility's policy titled, Care Plan Revisions Upon Status Change, revised on 11/10/2021, revealed the facility would provide a consistent process for reviewing and revising the care plans of those residents experiencing a status change. Per review of the policy, the procedure for reviewing and revising residents' care plans when a status change occurred was for the nurse to notify the Minimum Data Set (MDS) Coordinator, the resident's Physician, and his/her representative, if applicable. Continued review revealed the MDS Coordinator and the facility's Interdisciplinary Team (IDT) were to discuss the condition of a resident experiencing a status change and collaborate on intervention options for the resident. Record review revealed the resident's care plan was to be updated with the new modified interventions by the MDS Coordinator or other designated staff member. Further review revealed the Unit Manager or other designated staff member was to communicate the revised/modified care plan interventions to all staff involved in the resident's care. In addition, the MDS Coordinator would determine whether a Significant Change in Status MDS Assessment was warranted for the resident experiencing a status change, and if warranted,the assessment would be completed according to the facility's established procedures. Review of the facility's policy titled, Accidents and Supervision Policy, revised on 03/23/2022, revealed the residents' environment would remain as free of accident hazards as possible. According to the policy, each resident was to receive adequate supervision and assistive devices to prevent accidents. Continued review revealed in order to ensure this, the facility would identify hazard(s) and risk(s); and evaluate and analyze any hazard(s) and risk(s) identified. Further review revealed the facility would implement interventions necessary to reduce hazard(s) and risk(s); and monitor for the effectiveness of interventions, modifying the interventions as necessary. 1. Record review revealed the facility admitted Resident #3, on 12/22/2017, with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #3's fall risk assessment revealed the facility assessed the resident as a high risk for falls. Review of Resident #3's Quarterly MDS, dated [DATE], revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of eleven (11), which indicated moderate cognitive impairment. Continued MDS review revealed the facility assessed Resident #3 as requiring the extensive assistance of one (1) staff for bathing and dressing, and extensive assistance of two (2) staff for transfers due to his/her unsteady balance. Further review of the MDS revealed the facility assessed Resident #3 as not ambulating, and to have a history of two (2) or more falls. In addition, the MDS stated the facility noted Resident #3 was to receive Physical and Occupational Therapies five (5) days per week. Review of Resident #3's Comprehensive Care Plan revealed the facility care planned the resident for falls. Further review revealed interventions included: on 10/29/2021, to place signs to remind the resident to ask for staffs' assistance; on 11/04/2021, to change the resident's hi/low bed to a manual bed; on 12/20/2021, to return the resident to bed after breakfast, if he/she agreed to get up out of bed; on 01/05/2022, to place Dycem on meal trays; and when the resident was eating while in bed to ensure the head of the bed was elevated appropriately to facilitate good visibility of food as well as to prevent aspiration. Further review of the Care Plan revealed Resident #3's interventions were revised on 01/05/2022 to ensure the resident's food tray was set up so food and drink items were within reach to prevent the resident from dropping things, thereby preventing falls; on 03/07/2022, for a soft mat to be placed on the floor beside the resident's bed; on 04/26/2022, to offer to assist the resident back to bed after meals; on 05/27/2022, to re-configure the resident's room and repositioning of his/her bed. On 07/26/2021, for staff to visualize the resident every hour was added. However, this intervention was previously added to Resident #3's care plan on 05/17/2018. Review of Resident #3's Post Fall Reports, revealed the resident experienced fourteen (14) falls from 01/16/2021 through 06/12/2022. Record review revealed on 04/29/2021 at 6:50 AM, the resident fell from his/her bed as he/she attempted to get up and ambulate without assistance. Record review revealed Resident #3 sustained lacerations to his/her left lower extremity and left elbow. Review of the immediate intervention revealed staff were to remind Resident #3 to always call for assistance when wanting to get up. Review of the IDT's recommendation revealed staff were to obtain a Speech Therapy referral for Resident #3, add a soft touch call light, and encourage the resident to use it before getting up and self ambulate. However, review of the Care Plan revealed the IDT's recommendation for the soft touch call light had been initiated on 02/02/2021. Record review revealed on 07/22/2021 at 1:00 PM, Resident #3 had an unwitnessed fall onto the floor mat from his/her bed. Further review revealed Resident #3 had complaints of right shoulder pain after the fall, and had x-rays ordered of the right shoulder. Per review of the immediate intervention, staff were to remind Resident #3 to call for help when needing something. Review of the IDT's recommendation revealed staff were to educate and remind Resident #3 to use his/her call light to call for assistance. Care Plan review revealed it was updated/revised on 07/26/2021, with the IDT's recommended intervention to use his/her call light to call for assistance. Record review revealed on 10/27/2021 at 3:05 AM, Resident #3 attempted to self ambulate to the bathroom and fell , hitting his/her head on the floor. Further review revealed the facility assessed the resident to have a possible left wrist fracture and sent him/her out to the hospital emergency room (ER). Review of the hospital records, dated 10/29/2021, revealed Resident #3 was diagnosed with acute fractures of his/her right maxillary facial area, nasal bone, nasal septum, left displaced distal ulnar metaphysis, left comminuted displaced distal radial fracture, and a comminuted intra-articular fracture of the distal radius. Continued review of the hospital records revealed the resident's left wrist fractures required surgical repair. Review of the IDT's intervention revealed upon Resident #3's return to the facility from the hospital, signs were to be placed to remind the resident to ask for staff's assistance. Care Plan review revealed on 10/29/2021, the facility implemented interventions which included: placing signs in Resident #3's room to remind him/her to ask for assistance. However, the intervention for Resident #3 to ask for assistance had previously been noted as an intervention on 07/22/2021. Record review revealed on 11/05/2021 at 2:30 PM, the resident slid out of his/her wheelchair in the dining room while waiting for a family visit. Further review revealed the immediate intervention was for the facility to assess Resident #3 and he/she was placed back in his/her wheelchair. Review of the IDT's recommendation revealed for staff to place Resident #3 in the hallway until his/her family arrived and then to take him/her to the lobby. Care Plan review revealed it was revised/updated on 11/08/2021, with the IDT's recommended intervention to place Resident #3 in the hallway until his/her family arrived and then take him/her to the lobby. Record review revealed, on 03/06/2022 at 3:00 PM, the facility found Resident #3 on the floor beside his/her bed. The resident informed staff he/she had been trying to sit up straighter in the bed and rolled out of it. Further review revealed the immediate intervention was for Resident #3's manual bed to be replaced with an electric low bed. Review of the IDT's recommendation revealed the resident's manual bed was to be replaced with an electric low bed, with the remote placed near the foot of his/her bed to prevent Resident #3 from placing the bed too high. Continued review revealed the Care Plan was revised/updated on 03/07/2022, with the immediate and recommended intervention for the electric low bed. Record review revealed, on 04/26/2022 at 5:53 PM, the resident fell from his/her wheelchair while alone in his/her room after the dinner meal. Resident #3 had attempted to self transfer onto his/her bed. Per review, the immediate interventions implemented were for signs to be posted for the resident to use the call light to call for help, place the call light close to the resident when he/she was out of bed, and place gripper socks on the resident's feet when he/she got up out of bed. Review of the IDT's recommendation revealed staff were to place the resident back to bed after all meals, and to have his/her medications reviewed. Care Plan review revealed it was revised/updated on 04/26/2022, with the immediate and recommended IDT interventions. Record review revealed, on 05/26/2022 at 11:30 PM, the resident was found on the floor beside his/her bed, and told staff he/she just fell out of bed. Continued review revealed Resident #3 had his/her electric low bed at the time of this fall. Further review revealed the immediate interventions implemented included: placing the resident's bed in the lowest locked position and remind him/her to call for assistance. This intervention had previously been noted on Resident #3's Care Plan on 07/22/2021 and 10/29/2021. Record review revealed this intervention had not been effective for the resident. Review of the IDT's recommendation revealed Resident #3's room was to be re-configured with the bed repositioned in the room. Care plan review revealed it was revised/updated on 05/27/2022, with immediate and IDT's recommended interventions. Observation of and interview with Resident #3 on 06/08/2022 at 3:00 PM, revealed the resident was sitting up in his/her wheelchair watching television with no staff present. However, review of Resident #3's care plan revealed an intervention implemented on 07/26/2021 for staff to assist the resident to bed after meals and activities. During interview with Resident #3, he/she stated when he/she pushed the call light and staff came to answer it, They stand there like they have their finger up their ass a lot of times. Interview with Certified Nursing Assistant (CNA) #2, on 06/15/2022 at 2:30 PM, revealed Resident #3 was to be checked on every two (2) hours; however, she checked on the resident more often because he/she scoots around in bed. However, review of Resident #3's Care Plan revealed an intervention dated 07/26/2021, for the resident to be visualized by staff every hour. Per interview, when staff got Resident #3 up, he/she tried to lay right back down down. According to CNA #2, Resident #3 could be a determined individual, and yelled and cursed at staff when they provided care for him/her, then laughed about it later. Further interview revealed Resident #3 knew how to use his/her call light, but chose not to use it. Interview with CNA #9, on 06/15/2022 at 2:45 PM, revealed she had provided care for Resident #3 in the past. Per CNA #9, when she had cared for Resident #3 in the past, the resident transferred with assistance of one (1) staff person. Continued interview revealed staff had to watch Resident #3 because the resident thought he/she was able to walk, but could not walk. CNA #9 further stated when she cared for Resident #3 previously, she had rounded on the resident every two (2) hours like the care plan said. However, review of Resident #3's care plan noted an intervention, dated 07/26/2021, for staff to visualize the resident every hour. Observation and interview with Resident #3, on 06/15/2022 at 3:00 PM, revealed the resident was lying on his/her bed. When the State Survey Agency (SSA) Surveyor interviewed Resident #3 regarding the details of his/her fall that resulted in the facial and left arm fractures, the resident answered in a nonsensical manner. When the SSA Surveyor inquired how Resident #3's wrist was fractured, the resident stated, I was going for the train, walking .I lost my balance, and put my hand down to break my fall. I was sent to the hospital. The Doctor put a bandage on my arm, and I took the bandage off when I got home. Interview with CNA #8, on 06/15/2022 at 3:20 PM, revealed she was supposed to check on her residents at least every two (2) hours with rounds; however, she looked in on Resident #3 more often than that because, I know how (he/she) is. Per CNA #8, she looked in on the resident every time she went down the hall, and also did that for all her residents. Review of the resident's Care Plan revealed staff were to visualize him/her every hour. Further interview revealed she always got another staff member to help her when transferring Resident #3 as the resident got busy fidgeting when being transferred. Interview with Licensed Practical Nurse (LPN) #3, on 06/15/2022 at 3:45 PM, revealed staff checked on Resident #3 often because he/she squirmed around in the bed. Further interview revealed she looked into Resident #3's room every time she walked down the hall. LPN #3 stated that was why Resident #3's bed had been placed against the wall facing the door, so staff could visualize him/her. Interview with CNA #4, on 06/16/2022 at 10:30 AM, revealed Resident #3 was care planned to be checked on every two (2) hours. However, review of the resident's care plan revealed he/she was to be visualized by staff every hour. Per interview, CNA #4 looked in on Resident #3 more often because of the way the resident was. CNA #4 stated at the time of Resident #3's fall on 10/27/2021, the resident was an assist of one (1) person for transfers. Further interview revealed Resident #3 liked to turn sideways in the bed and always leaned towards the side of the bed. Interview with CNA #6, on 06/16/2022 at 1:00 PM, revealed when Resident #3 fell on [DATE], she had been the one (1) who found the resident lying on the floor. CNA #6 stated when she found the resident lying on the floor, she immediately went to get the Nurse on duty and another CNA. Continued interview revealed the three (3) of them got the resident back to bed. Further interview revealed CNA #6 stated a team decision was made to move the left side of Resident #3's bed against the wall, because the resident was always leaning towards that side of the bed. Interview with CNA #7 on 06/16/2022 at 1:25 PM, revealed Resident #3 moved a lot when lying on his/her bed, and moved around sideways in the bed. Per CNA #7, on 06/12/2022, a co-worker came and got her because Resident #3 was found lying on the floor beside his/her bed. Continued interview revealed Resident #3 was mad about sliding off his/her bed onto the floor, but he/she would not tell staff what he/she had been doing that caused the fall. CNA #7 stated staff decided to move the left side of Resident #3's bed against the wall. Interview with the Director of Nursing (DON) and Assistant DON on 06/22/2022 at 3:30 PM, revealed the interventions to remind and educate Resident #3, were the type of interventions they would be trying very hard to move away from. Per interview, when Resident #3's BIMS' score was eleven (11) he/she continued to be impulsive and did not think he/she required assistance from staff. Further interview revealed the facility would be re-evaluating Resident #3's perimeter mattress, and would find another perimeter mattress that would better fit his/her needs. 2. Review of Resident #5's closed medical record revealed the facility admitted him/her on 01/29/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #5's Quarterly MDS Assessment, dated 05/04/2021, revealed the facility assessed the resident with a BIMS score of three (3) which indicated severe cognitive impairment. Additional review of Resident #5's closed medical record revealed the resident experienced twenty (20) unwitnessed falls from 01/30/2021 to 05/05/2021. Continued review revealed the fall Resident #5 experienced on 04/15/2021, resulted in a laceration to the back of the resident's head. Record review revealed this fall required transfer to the hospital where he/she received staples to close the laceration. Further review revealed Resident #5 was discharged from the facility on 05/06/2021, to a sister facility with a dedicated Alzheimer's unit. Review of Resident #5's 01/29/2021, Baseline Care Plan revealed a Risk for Falls care plan had been developed related to the resident's decreased safety awareness, impaired cognitive function, [CONDITION(S)], history of falls, and impulsive behavior. Review of the resident's Comprehensive Care Plan revealed the facility updated/revised Resident #5's care plan. Interventions included: on 02/05/2021, the resident was to wear non-skid footwear; on 02/06/2021, Resident #5 was to have floor mats placed beside the bed; an intervention on 02/07/2021, was noted for Resident #5 to be placed in high traffic areas when up in his/her wheelchair. Continued review of Resident #5's Comprehensive Care Plan revealed an intervention, dated 03/01/2021, to remind him/her to use the call light; an intervention dated 03/06/2021, fall mats were added; and, on 03/07/2021, an intervention was added for Dycem to the resident's wheelchair. Further review of the care plan revealed an intervention, dated 04/21/2021, for the resident to have a lap buddy (a device that acted as a reminder for the resident to ask for assistance before attempting to get up out of the wheelchair); an intervention dated 05/03/2021, for a self-release belt to be added to the resident's wheelchair; and an intervention dated 05/05/2021, for one to one (1:1) supervision of the resident twenty-four (24) hours per day, seven (7) days a week. Closed record review revealed Resident #5 experienced an unwitnessed fall on 01/31/2021, and staff found the resident on the floor in the doorway of his/her room. Further review revealed the facility assessed Resident #5 to have no injury. Review of Resident #5's Care Plan revealed an intervention for the resident to have a sensor pad alarm placed on his/her bed on 01/30/2021, with the same revision noted after his/her fall on 01/31/2021. Closed record review revealed Resident #5 experienced an unwitnessed fall on 02/05/2021, and was found by staff lying on the floor in front of his/her closet. Continued review revealed Resident #5 had been in bed and gotten up unassisted to try to change his/her clothes, no injury was noted. Further review revealed no documentation that Resident #5's bed alarm was on and working at the time of the fall. Review of the resident's Care Plan revealed an intervention for Resident #5 to have non-skid footwear was added on 02/08/2021. Closed record review revealed Resident #5 experienced an unwitnessed fall on 02/07/2021, and was found lying on the floor. Continued review revealed Resident #5 attempted to go to the bathroom without assistance at the time of the fall. Further review revealed no documentation that Resident #5 had his/her non-skid footwear on at the time of the fall. Review of Resident #5's Care Plan revealed the facility implemented an intervention on 02/15/2021, for the resident to be placed in a high traffic area when up in his/her wheelchair. Closed record review revealed Resident #5 experienced an unwitnessed fall from his/her bed on 02/26/2021. Further review revealed no documentation that Resident #5's bed alarm was on and working at the time of the fall. Review of Resident #5's Care Plan revealed the facility implemented an intervention on 02/26/2021, for signage to be placed in the resident's room to remind him/her to use the call light. However, this intervention was implemented for Resident #5, whom the facility had assessed as severely cognitively impaired. Closed record review revealed Resident #5 experienced an unwitnessed fall, on 03/06/2021, and was found by staff lying on the floor on his/her back, with no injury assessed. Further record review revealed no documentation why Resident #5 was left in his/her room instead of in a high traffic area as per the Care Plan. In addition, record review further revealed no documentation that Resident #5's sensor alarm pad was in place and working, and no documentation that the resident had his/her non-skid footwear on at the time of the fall, as per the Care Plan. Review of the Care Plan revealed it was revised on that date with an intervention for a fall mat to be placed on the floor beside his/her bed. Continued review revealed the fall mat intervention was also noted as an intervention implemented on 02/06/2021. Closed record review revealed Resident #5 experienced an unwitnessed fall on 04/01/2021, and was found by staff lying on the floor on the right side of his/her bed. Further record review revealed no documentation that Resident #5's sensor pad alarm was in place and working at the time of the fall. Review of Resident #5's Care Plan revealed the facility noted an intervention for the resident to be transferred to alternative placement, due to not being able to meet his/her needs. Closed record review revealed Resident #5 experienced an unwitnessed fall, on 04/03/2021, and was found by staff lying on the floor beside his/her bed. Further record review revealed no documentation that Resident #5's sensor pad alarm was present and functioning at the time of the fall. Review of Resident #5's Care Plan revealed the facility implemented an intervention on 04/03/2021, to educate staff to ensure Resident #5's bed alarm was on and functioning Additional closed record review revealed, on 04/15/2021, Resident #5 experienced another unwitnessed fall and was found on the floor in his/her room with a laceration assessed to the back of his/her head. Further review revealed the facility transferred Resident #5 to the hospital emergency room (ER) where he/she received staples to close the laceration on the back of his/her head. Review of Resident #5's Care Plan revealed the facility implemented an intervention for staff to continue to remind resident not to stand or transfer alone. However, the facility had assessed Resident #5 as severely cognitively impaired. Review of a Progress Note for Resident #5, dated 04/30/2021 at 10:47 AM, documented by the former Social Services Director (SSD), revealed a care plan meeting had been held involving the resident, his/her daughter, nursing staff, the former DON, the former Assistant Director of Nursing (ADON), the former MDS Coordinator, the former SSD, and therapy staff. Per review of the Progress Note, the former DON stated that Resident #5 had experienced nineteen falls since his/her admission on 01/29/2021. She stated with each fall Resident #5 declined a little bit more. Continued review of the Progress Note revealed the DON informed those present, that the facility had put alarms, and floor mats in place for Resident #5, and attempted a lap buddy, but the resident refused that intervention. Review of the Progress Note revealed the facility would try a seat belt alarm for Resident #5 when he/she was up in the wheelchair, that he/she would be able to remove. Further review of the Progress Note, dated 04/30/2021 at 10:47 AM, revealed Resident #5 required one to one (1:1) care which the facility could not provide; however, the DON offered the family options. Continued review of the Progress Note revealed the options offered to the family included: the family could hire a sitter for Resident #5; or the facility could send a referral to facilities with a memory care unit that had the capability for the 1:1 staffing the resident needed. Review of the Progress Note revealed the DON offered several facilities for the referral to be sent. The family agreed to send referrals to the facilities that were not to far away. Interview, on 06/22/2022 at 3:30 PM, with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) revealed most of the staff that had worked at the facility when Resident #5 resided there, were agency staff. Per interview, the facility had looked at the use of pressure alarms for residents, and had found them to be ineffective because the residents were always moving around causing the alarms to constantly go off. The DON stated many pressure alarms had been removed and in time she hoped all pressure alarms would be removed. Per the DON, reminding cognitively impaired residents to call for assistance would not be an effective intervention for those residents. According to the DON, as most of the staff currently working at the facility were new, if a resident experienced a fall, the Interdisciplinary Team (IDT) was taking a closer look at each resident's care plan in order to determine the best interventions. Interview with former MDS Coordinator #23, on 06/23/2022 at 4:15 PM, revealed she was not familiar with Resident #3 because she had only worked at the facility for a few months. Continued interview revealed the current staff had replaced the agency staff who had been working there in the past. Further interview revealed there had been several MDS staff and Social Services staff in those positions over the last eighteen (18) to twenty-two (22) months. In addition, MDS Coordinator #23 stated there had also been a change in the Administrator and the DON. Interview with the facility's current MDS Coordinator #22, on 06/23/2022 at 4:30 PM, revealed she went to the facility's clinical meetings held after residents' falls, and updated their care plans while participating in the meeting. Per MDS Coordinator #22, she also attended the facility's IDT meetings and also updated residents' care plans during that meeting. Continued interview revealed the staff present in the IDT meetings went over the residents' falls. She stated she checked their care plan to see what interventions were in place, and what might be needed to be changed or added to the care plan. Further interview revealed she followed the facility's policy and procedures regarding falls and accident/incidents. The MDS Coordinator further revealed she followed the Centers for Medicare and Medicaid Services' (CMS) Resident Assessment Instrument manual when completing residents' care plans. Interview, on 06/28/2022 at 10:00 AM, with the facility's Administrator (who was also serving at the facility's current DON) revealed the IDT meetings included department heads. Per the Administrator, the IDT went over residents' falls, and assessed them to identify the root cause of the fall. Continued interview revealed the IDT looked at residents' care plans during the meeting and reviewed the current interventions in place, then tried to put an appropriate intervention in place for the current fall. Interview revealed the facility had provided education for staff related to residents' falls with a focus on ensuring the root cause of the fall was determined, and appropriate interventions implemented. Further interview revealed the Administrator and IDT ensured the Post Fall Reviews were completed for review. Interview further revealed if nursing staff were unsure about what interventions were needed they called the DON or ADON for guidance and/or assistance. In addition, the Administrator revealed the facility had a falls box in place for staff to utilize which contained different interventions to use such as Dycem, touch call light pads, non-skid strips, etc.

Based on observation, record review, interview, and facility policy review it was determined the facility failed to implement an effective infection control program for eight (8) of eight (8) sampled residents (Residents #1, #2, #3, #4, #5, #6, #7, and #8). Residents #1 through #7 were on isolation precautions and/or received [MEDICAL TREATMENT] offsite; however, there was no personal protective equipment (PPE) available in room/on the door/or outside the door for easy access. In addition, a staff failed to don gown, gloves, and shield per facility policy while providing Occupational Therapy to Resident #3 ([MEDICAL TREATMENT]) and care for Resident #8 at the time he/she was readmitted to the facility. Furthermore, staff failed to set up PPE for Resident #8 outside resident room when readmitted from acute care facility. The findings include: Review of facility policy titled, Guidelines for Care of In-House Residents with Known or Suspected COVID-19, not dated, revealed residents with known or suspected COVID-19 would be placed in droplet isolation and should be housed in the same room for the duration of stay to minimize room transfers and decrease spread of infection. Resident doors should remain closed as safety of the resident allows and the curtain be pulled between those who are sharing a room at all times. The designated unit shall have designated equipment such as blood pressure cuff, thermometer, pulse oximeter, etc.; and be properly cleaned between use. Review of facility documents titled, Provider Guidance Memo: Admission, Discharge, and Transfer for Long-Term-Care Facility (LTCF) Residents, dated 08/28/2020 revealed if resident was without a history of COVID-19 and without COVID-19 symptoms, quarantine and monitor the resident for COVID-19 signs and symptoms for fourteen (14) days following admission. Wear facemask, eye protection and perform hand hygiene for all caregiver-resident interactions; and gowns and gloves for any activity involving close contact with the resident or the resident's environment. Review of facility policy titled Guidelines for All Masks and other PPE, not dated, revealed full PPE should be worn per Center for Disease Control (CDC) guidelines for the care of any resident with known or suspected COVID-19 per CDC guidance on conservation of PPE. Review of facility documentation of Use of Personal Protective Equipment (PPE) when caring for patients with confirmed or suspected COVID-19 from the CDC dated 03/03/2020, revealed PPE must be donned before entering the patient area, and must remain in place and be worn correctly for the duration of work in potentially contaminated areas. Review of facility documents titled, Interim Infection Prevention and Control Recommendation for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings from the CDC (Section #5), not dated, revealed heath care professionals (HCP) who enter the room of a patient with known or suspected COVID-19 should adhere to Standard Precautions and use a respirator or facemask, gown, gloves, and eye protection. When available respirators instead of face masks were preferred. Dedicated medical equipment should be used when caring for patients with known or suspected COVID-19. 1. Review of the facility Center for Medicaid Services (CMS) 802 revealed Residents #1, #2, #3, #4, #5, and #6 were on transmission based precautions. In addition, the CMS 802 revealed Resident #1, #2, and #7 received [MEDICAL TREATMENT] offsite. However, observation on initial tour on 12/16/2020, beginning at 11:25 AM, revealed there was no PPE at entrances to Residents #1, #2, #3, #4, #5, #6, and #7's rooms to provide easy access to the supplies needed. Further observation revealed there were trash bins in the rooms with red trash bags in them. Further observation on 12/16/2020 at approximately 12:32 PM, while at Resident #2 ([MEDICAL TREATMENT] patient) and Resident #3's room with Certified Nurse Aide (CNA) #1, revealed an Occupational Therapist was providing hands on therapy with Resident #3 while wearing only a mask. She had no gown and/or gloves on. There was no PPE outside or inside room and interview with CNA #1 at that time, revealed when there was no PPE at door of rooms, staff had to go to Central Supply to get PPE, and had to sign it out. Interview and observation, on 12/16/2020 at 12:40 PM, with Central Supply (CS) personnel, revealed she unlocked the supply room door with her keys. Review of the sign-out clipboard in the room revealed there had been no PPE (gowns, gloves, shoes, disinfectant wipes, or shoe covers) signed out for use that day. She stated if there were residents on isolation she would have expected there to be some PPE signed out for use, but there was not. In addition, the CS personnel and State Surveyor observed an empty PPE storage bin on Resident #7's door (a [MEDICAL TREATMENT] patient). The CS personnel stated the storage bin needed restocking of gowns and gloves. Interview with the Occupational Therapist (OT), on 12/16/2020 at 2:25 PM, revealed she thought since Resident #3 had been at the facility for a long time it was not necessary to wear the PPE (gown, gloves, shield). Interview with Rehab Director on 12/16/2020 at approximately 3:26 PM revealed she expected her staff to wear proper PPE (gown , gloves, face-shield, and mask). She stated she expected the PPE to be readily available for usage at the room. Interview on 12/16/2020 at approximately 12:20 PM with CNA #1 revealed Resident #1 was a new admit and on isolation precautions for fourteen (14) days in case he/she has COVID-19. She stated staff have to gown up (wear PPE such as gown, gloves, and mask) prior to entering room and the PPE was supposed to be on door or staff should obtain from hallway closet. Observation of closet on hallway revealed storage bins tossed behind a linen cart and some storage bins tossed against a back wall with no PPE available within them. Interview on 12/16/2020 at 2:15 PM, with Certified Medication Technician (CMT) #1, revealed PPE was the responsibility of the charge nurse and if there was none in the linen closet they would have to go with the charge nurse to central supply for PPE. Interview with Licensed Practical Nurse (LPN) #1, on 12/16/2020 at 12:55 PM, revealed Resident #1, #2, #6, and #7 were on isolation precautions due to [MEDICAL TREATMENT]. LPN #1 stated it was the nurses/or the admitting nurses responsibility to fill the PPE storage bins with the needed PPE and it had not been done that day. She revealed the PPE should be used upon entrance into the [MEDICAL TREATMENT]/or new admits room. Additionally, LPN #1 stated the equipment used for vital signs (stethoscope, blood pressure cuff, pulse oximeter, thermometer) should be in the room and/or outside the door to check vital signs (VS), because of precautions for infection control. 2. Observation on 12/16/2020 at 2:05 PM, revealed Resident #8 being brought into his/her room by Emergency Medical Technicians (EMT) via a stretcher. LPN #4 and CNA #2 were going in and out of the room only wearing masks. At approximately 2:15 PM, LPN #4 and CNA #2 were observed straightening bed linens for Resident #8 to get into bed with just masks being worn. The LPN and CNA were not wearing gowns and there was no PPE on or outside the resident's room. Further observation on 12/16/2020 at 4:30 PM, revealed Resident #8's room still had no PPE on door, in the storage bin, or within the perimeter of Resident #8's room. Interview with CNA #2, on 12/16/2020 at 2:50 PM, revealed the nurses had to unlock the Central Supply door to get PPE for staff. CNA #2 stated if resident had signs or symptoms of COVID 19, then the resident needed to be on isolation. She revealed Resident #8 had been to the hospital and was just coming back to the facility. Interview with LPN #4, on 12/16/2020 2:00 PM, revealed Resident #8 was a readmit. He stated a new admit was supposed to quarantine for fourteen (14) days and he was supposed to put gowns, gloves, blood pressure cuffs, and stethoscope on door for readmits related to the possibility of being COVID positive. He revealed he was not sure about [MEDICAL TREATMENT] residents. LPN #4 stated he had not been told what kind of precautions residents were on so he assumed droplet and that was about all he knew. Interview with LPN #2/Charge Nurse, on 12/18/2020 at 2:29 PM, revealed residents that came to the facility as new admits, or go out to the emergency room and return were placed on isolation for fourteen (14) days. LPN #2 stated if residents go out of facility for [MEDICAL TREATMENT] they stayed in isolation. She revealed Resident #8 should have been on isolation when he/she arrived. LPN #2 revealed there was an inservice for this the night of the initial FICS (Focused Infection Control Survey). She revealed she did not know why the PPE was not available on the doors for the staff to provide care to the residents; and this could result in possible transmission of infections. LPN #2 stated the charge nurse was responsible for hanging PPE on the door, if not available, and she had tried to keep up with it, but with no PPE on the doors she stated it looked like a fail to her. LPN #2 stated the ADON, the DON, and the Administrator would be who monitored to ensure the Charge Nurse was keeping the items restocked. Interview with Assistant Director of Nursing (ADON), on 12/16/2020 at 1:30 PM, and on 12/18/2020 at 3:09 PM, revealed PPE and the equipment should be available to staff to prevent staff from getting an infectious disease from the resident and the resident from getting one from staff. The ADON stated the admitting nurse should have ensured the needed PPE and equipment was available in the room or on the door. She revealed there was no Infection Control Nurse (IFCN) and no one assigned to perform the ICFN's duties. She stated a couple of nurses have tried to work on it, out of the kindness of their hearts, but no one was overseeing infection control, at this point and time. Additionally, the ADON stated when a resident returned to the facility he/she should be placed on isolation precautions and PPE placed on resident's door at that time. Interview and observation tour on 12/16/2020 at 1:02 PM, and at 12/18/2020 at 1:29 PM, with acting Director of Nursing (DON), revealed if a resident was on [MEDICAL TREATMENT] or was a new admit, they should have PPE in the storage bin or on the door (gown, gloves, and face-shield). The acting DON stated it was the charge nurse or the admitting nurse's responsibility. She revealed there should be equipment in the rooms to take the residents vital signs for each resident on isolation, and these things should always be there because of the possibility of cross-contamination. The DON stated there was no IFCN and she was not covering those duties. The DON further revealed residents on transmission based isolation precautions required staff to wear PPE anytime they provided care to the resident. She stated the PPE should be on door or just inside the door. The DON stated the IFCN was responsible to ensure PPE hung on doors, but the facility did not have one at this time, so the responsibility fell on herself or the ADON. She revealed this failure could result in something contagious being spread to staff and residents. The DON stated the monitoring should be a group effort with CNA's, therapy, etc. reporting when there was no PPE available at the doors to nurse. Interview upon entrance to the facility on [DATE] at 11:15 AM and on 12/17/2020 at 3:04 with Administrator revealed the facility had no IFCN. The Administrator stated an IFCN and new DON would be starting in two (2) weeks. She revealed the ADON was doing the tracking and trending of infections since IFCN left and LPN #2 was helping with oversight along with the ADON, since the SDC left approximately two months ago.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to treat each resident with respect, dignity, and care in a manner and environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for one (1) of seventeen (17) sampled residents, (Resident #13). Observations revealed the facility failed to ensure Resident #13's urine drainage tubing was not visible by visitors, and other residents in the hallway. The findings include: Review of the facility's policy titled, Promoting/Maintaining Resident Dignity, dated 08/15/2020, revealed it is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment that maintains or enhances resident's quality of life by recognizing each resident's individuality. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights. Record review revealed the facility admitted Resident #13 on 02/03/18 with [DIAGNOSES REDACTED]. Review of Resident #13's Annual Minimum Data Set (MDS assessment, dated 07/02/2020, revealed the facility assessed Resident #13's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of one (1), which indicated the resident was not interviewable. Review of Section H: Bladder and Bowel revealed the resident had an indwelling urinary catheter. Observations on 09/15/20 at 11:04 AM; 09/16/2020 at 8:30 AM and 1:30 PM; 09/17/20 at 9:06 AM and 09/17/20 at 11:06 AM, revealed Resident #13's urine drainage tubing was exposed and visible to visitors and other residents in the hallway on the West Unit. Resident #13's urine characteristics were straw colored, cloudy, with moderate amount of sediment noted at base of catheter drainage tubing. Observation of Resident #13's catheter care, on 09/17/20 at 11:06 AM, which was performed by State Registered Nurse Aide (SRNA) #2 revealed the resident's catheter tubing was not secured to a leg bag. Interview with SRNA #2 on 09/17/20 at 1:40 PM revealed Resident #2's urine catheter tubing should not be visible for others to see urine in drainage tube. She stated the urine drainage tube should be positioned by staff to ensure others can not see the urine in tubing and should be secured to a leg bag however, the resident refuses to wear a leg bag. Interview with Registered Nurse (RN) #1, on 09/17/20 at 1:45 PM, revealed Resident #13's urine drainage tube should not be visible for others to see and should be positioned under the resident's covers. She stated that all staff performing the resident's care was responsible to ensure the catheter drainage tubing was secured properly and not visible for others to see. Interview with the Director of Nursing (DON), on 09/17/2020 at 3:05 PM, revealed she would expect the residents urine drainage bag to be secured in a dignity bag however, she did not have a concern with the resident's urine drainage tubing being visible to others.

Based on observation, interview, record review and facility policy review, it was determined the facility failed to implement a comprehensive person-centered care plan for two (2) of seventeen (17) sampled residents, (Resident #10 and #13). The facility failed to implement the care plan for Resident #10 related to securing the catheter tubing to prevent trauma and pain; and, Resident #13 related to weekly weights. The findings include: Review of the facility policy titled, Care Plans, Comprehensive Person-Centered Policy, last revised December 2016 revealed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The comprehensive, person-centered care plan will include measurable objectives and timeframe. Record review revealed the facility admitted Resident #10 on 12/10/19 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed Resident #10's cognition as moderately impaired with a Brief Interview of Mental Status (BIMS) score of eight (8) which indicated the resident to be interviewable. Review of the Comprehensive Care Plan for [MEDICAL CONDITION] Bladder dated 12/17/19 revealed an intervention that the resident will be/remain free from catheter-related trauma; however, observation of catheter care on 09/16/2020 at 3:55 PM revealed there was no device that secured the catheter tubing to the thighs or abdomen. Further observation revealed when the catheter was moved, the resident yelled out in pain and he/she revealed that it hurt when moved. Interview with Resident #10 on 09/17/2020 at 8:44 AM revealed he/she would want the catheter anchored to his/her thigh if it would keep it from hurting. Interview with State Registered Nurse Aide (SRNA) #1 on 09/17/2020 at 1:16 PM revealed she was not sure what the Care Plans for the resident said. Interview with Licensed Practical Nurse (LPN) #1 on 09/17/2020 at 9:10 AM revealed the Care Plan should reflect the care given to the resident. Interview on 09/17/2020 at 2:19 PM with the Assistant Director of Nursing (ADON) revealed the care plan should be followed by staff. Surveyor:(NAME) Beanita 2. Record review revealed the facility admitted Resident #13 on 04/18/18 with [DIAGNOSES REDACTED]. Review of Resident #13's Annual Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #13's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of one (1), which indicated the resident was not interviewable. Review of Resident #13's Comprehensive Care Plan titled, Nutritional Problem or Potential Nutritional Problem related to Recent [MEDICAL CONDITIONS] with Chewing /Swallowing Impairment, dated 02/05/18, revealed an intervention, added by the Registered Dietician, dated 08/05/19, to obtain weekly weights. However, review of Resident #13 weights record revealed there was no documented evidence the resident's weight was obtained after 08/27/2020 through 09/16/2020 (two {2} days shy of three {3} weeks}. Interview with SRNA #2, on 09/17/20 at 1:40 PM, and Assistant Director of Nursing on 09/17/2020 revealed the SRNA's are responsible to obtain resident weights, and the Assistant Director of Nursing (ADON) is responsible to document weights in the resident's medical record. SRNA #2 and ADON stated Resident #13's weight should have been obtained per care plan. The ADON stated she was not sure as to why the weights were not obtained per care plan. Interview with the Director of Nursing (DON), on 09/17/2020 at 3:05 PM, revealed she would expect care plan interventions to be carried out. She stated Nurse Management is responsible to monitor and ensure interventions are implemented.

Based on observation, interview, record review, and facility policy review it was determined the facility failed to provide appropriate treatment and services for one (1) of four (4) residents with indwelling urinary catheters in the selected sample of seventeen (17) residents. Observation revealed the facility failed to ensure Resident #1's catheter tubing was secured to his/her upper thigh per facility policy to prevent urethra trauma. The findings include: Review of the facility policy, titled, Catheterization of a Male, last revised 08/15/2020 revealed urinary catheterizations will be performed in accordance with current standards of practice to minimize risk for bacterial contamination or urethral trauma. Further review of the policy revealed to secure catheter tubing to the resident's upper thigh. Record review revealed the facility admitted Resident #10 on 12/10/19 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed Resident #10's cognition as moderately impaired with a Brief Interview of Mental Status (BIMS) score of eight (8) which indicated the resident to be interviewable. Review of the Comprehensive Care Plan for [MEDICAL CONDITION] Bladder dated 12/17/19 revealed interventions to prevent catheter related trauma. Observation of catheter care for Resident #10 by State Registered Nurse Aide (SRNA) #1 on 09/16/2020 at 3:55 PM revealed the urinary catheter tubing was not secured to the resident's thigh per facility policy. Further observation revealed when SRNA #1 moved the catheter, the resident yelled out in pain and he/she revealed that it hurt when moved. Interview with Resident #10 on 09/17/2020 at 8:44 AM revealed if it would help keep the catheter from hurting, he/she would want the catheter anchored to his/her thigh. He/She stated he/she did not know why the tubing holder was not there. Interview SRNA #1 on 09/17/2020 at 1:16 PM revealed she did notice the resident did not have the catheter secured and the resident did not want it secured. She stated she was not sure what the policy stated related to securing urinary catheter tubing but she would ask the Director of Nursing (DON). She further revealed she was supposed to follow the facility policy. Interview with Licensed Practical Nurse (LPN) #1 on 09/17/2020 at 9:10 AM revealed she was one of the nurses on Resident #10's unit and if put in a indwelling urinary catheter, she always secures the tubing to the upper thigh. She revealed it would decrease pain and trauma with movement. Interview with DON on 09/17/2020 at 9:07 AM revealed she was unsure what the policy said but if it requires the tubing to be secured to leg, then she expects the catheter to be anchored per policy.

Based on interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of seventeen (17) sampled residents (Resident #13) maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise. The facility assessed Resident #13 had a significant weight loss in thirty (30) days; ninety (90) days; and one hundred and eighty (180) days; however, the facility failed to monitor the resident's weights weekly to try to prevent further decline per facility policy. The findings include: Review of the facility's policy titled, Clinically at Risk Program Guidelines dated 12/01/18, revealed every effort will be made to identify those residents who are clinically at risk and provide proactive interventions to manage their medical needs and minimize/eliminate further decline when possible. Criteria for residents who will be followed by the Clinically At Risk (CAR) team include residents who have experienced a significant weight change. Significant weight change is defined as a variance of 5% in 30 days; 7.5% in 90 days; or 10% in 180 days. Record review revealed the facility admitted Resident #13 on 02/03/18 with [DIAGNOSES REDACTED]. Review of Resident #13's Annual Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #13's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of one (1), which indicated the resident was not interviewable. Further review of the MDS assessment, Section G: Functional Abilities, revealed the facility assessed the resident required encouragement or cueing to feed self after staff set up his/her meal tray. Review of Resident #13's Physician Orders, dated 01/17/2020, revealed diet order for Regular diet with Puree texture, thin consistency, Frozen Nutritional Cup two (2) times a day with lunch and dinner, ordered on [DATE], and Glucerna 1.5 Cal liquid (Nutritional Supplements) give eight (8) ounces via Gastrostomy Tube (GT) five (5) times a day for supplement, dated 07/14/2020. Review of Resident #13's Comprehensive Care Plan for Nutritional Problem or Potential Nutritional Problem related to recent [MEDICAL CONDITIONS] with Chewing /Swallowing Impairment, dated 02/05/18, revealed an intervention for weekly weights which was added on 08/05/19 by the Registered Dietician. Review of Resident #13's Nutritional Assessment conducted by the Registered Dietician on 09/06/2020 revealed the resident was consuming only thirty-seven percent (37%) average of his/her pureed diet and thin liquids over past seven (7) days. Further review revealed recommendation to continue with Nutritional Plan of Care (POC) and continue with weekly weights. Review of Resident #13's weights revealed ten (10) percent weight loss in thirty (30) days (May to June 2020); nine (9) percent weight loss in ninety (90) days (June to August 2020); and fifteen (15) percent weight loss in one hundred eighty (180) days (March to August 2020). Further review revealed there was no documented evidence the resident's weights were obtained after 08/27/2020 until 09/16/2020 (19 days) later. Interview with State Registered Nurse Aide (SRNA) #2, on 09/17/20 at 1:40 PM, revealed it is the responsibility of the SRNA's to obtain residents weight. SRNA #2 stated the Assistant Director of Nursing (ADON) notifies the staff of weights needed, and after weights are obtained, the ADON documents the weight in the resident's medical record. Interview with the ADON, on 09/17/20 at 2:26 PM, revealed she is responsible to ensure weekly and monthly weights are obtained. The ADON stated she and/or the Unit Manager are responsible for documenting weights in the medical record. She stated I'm not sure why the weights were not obtained weekly as care planned and recommended by the Registered Dietician. She revealed she expected Resident #13 weights to be obtained and documented weekly because the resident receives bolus tube feedings five (5) times a day for nutritional supplement due to weight loss and was being assessed as Nutritionally At Risk. Interview with the Director of Nursing (DON), on 09/17/2020 at 3:05 PM, revealed she expected Resident #13's weights be obtained and documented in his/her medical record. The DON stated the ADON was responsible for documenting weights in the resident's medical record and weight was not given to the ADON to document. She further revealed the ADON is responsible to provide staff with a list of weights to obtain.

Based on interview, record review, review of facility Investigation information, and review of facility policy, it was determined the facility failed to report an allegation of abuse immediately, not later than two (2) hours after the incident was observed by staff member for one (1) of three sampled residents (Resident #1). Resident #1 was pushed down into a wheelchair by Licensed Practical Nurse (LPN) #1 on 10/15/19; however, Hospitality Aide (HA) #1 that observed the interaction failed to report the incident to supervisor per facility policy. The findings include: Review of the facility policy titled, Prohibiting Abuse, Neglect, Misappropriation and Exploitation, last revised November 2017, revealed staff shall immediately report any alleged incidents of suspected abuse to their supervisor and/or the Administrator. Any alleged incidences of abuse, neglect, misappropriation, exploitation, or incidents that you may have knowledge of must be reported immediately (not later than 2 hours if abuse or serious bodily injury, and twenty-four (24) hours if no abuse and does not result in serious bodily injury) to your supervisor and/or to the Administrator of the facility. Record review revealed the facility admitted Resident #1 on 12/01/17 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility timeline provided by the facility Administrator revealed HA #1 reported she observed LPN #1 push Resident #1 down into wheelchair on 10/15/19 during breakfast tray pass (between 6:45 AM and 7:30 AM). Further review revealed HA #1 did not report the allegation to the Administrator until 1:40 PM (approximately six (6) hours after the incident occurred). Interview with Hospitality Aide (HA) #1, on 11/18/19 at 1:06 PM, revealed she observed LPN #1 push Resident #1 down into wheelchair after being verbally redirected to sit down in the dining room while breakfast trays were being passed. HA #1 stated she could not decide if it was really abuse and did not report it until after lunch. Time line provided by the facility revealed the Administrator was notified at 1:40 PM. Interview with Certified Nurse Aide (CNA) # 2, on 11/18/19 at 11:33 AM, revealed she was assisting residents to eat in the dining room and heard Resident #1's chair alarm and turned around seeing LPN #1 heading to the resident so turned back around to continue with assisting residents and did not observe LPN #1 push resident down into chair but did not hear anything out of ordinary to turn around again. Interview with the Director of Nursing (DON) and time line provided by facility, on 11/18/19 at 2:29 PM, revealed incident was not reported to the Administrator until 1:40 PM and investigation was initiated. DON stated when HA #1 observed the incident and had any concern it should have been reported immediately to supervisor or Administrator. **The facility implemented the following actions to correct the deficient practice. 1. The DON and the Administrator terminated the HA #1 on 10/22/19 for failure to follow facility policy to report immediately. 2. On 10/15/19, the Staff Development Coordinator (SDC) completed training of all staff related to reporting abuse. 3. A Quality Assurance tool will be used for monitoring each allegation weekly for four (4) consecutive weeks, then monthly for two (2) months, to ensure allegations are reported timely. **The State Survey Agency validated the corrective action taken by the facility as follows: 1. Review of HA #1's personnel file revealed she was terminated from employment on 10/22/19. Interview with HA #1, on 11/18/19 at 1:06 PM, revealed she had been terminated. 2. Interview with the Staff Development Coordinator (SDC), on 11/18/19 at 11:14 AM, revealed she provided training on reporting abuse. She stated she started training on 10/15/19 and completed training with all staff by 10/16/19. Review of the training roster dated 10/15-16/19 revealed all facility staff were educated on the facility's Abuse Policy which included when to report. Interviews on 11/18/19 with Certified Nurse Aide (CNA) #1 at 11:24 AM, CNA #2 at 11:33 AM, CNA #3 at 1:48 PM, Assistant Director of Nursing (ADON) at 2:51 PM, LPN #2 at 2:08 PM, and Registered Nurse (rN) #1 at 2:19 PM revealed they were all educated on reporting of abuse immediately. 3. Interview with the Administrator, on 12/09/19 at 3:01 PM, revealed he has been using a Quality Assurance tool to review all allegations to ensure the allegations were reported timely per facility policy.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to implement a comprehensive person-centered care plan for two (2) of seventeen (17) sampled residents (Resident #48 and #9). Observations on 12/18/18, revealed staff failed to follow interventions to administer oxygen (O2) at 2 liters per minute (LPM) via nasal cannula for Resident #48 and #9. The findings include: Review of the facility's policy, Development of a Care Plan, not dated, revealed care plan interventions are to be implemented consistently as documented, unless the charge nurse and/or supervisor has been notified of circumstances which prevent implementation. 1. Record review revealed the facility admitted Resident #48 on 03/31/10 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 11/27/18, revealed the facility assessed Resident #48's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of three (3), which indicated the resident was not interviewable. Review of Resident #48's Comprehensive Care Plan, dated 09/23/13, revealed an intervention for O2 per physician's orders [REDACTED]. However, observation on 12/18/18 at 2:35 PM and 4:21 PM, revealed Resident #48's oxygen was on three (3) LPM per nasal cannula. 2. Record review revealed the facility readmitted Resident #9 on 09/20/18, with [DIAGNOSES REDACTED]. Review of the Significant Change MDS assessment, dated 10/04/18, revealed the facility assessed Resident #9's cognition as intact with a BIMS score of thirteen (13), which indicated the resident was interviewable. Review of Resident #9's Comprehensive Care Plan, dated 02/26/18, revealed an intervention for O2 per physician's orders [REDACTED]. However, observation on 12/18/18 at 3:27 PM, revealed Resident 9's oxygen concentrator was on 3 LPM. Interview with Registered Nurse (RN) #1 on 12/18/18 at 4:52 PM, revealed she expected the oxygen settings to be correct as per the physicians order for Residents #48 and #9. She stated she had not checked the settings on her shift, however, would have expected the settings to be correct. Interview with Licensed Practical Nurse (LPN) #1 on 12/19/18 at 10:18 AM, revealed she had checked Resident's #48 and #9 oxygen concentrators on 12/18/18 around 6:15 AM to 6:30 AM, and both concentrators were on 2 LPM. She stated oxygen should be administered at the prescribed rate. Interview with the Director of Nursing (DON) on 12/20/18 at 12:29 PM, revealed she expected the nurses to follow the care plan and physician orders. .

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to provide oxygen (O2) therapy according to the physician's orders [REDACTED].#48 and #9). Observations on 12/18/18, revealed staff failed to ensure Resident #48 and #9, received O2 at two (2) liters per minute (LPM) per the physician's orders [REDACTED]. The findings include: Review of the facility's policy, Respiratory Care Services Policy and Procedure, Oxygen Concentrator Management, not dated, revealed oxygen concentrators are used to effectively manage and maintain an electronically driven oxygen delivery system. The policy further revealed a physician's orders [REDACTED]. 1. Record review revealed the facility admitted Resident #48 on 03/31/10 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 11/27/18, revealed the facility assessed Resident #48's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of three (3), which indicated the resident was not interviewable. Review of Resident #48's Comprehensive Care Plan, dated 09/23/13, revealed an intervention for O2 per physician's orders [REDACTED]. Review of the physician's orders [REDACTED]. Review of the (MONTH) (YEAR) Treatment Administration Record (TAR) revealed to administer O2 at 2 LPM. Further review revealed the TAR had been initialed by Licensed Practical Nurse (LPN) #1 on 12/17-18/18, 7P-7A shift which meant O2 was observed in place at 2 LPM. There were no initials documented by Registered Nurse (RN) #1 for 12/18/18, 7A-7P shift. Observations on 12/18/18 at 2:35 PM and 4:21 PM, revealed Resident #48's oxygen concentrator was on three (3) LPM via nasal cannula. 2. Record review revealed the facility readmitted Resident #9 on 09/20/18, with [DIAGNOSES REDACTED]. Review of the Significant Change MDS assessment, dated 10/04/18, revealed the facility assessed Resident #9's cognition as intact with a BIMS score of thirteen (13), which indicated the resident was interviewable. Review of Resident #9's Comprehensive Care Plan, dated 02/26/18, revealed an intervention for O2 per physician's orders [REDACTED]. Review of the physician's orders [REDACTED]. Review of the (MONTH) (YEAR) TAR revealed to administer O2 at two (2) LPM via nasal cannula. Further review revealed the TAR had been initialed by LPN #1 on 12/17-18/18, 7P-7A shift which meant O2 was observed in place at 2 LPM. There were no initials documented by RN #1 for 12/18/18, 7A-7P shift. Observation on 12/18/18 at 3:27 PM, revealed Resident 9's oxygen concentrator was on 3 LPM. Interview with RN #1 on 12/18/18 at 4:52 PM, revealed she expected the oxygen settings to be correct as per the physician's orders [REDACTED].#9. She stated she had not checked the setting for her shift, however, would have expected the settings to be correct. Interview with LPN #1 on 12/19/18 at 10:18 AM, revealed the medication nurse is responsible for initialing oxygen settings on the TAR. She stated she had checked Residents #48's and #9's concentrators on 12/18/18 during the morning around 6:15 AM to 6:30 AM, and both concentrators were on 2 LPM. She revealed she initialed the TAR when she completed the treatments/observations and she did not check the concentrators again during her shift. She stated oxygen should be administered at the prescribed rate. Interview with the Director of Nursing (DON) on 12/20/18 at 12:29 PM, revealed she expected the nurses to check the oxygen settings at least once during their shift and periodically as they go in the resident's rooms during their shift. She stated she would expect the nurses to follow the care plan and physician orders.

Based on observation, interview and review of the facility's policy and procedure, it was determined the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Observation on 12/18/18 revealed hand sanitation was not being performed during the lunch meal. The findings include: Review of the facility's policy and procedure, titled Handwashing, not dated, revealed handwashing and hand antisepsis would be regarded by this facility as the single most important means of prevention of the spread of infections. The protocol included: 1. All personnel should follow the established handwashing and hand antisepsis procedures to prevent the spread of infection and disease to other personnel, residents and visitors. Observation of a Lunch meal pass 12/18/18 at 12 PM, revealed Certified Nursing Assistant (CNA) #4 did not wash or sanitize her hands prior to the first tray passed or throughout the remainder of the tray passes for five (5) or more trays. Interview with CNA #4 on 12/20/18 at 12:40 PM revealed she was aware of the facility's policy for appropriate hand hygiene during tray pass. She stated the policy was to wash hands prior to passing the first tray, use hand sanitizer between tray passes, and to wash hands after several tray passes. She stated she was aware she did not wash her hands during tray pass because she was nervous. Interview with the Director of Nursing (DON) on 12/20/18 12:50 PM revealed she expected staff to wash their hands prior to passing the first tray and to use hand sanitizer during tray pass.

Based on interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of three (3) sampled residents had the right to be free from misappropriation of property (Resident #1). On 12/24/17, Certified Nurse Aide (CNA) #1 misappropriated Resident #1's property (robe) from his/her closet and took it home. The findings include: Review of the facility policy titled, Resident Property Policy, not dated, revealed the facility shall not misappropriate resident property defined as the deliberate misplacement, exploitation of wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. Review of the facility policy Missing Items, not dated, for recording resident, family, and staff reports of missing items. Descriptions of the items are obtained and documented on the log located at the nursing station. The list is available for staff to review and be aware of items that cannot be located. Weekly a staff member is assigned to search room to room for items on the list as well as out of place items and return items to known owners. Laundry is also provided with the list to help identify misplaced items. Recovered items are marked off the list as they are returned to owners. Record review revealed the facility admitted Resident #1 on 08/25/17 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 01/17/18, revealed the facility assessed Resident #1's cognition as intact with a Brief Interview for Mental Status (BIMS) score of fifteen (15) which indicated the resident was interviewable. Review of facility final investigation report revealed Resident #1's spouse reported to Registered Nurse (RN) #1 the resident's bathrobe could not be located in his/her room on 12/26/17 at 9:00 PM. Resident #1 alleged CNA #1 removed something that looked like a robe from his/her closet on 12/24/17. Further review of the investigation revealed the Police were called and after taking report from Resident #1 went to CNA #1's home and recovered a robe which Resident #1 identified as his/her robe. Interview with Resident #1, on 01/22/18 at 2:55 PM, revealed the resident was awakened by CNA #1 when she walked into the room and removed an item from the closet. Resident #1 stated CNA #1 put what looked like his/her bath robe into a bag and left the room. Further interview revealed when Resident #1's family arrived to visit, he/she told them to look in closet at the bath robe and it was not to be found. Resident #1 stated the family reported the missing robe to staff and RN #1 came in to investigate the missing item. Interview with RN #1, on 01/24/18 at 1:28 PM, revealed Resident #1's spouse told her a bath robe was missing and thought it had been stolen on 12/26/17. RN #1 stated she questioned the resident to get a description of item and more details about the allegation. She also got a description of the staff member that Resident #1 thought had taken the bath robe. Interview with the Assistant Director of Nursing (ADON), on 01/23/18 at 12:49 PM, revealed through the investigation they determined Resident #1 observed CNA #1 remove an item from his/her closet, wrap it around her arm, and place it in a bag. The ADON stated the resident did not report the item missing until his/her spouse came to visit and could not find the bath robe in the room. The ADON stated she talked to the resident and started an investigation searching the building for the bath robe. The ADON revealed she notified the Administrator, Adult Protective Services (APS), Office of Inspector General (OIG), and the local police department. The ADON stated she tried to call CNA #1 without response, but took her off the schedule and ensured she would not be called in to work. She stated the police came to the facility, took the report, and questioned Resident #1. She revealed the Police Officer returned to the facility with a bath robe he recovered from CNA #1's home and confirmed with Resident #1 it did belong to him/her. Review of police investigation, dated 12/28/17, revealed the officer took report of the theft and a description from Resident #1 and the ADON. The Officer went to CNA #1's home and her husband found a robe that met the resident's description. Resident #1 identified the robe and it was returned to the resident undamaged. Interview with the Administrator, on 01/24/18 at 3:33 PM, revealed he was not present when incident occurred but was notified by the ADON of allegation and investigation. Through the investigation other interviewable residents were questioned if they had items missing. Staff were also questioned as to whether there was any resident property missing and none was reported. Staff denied any personal property of their own that had been missing from the facility. CNA #1 was terminated after investigation competed but had not returned to facility since working the evening of 12/24/17. **The facility implemented the following actions to correct the deficient practice: 1. CNA #1 was suspended on 12/27/17 while the facility investigated and terminated on 12/28/17 after Resident #1 identified the bath robe recovered by the Police from CNA #1's home. 2. The ADON asked interviewable residents on 12/27/18-12/28/17 if they had any property missing during the last weekend worked by CNA #1 with no missing items identified. 3. Abuse and Neglect training, to include misappropriation of property, was conducted on 12/27/17-12/28/17. No staff who was not at work on 12/27-28/17 will work until in-serviced in person or by phone. 4. The facility maintains a list of missing items at the nursing station that staff review daily and when missing items found, verified, and returned to resident the item is marked off the list. The Social Services Director is notified of items not found and referred to Administrator to be filed as complaint/grievance so the missing item can be investigated. **The State Survey Agency validated the facility's plan of action was carried out by: 1. Interview with ADON, on 01/23/18 at 12:49 PM, revealed CNA #1 was suspended during investigation and terminated based on findings. Review of CNA #1's personnel file revealed the CNA was suspended on 12/27/17 and terminated on 12/28/17 for Misappropriation of property. 2. Interview with ADON, on 01/23/18 at 12:49 PM, revealed she performed resident and staff interviews on 12/27-28/17 asking if any property or personal items was missing with none reported. The ADON provided a list of residents and staff interviewed by date from her investigation with responses. Interviews on 01/23/18 with CNA #2 at 9:32 AM, CNA #3 at 9:40 AM, CNA #4 at 9:45 AM, CNA #5 at 9:50 AM, CNA #6 at 9:55 AM, Hospitality Aide (HA) #1 at 10:05 AM, RN #2 at 10:10 AM, Licensed Practical Nurse (LPN) #1 at 10:20 AM, HA #2 at 10:35 AM, LPN #2 at 10:50 AM, and CNA #7 at 10:54 AM, revealed they had been asked if they were aware of any missing items and were not aware of any missing items that had not been recovered or replaced. 3. Review of Acknowledgement of training forms signed by employee signatures dated 12/27/17 through 01/03/18 verified all employees received training on Abuse and Neglect. Interviews on 01/23/18 with CNA #2 at 9:32 AM, CNA #3 at 9:40 AM, CNA #4 at 9:45 AM, CNA #5 at 9:50 AM, CNA #6 at 9:55 AM, Hospitality Aide (HA) #1 at 10:05 AM, RN #2 at 10:10 AM, Licensed Practical Nurse (LPN) #1 at 10:20 AM, HA #2 at 10:35 AM, LPN #2 at 10:50 AM, and CNA #7 at 10:54 AM, revealed they had training on Abuse and Neglect to include Misappropriation of Property on 12/27/17 either in person, by phone, or before returning to work after 12/27/17. 4. Interview with Director of Nursing, on 01/23/18 at 10:25 AM, revealed all items placed on the missing items list have been either found or location verified. Interview with Social Services Director, on 1/23/18 at 12:12 PM, revealed she is notified of missing items not located and given items that are out of place that have not been reported to determine who may own them. Interview with Activities Director (AD), on 1/22/18 at 1:19 PM, revealed she always asks about missing items related to resident rights and review of grievance process during resident council and has helped search for items reported. The AD stated most items are found in laundry, clothing pockets, or lost and found. Interview (Post Survey) with the Administrator, on 02/06/18 at 7:42 AM, revealed missing items reported have been recovered or located. He stated during his walk through and questioning of residents there have been no missing items that have been reported directly to him that were not found.

Based on observation, interview, record review, and facility policy review it was determined the facility failed to ensure services were provided by the facility as outlined by the comprehensive care plan for one (1) of five (5) sampled residents (Resident #7) requiring a lift. Resident #7 was care planned for two (2) staff to transfer the resident with a mechanical lift using a brown lift sling (extra-large); however, observation on 03/07/17 revealed Resident #7 was sitting on a large blue lift sling (large) and the Certified Nurse Aide (CNA) verified the resident had been transferred using the blue lift sling. The findings include: Review of facility policy, CNA Care Plan Record, dated 09/02, revealed the purpose of this form is to provide information to the nursing staff regarding residents' daily care needs as outlined in the Comprehensive Care Plan in accordance with the guidelines of the Resident Assessment Instrument (RAI) process. The nurse overseeing the resident's care will provide how much assistance the resident requires to transfer in/out of bed and chairs and include any assistive devices for mobility. In addition, by the CNA signing their name for a particular date and shift signifies the information was correct as outlined in the CNA care card. Record review revealed the facility admitted Resident #7 on 09/25/16 with [DIAGNOSES REDACTED]. Review of the type Quarterly MDS assessment, dated 02/21/17, revealed the facility assessed Resident #7's cognition as severely impaired with a BIMS score of three (3) which indicated the resident was not interviewable. Further review of the MDS revealed the resident required total assist with transfers. Review of the Activities of Daily Living (ADL) Care Performance Deficit Care Plan for transfers, dated 05/25/16; and, Certified Nurse Aide (CNA) Kardex (care plan), dated 03/07/17, revealed to use mechanical lift with assist of two (2) staff for transfers with a brown lift sling; however, observation on 03/07/17 at 8:13 AM and 9:00 AM revealed Resident #7 was sitting in a wheelchair with a blue lift sling underneath the resident. Interview with CNA #6, on 03/07/17 at 9:05 AM, revealed Resident #7 uses a blue lift sling for transfers and stated that a blue lift sling was used with Resident #7. CNA #6 then reviewed the CNA Kardex and verified staff should have used a brown lift sling. She stated she did not think Resident #7 was a brown lift sling as the resident had always been blue. The Director of Nursing (DON) walked by at the time and the CNA asked the DON about the conflict in the lift slings. The DON told CNA #6 she had been off sick; however, some assessments had been done and possibly the lift sling had been changed for Resident #7 and she would check. Interviews on 03/06/17 with CNA #4 at 2:55 PM and CNA #5 at 4:30 PM; and interviews on 03/07/16 with CNA #7 and #8 at 9:53 AM, revealed the staff know which lift sling to use on each resident by looking at the Kardex in the kiosk (facility computer system). Interview with Licensed Practical Nurse (LPN) #1 on 03/07/17 at 9:53 AM revealed she expected the CNAs to follow the Kardex. Interviews on 03/07/17 with MDS #1 at 1:39 PM and MDS #2 at 3:45 PM, revealed they expected the staff to follow the care plan. Interview with the Staff Development Coordinator, on 03/07/17 at 2:11 PM, revealed she instructed the CNAs to follow the Kardex. She stated if the staff are using the incorrect sling that is not approved for the resident there would be a risk of the resident falling in the hole in the lift. Interview with the Director of Nursing, on 03/07/17 at 2:23 PM, revealed she expected the CNAs and nurses to follow the care plan. Interview with the Administrator, on 03/07/17 at 3:15 PM, revealed she expected the staff to follow the care plan.

Based on observation, interview, record review, and review of the Mechanical Lift Operating Manual, it was determined the facility failed to provide adequate assistive devices to prevent accidents for five (5) of five (5) sampled residents related to the use of lifts (Residents #1, #2, #5, #6, and #7). The facility assessed Resident's #1, #2, #5, #6, and #7 for the appropriate sized mechanical lift sling on 03/02/17; however, review of Resident #1, #2, #5 #6 and #7's care plans and/or observations and interviews on 03/07/17, revealed the care plans were not updated with the appropriate sized lift sling and the wrong sized lift sling was used to transfer the residents. The findings include: Review of the Mechanical Lift Operating Manual, dated March 2007, revealed a warning label stating that before using the lift the resident must be assessed to determine which residents are suitable for transfer with the lift as well as the transfer technique to use, size of the sling, and the number of staff members required to transfer the resident. There are two methods of connecting the sling to the lift. Method one (1) is the Crossed Loop Connection which crosses the leg loops for one leg support through the leg loop closest to the leg support on the other side of the sling. The resident may be transferred in a sitting, half-lying, or lying position. The resident must have normal to rigid muscle tone, no injury or medical conditions that might be aggravated by the crossed loop connection transfer and be able to separate the knees comfortably during transfers, and have predictable, cooperative behavior. Method two (2) is the Crossed Leg Support Connection which crosses one (1) leg support under both of the resident's legs then cross the other leg support under both of the resident's legs. The resident may be transferred in a sitting, half-lying, or lying position. When transferring residents who have loose muscles with little tone, it is safest to transfer them in a lying position. The Crossed leg support connection is risky for the residents who bend forward while in the sling, as these residents should be transferred in a lying position with a one (1) piece amputee sling that has double safety belts. Furthermore, the lift slings are in different sizes. The sling should be long enough to fit from the patient's coccyx to the top of, or a few inches above, the resident's head and wide enough for the sling fabric to extend at least two (2) inches in front of the resident's anterior shoulder. A large sling has blue stabilizing handles and an extra-large has brown stabilizing handles. In addition, the lift transfer procedures revealed when transferring a resident from a bed to make sure the staff have the correct sling size and which method of connecting the sling to the hanger bars to be used. Ensure the correct number of staff are present for the transfer. 1. Record review revealed the facility admitted Resident #1 on 04/14/11 with [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set (MDS) assessment, dated 01/20/17, revealed the facility assessed Resident #1's cognition as intact with a Brief Interview Mental Status (BIMS) score of fifteen (15) which indicated the resident was interviewable. Further review of the MDS assessment revealed the resident was dependent on staff for transfers. Review of Resident #1's Activities of Daily Living (ADL) Self Care Performance Deficit Care Plan for transfers, dated 10/11/16, and Certified Nurse Aide (CNA) Kardex, dated 03/07/17, revealed the resident required two (2) to assist with transfer and to transfer with a mechanical lift using a brown lift sling (extra-large). Review of Resident #1's Transfer Assessment, dated 03/02/17, revealed the resident required extensive assist with transfers with the use of a mechanical lift, and two (2) staff should transfer the resident using mechanical lift Method two (2), with the resident in an upright/sitting position with a large blue sling. However, observation on 03/06/17 at 10:34 AM and 1:08 PM revealed Resident #1 was sitting in his/her wheelchair with a brown lift sling underneath him/her instead of a blue lift sling as assessed. Further review of Resident #1's Activities of Daily Living (ADL) Self Care Performance Deficit Care Plan for transfers, dated 10/11/16, and Certified Nurse Aide (CNA) Kardex, dated 03/07/17, revealed the care plan/kardex had not been update with the appropriate size lift sling. Interview with CNA #4, on 03/06/17 at 2:55 PM, revealed Resident #1 uses a brown lift sling for transfers. She stated that staff know which lift sling to use on each resident by looking at the kardex in the kiosk (facility computer system). 2. Record review revealed the facility admitted Resident #2 on 02/23/15 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 01/06/17, revealed the facility assessed Resident #2's cognition as intact with a BIMS score of fourteen (14) which indicated the resident was interviewable. Further review revealed the resident required extensive assist with transfers. Review of the ADL Self Care Performance Deficit Care Plan for transfers, dated 11/18/14, and CNA Kardex, dated 03/07/17, revealed the resident required use of a mechanical lift with a brown lift sling. Review of Resident #2's Transfer Assessment, dated 03/02/17, revealed for two (2) staff to transfer Resident #2 with a mechanical lift using a blue lift sling and mechanical lift Method one (1) with the resident in an upright position. However, observations on 03/06/17 at 10:40 AM and 2:08 PM and 03/07/16 at 8:04 AM, revealed Resident #2 was sitting with a brown lift sling underneath him/her. Further observation on 03/07/17 at 9:12 AM revealed CNA #7 and #8 transferred Resident #2 with the lift with a brown lift sling from the bed to the chair. Further review of the ADL Self Care Performance Deficit Care Plan for transfers, dated 11/18/14, and CNA Kardex, dated 03/07/17, revealed the care plan/kardex had not been updated with the appropriate size lift sling. Interview with CNA #7 and #8, on 03/07/17 at 9:15 AM, revealed Resident #2 uses the brown lift sling pad which is an extra-large. They both stated they look at the care plan to determine which sling to use for each resident. Interview with CNA #3 on 03/06/17 at 2:50 PM revealed Resident #2 uses the brown lift sling for transfers. 3. Record review revealed the facility admitted Resident #5 on 02/15/14 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 02/28/17, revealed the facility assessed Resident #5's cognition as moderately impaired with a BIMS score of eight (8) which indicated the resident was interviewable. Further review revealed the resident required extensive assist with transfers. Review of the ADL Self Care Performance Deficit Care Plan for transfers dated 10/17/13 and CNA Kardex, dated 03/06/17, revealed to use a mechanical lift with assist of two (2) with extra-large brown sling. Review of Resident #5's Transfer Assessment, dated 03/02/17, revealed the resident required two staff to transfer with Mechanical lift with a blue lift sling using mechanical lift Method two (2) with the resident in a reclined position. However, observation on 03/06/17 at 4:28 PM and 03/07/17 at 8:10 AM and 9:03 AM, revealed Resident #5 sitting in a wheelchair with a brown lift sling underneath her/him. Further review of the ADL Self Care Performance Deficit Care Plan for transfers, dated 10/17/13, and CNA Kardex, dated 03/07/17, revealed the care plan/kardex had not been updated with the appropriate size lift sling. Interview with CNA #4 on 03/06/17 at 4:25 PM revealed Resident #5 uses the brown lift sling pad for transfers. 4. Record review revealed the facility admitted Resident #6 on 06/20/11 with [DIAGNOSES REDACTED]. Review of the Significant Change MDS assessment, dated 02/05/17, revealed the facility assessed Resident #6's cognition as severely impaired with a BIMS score of three (3) which indicated the resident was not interviewable. Further review of the MDS revealed the resident required extensive assist with transfers. Review of the Resident #6's Transfer Assessment, dated 03/02/17, revealed the resident was required to be transferred by two (2) staff using a mechanical lift with a blue lift sling with the resident in the upright position; however, interview with CNA #4, on 03/06/17 at 4:25 PM, revealed Resident #6 went to the hospital today but uses a brown sling pad for transfers per the resident kardex. Review of the ADL Self Care Performance Deficit Care Plan for transfers dated 02/07/17 and CNA Kardex, dated 03/06/17, revealed to use a mechanical lift and assist of two (2) staff participation with transfers with use of brown sling. The facility had failed to update the resident care plan/kardex to ensure staff were aware to use the blue lift sling. 5. Record review revealed the facility admitted Resident #7 on 09/25/16 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 02/21/17, revealed the facility assessed Resident #7's cognition as severely impaired with a BIMS score of three (3) which indicated the resident was not interviewable. Further review of the MDS revealed the resident required total assist with transfers. Review of the Activities of Daily Living (ADL) Care Performance Deficit Care Plan for transfers, dated 05/25/16, and, Certified Nurse Aide (CNA) Kardex, dated 03/07/17, revealed to use mechanical lift with assist of two (2) staff for transfers with a brown lift sling. In addition, review of the Resident #7's Transfer Assessment, dated 03/02/17, revealed the resident required two staff to transfer with a mechanical lift with extra-large brown lift sling using mechanical lift Method two (2) with the resident in a reclined/lying position; however, observation on 03/07/17 at 8:13 AM and 9:00 AM revealed the resident was sitting in a chair with a blue lift sling underneath him/her instead of a brown lift sling as care planned. Interview with CNA #6 on 03/07/17 at 9:05 AM revealed Resident #7 uses a blue lift sling for transfers and verified that Resident #7 was using a blue lift sling. CNA #6 then reviewed the CNA Kardex and verified staff should have used a brown lift sling for transfer. She stated she did not think the resident used a brown sling as the resident had always been blue. The Director of Nursing (DON) walked by and the CNA asked the DON regarding the concern of the conflict in the lift slings. The DON stated to CNA #6 that she had been off sick however some assessments had been done and possibly the lift pad sling had been changed and would check. Interview with CNA #5 on 03/06/17 at 4:30 PM revealed the brown lift sling is an extra-large sling and she looks at the CNA Kardex to verify the sling size to use for each resident that requires a lift. Interview with CNA #7 and #8 on 03/07/17 at 9:15 AM revealed they were not aware of two (2) methods to transfer a resident only of one (1). They stated they do not go between the legs on anyone with a lift pad, only go on the outside of the resident's legs. Interview with Licensed Practical Nurse (LPN) #1 on 03/07/17 at 9:53 AM revealed she expected the CNAs to follow the Kardex. If the Kardex is not correct and the CNA notices something too small or too big to notify the MDS staff. Interview with the Staff Development Coordinator, on 03/07/17 at 2:11 PM, revealed the Assistant Director of Nursing (ADON) had checked her off to educate others on the lift and also watched the video. She further stated she instructed the CNAs to follow the Kardex. She stated the Transfer Assessments, Care Plans, and CNA Kardex should be the same and match and would expect the care plan to be updated to reflect the updated most recent assessment. She further stated if the staff are using the incorrect sling that is not approved for the resident there would be a risk of the resident falling in the hole in the lift. She stated the check offs with the staff had to be completed by 03/06/17 and told the staff to follow the Kardex when inserviced but if the Kardexes had not been updated that would create a problem for the resident. Interview with MDS #1, on 03/07/17 at 1:39 PM revealed every resident that required the use of a lift was measured and determined the correct sling size and it was placed on the assessment on 03/02/17 for what the resident needed to use. She stated no one was delegated to put the assessment information on the care plan; however, she revealed normally when an assessment is completed by MDS, then MDS updates the care plan. She stated she had provided some education to staff today on the correct sling size as well as updated two (2) Kardexes for Resident #1 and Resident #5 with the correct sling size and color to match the Transfer Assessments performed on 03/02/17. She further stated the Assistant Director of Nursing (ADON) was in charge when the DON was out of the building. Interview with MDS #2, on 03/07/17 at 3:45 PM, revealed she expected the staff to follow the care plan and MDS #1 and #2 are responsible to update the care plans. She stated the MDS staff would put the Transfer Assessments on the care plan and would alert staff of changes in the kiosk on the Kardex. She revealed she participated in the Transfer Assessments with the ADON and Administrator. She stated the staff needed education on the sling Methods so she had not gotten to the point to place the information on the care plan yet. She revealed since this Transfer Assessment was a new form and new system, MDS staff felt they needed to wait for the DON to come back to review with her before placing on the care plan. She stated we were going to review with her on Friday (03/03/17) but she was not here on Friday then we were going to review with her on Monday (03/06/17), but did not get to it and the DON was not here. Interview with the ADON, on 03/07/17 at 1:52 PM, revealed the MDS staff should update the care plan after the assessments are completed and or updated. She stated when the Transfer Assessments were completed they should have updated the care plans and educated staff on which sling to use for transfers. She revealed when a change is made there is an alert on the kiosk to the CNAs and nurses and the change is also placed on the twenty-four (24) hour report. She revealed she had measured all of the residents according to the lift manual and nothing was mentioned of waiting for the DON to approve the slings. Further interview with the ADON, on 03/07/17 at 3:35 PM, revealed the MDS, Administrator and herself were present in the meeting determining the assessment for each resident that used a lift. She stated she gave MDS the measurements to determine which measurement to use according to the manual. She revealed there was no concern the DON was not present or a concern of accuracy of measurements except for Resident #1 and another resident with an amputation. She stated after reading the manual the resident with the amputee was resolved and the MDS were to measure Resident #1 Friday afternoon (03/03/17). Interview with the DON, on 03/07/17 at 2:23 PM, revealed she expected the CNAs and nurses to follow the care plan. She stated MDS was responsible to update the care plan with new assessments or changes. She revealed if a resident was assessed for a new sling for transfers with a lift then the care plan should have been updated to show the changes. She stated the ADON is responsible in her absence and able to make decisions. She revealed the Interdisciplinary Team met last week even though she was not present and she was under the impression the assessments were done, education was provided, and changes were placed on the care plans. She stated the MDS staff stated they were waiting to update the care plan to have a meeting with her. She revealed there was a concern for the residents' safety while waiting to use the correct lift pads for the residents considering the residents had been assessed for the use of a specific lift pad since the assessment on 03/02/17 however the staff had not used them on the residents. She further revealed she was aware that the assessments did not match the care plan and Kardex. She stated Resident #1 and #5 CNA Kardex and care plan had been updated on 03/07/17. Interview with the Administrator, on 03/07/17 at 3:15 PM, revealed she expected the staff to follow the care plan. She stated when a Transfer assessment is completed, MDS is responsible to put the information on the care plan.

Based on interview, record review, review of hospital emergency room Report and Operative Report, and facility policy review it was determined the facility failed to follow the care plan for one (1) of three (3) sampled residents (Resident #1). Resident ##1 was care planned for three (3) staff to transfer the resident using a mechanical lift with a blue lift sling (large). However, on 02/07/17, facility staff failed to follow the care plan when only two (2) staff transferred the resident with the lift using a brown lift sling pad (extra-large). The lift sling began to slide up on the resident while he/she was in the air and the resident half flipped in the sling and the CNAs lowered him/her to the floor. The resident sustained [REDACTED]. The findings include: Review of the facility policy titled, Admission Care Plan, not dated, revealed the admission care plan will set forth the daily care needs of the resident which are to be provided by the nursing staff until the comprehensive care plan is formulated. Review of the facility policy tilted, Certified Nurse Aide (CNA) Care Plan Record, dated September 2002, revealed this record is for the provision of care for the resident. Further review revealed for mobility and transfer the record indicated how much assistance the resident requires to transfer in/out bed and chairs; if non-ambulatory, how much assist to be mobile in the wheelchair. Along with a list of any assistive devices used for mobility. Record review revealed the facility admitted Resident #1 on 03/03/10 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Sets (MDS) assessment, dated 12/15/16, revealed the facility assessed the resident was unable to complete the Brief Interview of Mental Status (BIMS) and determined the resident cognition was severely impaired which indicated the resident was not interviewable. Further review of the MDS assessment revealed the resident was totally dependent on staff for transfers with assist of two (2) plus. Review of the Comprehensive Care Plan for Falls, dated 02/07/14, and Certified Nurse Aide (CNA) Kardex for Safety, dated 02/07/14, revealed Resident #1 required assist of three (3) staff using a mechanical lift with the suspended blue sling. However, review of a Late Entry Nurse's Note by Registered Nurse (RN) #6, dated 02/07/17 at 11:15 AM, and interviews with RN #6 on 02/13/17 at 2:51 PM, CNA #1 on 02/14/17 at 8:25 AM and CNA #2 on 02/14/17 at 10:35 AM, revealed CNA #1 and CNA #2 (two {2} staff instead of three {3}) were transferring Resident #1 from the bed to a reclining high back chair using the mechanical lift with a brown sling (extra large) lift sling instead of the blue sling as care planned. While the resident was in the air, the sling slid upward causing the resident's upper body to lean forward and half flip so the CNAs lowered the resident to the floor. While sliding in the sling the resident sustained [REDACTED]. The resident was repositioned in the blue lift sling and placed back to bed. RN #6 stated there should have been three (3) nursing personnel transferring Resident #1 due to [DIAGNOSES REDACTED]. Review of Nurse's Note, dated 02/08/17 at 5:25 AM and 5:43 AM, and interview with CNA #3 on 02/14/17 at 9:10 PM, revealed when CNA #3 gave Resident #1 his/her bed bath and dressed him/her on 02/08/17, the CNA noted when she touched the resident's left foot he/she tensed up, then jumped, and made a loud noise. The resident's left foot was swollen as well as a portion of the leg and there was a small bruise to the leg. In addition, there was bruising noted on instep of the left foot, at ankle and lower extremity. Review of a Nurse's Note on 02/08/17 at 9:46 AM by Licensed Practical Nurse (LPN) #2 revealed new orders were received for X-ray to the left foot, ankle, tibia/fibula due to bruising, [MEDICAL CONDITION], and pain. A Nurse's Note at 10:49 AM revealed Resident #1 had a fracture and it was reported to the attending physician and an ambulance was called for transport to the hospital. Review of the Hospital emergency room Note, dated 02/08/17 at 1:42 PM, revealed the resident had been moved by a lift on 02/07/17 and the resident had a fall. The note revealed X-Rays taken revealed an impacted metatarsal [MEDICAL CONDITION] foot and spiral [MEDICAL CONDITION] left tibia and fibula. Review of the hospital Operative Report, dated 02/10/17 at 4:56 PM, revealed the preoperative [DIAGNOSES REDACTED]. Further review of the report revealed an open reduction and internal fixation of the left tibia fracture with plate and screws was performed. Interview with the Hospital's Orthopedic Surgeon on 02/14/17 at 4:30 PM and the emergency room Physician on 02/13/17 at 1:25 PM, revealed a spiral fracture does not occur from a fall but from the leg being caught in/on something and then twisted. The Orthopedic Surgeon stated the toe fracture was due to impact and had notable bruising. Interview with MDS Coordinator #2 on 02/14/17 at 9:48 AM revealed if the staff did not use a blue sling or the three (3) people to transfer Resident #1, they would not have been following the care plan as expected. Interview with the Assistant Director of Nursing (ADON) on 02/14/17 at 11:17 AM revealed the care plan should have been followed with three (3) people for transfers for Resident #1 but she was not sure if the problem had anything to do with the sling placement. Interview with the Director of Nursing (DON) on 02/14/17 at 11:38 AM revealed she expected the nursing staff to follow the care plan to use three (3) staff members with transfers and a blue lift sling. Interview with the Administrator on 02/13/17 at 5:45 PM revealed she expected the staff to follow the care plan and if needed assistance to ask. She stated she expected the staff to know how to apply the lift sling appropriately and to use the correct sling as care planned. She revealed if something is not available to accommodate what the care plan states for use, the CNAs should alert the charge nurse.

Based on observation, interview, record review, reviews of hospital emergency room Report and Operative Report, and facility policy review, it was determined the facility failed to provide adequate supervision and assistance devices to prevent accidents for one (1) of three (3) sampled residents. Resident #1 was assessed and care planned to use a mechanical lift using a blue lift sling (large size) and the assist of three (3) staff for transfers. However, on 02/07/17 only two (2) staff transferred the resident with the mechanical lift using the wrong size lift sling (brown, extra-large) and positioned the resident inappropriately on the lift sling. While the resident was lifted in the air, the sling slid up on the resident causing a weight shift, the resident half flipped and the resident was lowered to the floor. Resident #1 sustained an impacted metatarsal (toe) fracture of the left foot and spiral fracture of the distal left tibia and fibula (above ankle) and required surgical intervention to repair the spiral fractures. In addition, the facility failed to determine which method to use for this resident related to connecting sling to lift and failed to ensure Certified Nurse Aide #1 had hands on training in the use of the lift per the operating manual. The findings include: Review of the facility policy titled, Resident Safe Environment, dated 01/04/16, revealed residents should be evaluated for fall risk quarterly and as indicated to implement appropriate interventions. Review of the facility policy titled, Mechanical Lifts, not dated, revealed the policy of the facility is to have a safe working environment by utilizing a lift transfer system appropriate based on the comprehensive assessment and the resident care planning process. When a resident is assessed and care planned for a mechanical lift, employees are required to use the mechanical lift equipment. Employees are required to seek instruction when utilizing the mechanical lift for the first time. Review of the Mechanical Lift Operating Manual, dated March 2007, revealed a Digital Optical Disc (DVD) demonstrating transfer techniques can be used along with hands on training led by a nurse or professional rehabilitation staff member who has been designated as the facility's mechanical lift trainer, as part of the facility's mechanical lift education program. Only staff members who have been trained according to the procedures in the manual by a manufacturer's representative or by a nurse or professional rehabilitation staff member designated as the facility mechanical lift trainer, be allowed to use the lift. A warning label includes that watching the DVD without hands on training does not qualify as training. Staff members who have seen the video but who have not had hands on training by a nurse, manufacturer's representative, or therapy representative may not use the lift. A further warning label revealed, before using the lift the resident must be assessed to determine which residents are suitable for transfer with the lift as well as the transfer technique to use, size of the sling, and the number of staff members required to transfer the resident. There are two methods of connecting the sling to the lift. Method one (1) is the Crossed Loop Connection which crosses the leg loops for one leg support through the leg loop closest to the leg support on the other side of the sling. The resident may be transferred in a sitting, half-lying, or lying position. The resident must have normal to rigid muscle tone, no injury or medical conditions that might be aggravated by the crossed loop connection transfer and be able to separate the knees comfortably during transfers, and have predictable, cooperative behavior. Method two (2) is the Crossed Leg Support Connection which crosses one (1) leg support under both of the resident's legs then cross the other leg support under both of the resident's legs. The resident may be transferred in a sitting, half-lying, or lying position. When transferring residents who have loose muscles with little tone, it is safest to transfer them in a lying position. The Crossed leg support connection is risky for the residents who bend forward while in the sling, as these residents should be transferred in a lying position with a one (1) piece amputee sling that has double safety belts. Furthermore, the lift slings are in different sizes. The sling should be long enough to fit from the patient's coccyx to the top of, or a few inches above, the resident's head and wide enough for the sling fabric to extend at least two (2) inches in front of the resident's anterior shoulder. A large sling has blue stabilizing handles and an extra-large has brown stabilizing handles. In addition, the lift transfer procedures revealed when transferring a resident from a bed to make sure the staff have the correct sling size and which method of connecting the sling to the hanger bars to be used. Ensure the correct number of staff are present for the transfer. Record review revealed the facility admitted Resident #1 on 03/03/10 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Sets (MDS) assessment, dated 12/15/16, revealed the facility assessed the resident was unable to complete the Brief Interview of Mental Status (BIMS) and determined the resident cognition was severely impaired which indicated the resident was not interviewable. Further review of the MDS revealed the resident was totally dependent on staff for transfers with assist of two (2) plus. Review of the Transfer Assessment, last updated 09/22/14, revealed to use the mechanical lift during all transfers using the blue sling; however, the assessment did not indicate what transfer method to use, or by how many staff per the Mechanical Lift Operating Manual. Review of the Fall Risk Assessment, dated 12/15/16, revealed Resident #1 had a neuromuscular/functional health condition, orthopedic health condition, and psychiatric/cognitive health condition; and the resident always required physical support while sitting. The total score indicated the resident was a high risk for falls. Interview (Post Survey) with the Administrator, on 02/24/17 at 2:54 PM, revealed all aides are trained to use one (1) method for lift transfer which is Method two (2) and residents are not assessed for a method when assessed for the use of a lift. However, she stated if the method was not appropriate the staff would need to use another method. She further revealed there was not a place on the transfer assessments to document which method and she was not sure about documenting the method on the care plan. Review of the Comprehensive Care Plan for Falls, dated 02/07/14, and Certified Nurse Aide (CNA) Kardex for Safety dated 02/07/14, revealed for transfers Resident #1 required assist of three (3) using mechanical lift, due to seizure activity. Use suspended blue sling. However, the care plan did not specify which transfer technique should be used with Resident #1. Review of Nurse's Notes by Registered Nurse (RN) #6 revealed a late entry for 02/07/17 at 11:15 AM which stated the nurse was called to Resident #1's room by a Physical Therapist who was working with the resident's roommate. Resident #1 was being transferred via mechanical lift from the bed to the chair and began to slide downward in the lift sling, and was lowered to the floor slowly by Certified Nurse Aides (CNAs). While sliding in the sling the resident sustained [REDACTED]. Assessment revealed no change in Range of Motion (ROM) and no signs and symptoms of acute pain. Resident #1 was repositioned in the lift pad and placed back to bed. Interview with CNA #1, on 02/14/17 at 8:25 AM, revealed when Resident #1 was being transferred on 02/07/17, a brown sling was being used on the resident. She stated the Physical Therapist (PT) was in the room working with the resident's roommate, and she thought even though the PT was not providing hands on, the PT could be counted as the third person. She revealed she had been told in orientation that three (3) people were to be in the room when using a lift on Resident #1, two (2) providing hands on and the other controlling the lift. She also stated that the resident usually had two (2) people with transfers even though the CNA Kardex states to use three (3) people with transfers. She revealed the brown lift sling was placed under the resident and her and the other CNA used the crossed leg support method (Method two {2}) to transfer the resident from the bed to the high back reclined chair. She stated while the resident was in the air she saw the resident slipping through the lift sling and due to the resident having no upper body control, the resident made a half flip and the resident's head was where his/her feet were supposed to be. She revealed she was at the lift controls and began lowering the resident to the floor. She then stated CNA #2 guided the resident down the floor manipulating the resident's body to land on his/her left side while the CNA protected his/her head. She revealed RN #6 was called to the room and used the brown sling to show us how to get the resident back into the bed and inserviced us on how to determine which sling to use for the resident. We were then required to watch a lift video. Further interview on 02/14/17 at 11:10 AM revealed since Resident #1's legs are so contracted and he/she is in a fetal position with his/her knees up to his/her chest it's possible the lift strap caught the resident's shin area as she fell and twisted, as the lift strap was taut on the third loop which made it tight and made him/her be in a seated position instead of reclined. She stated she had not received any specific lift training when hired; she stated her CNA preceptor showed her how to use the lift while she was orientating on the floor. Review of CNA #1 Orientation Checklist, dated 12/13/16, revealed a check next to mechanical lift. Interview with the Administrator, on 02/14/17 at 2:55 PM revealed the check indicated the therapist inserviced CNA #1 on the Mechanical Lift policy but did not provide hands on training as the hands on training was provided by the preceptor, which was a CNA on the floor. Interview with CNA #2, on 02/14/17 at 10:35 AM, revealed a blue sling should have been used with Resident #1 for the transfer but they may have used the brown sling that day, she could not remember. She stated the resident was in the air in the lift and was sitting up too straight. She further revealed the top of the lift pad was too high on the resident's head and the pad slid up the resident's buttock and the resident began to slide out of the pad. She stated she tried to break the resident's fall and was concentrated on his/her head not getting hurt. She revealed the resident's legs could have gotten caught up in the lift pad but she was not for sure. She revealed the PT was in the room working with the resident's roommate and they thought that it was okay to count her as the third person. She stated she was inserviced after the incident that the PT could not be used as the third person and given instruction on the proper positioning of the lift sling. Interview with the PT, on 02/13/17 at 3:49 PM, revealed she was in the room providing treatment to Resident #1 roommate and did not participate with the lift transfer on 02/07/17. She stated the CNAs had closed the curtain to provide privacy and she was unable to visualize the incident. She further stated she heard something hit the floor and opened the curtain and saw the resident lying on his/her left side on the floor. She revealed she went to the desk to get the RN #6. Interview with RN #6, on 02/13/17 at 2:51 PM, revealed the PT came to the desk to alert her of the incident with Resident #1. She stated when she entered the room the resident was laying on the floor on his/her left side in between the lift legs. She stated she was pretty sure the brown sling was being used, 95% sure. She further stated the bottom part of the sling that went under the resident's legs was too far up on the resident's bottom and the part that goes around his/her head was too far up which made the resident lean forward and made the bottom heavy. She revealed the only injuries she identified were two (2) skin tears, one to left hand and right arm. She stated there should have been three (3) nursing personnel in the room with every transfer for Resident #1 due to his/her [DIAGNOSES REDACTED]. The nurse then proceeded to leave the conference room to obtain the sling for demonstration and when she returned minutes later, she brought in a blue sling and stated, Oh I was wrong it was the blue sling he/she was using. She stated when she provided ROM there was nothing abnormal for the resident. She revealed the two (2) CNAs thought it was okay to count the PT as the third person, but the PT was working with another resident. She further revealed she demonstrated with the sling how to properly use the lift sling. She stated human error with the lift sling was the reason the resident fell . Review of a Nurse's Note by RN #7, dated 02/07/17 at 9:37 PM, revealed Resident #1 had no new injuries from assisted fall from the lift with no signs and symptoms of discomfort with ROM within normal limits for the resident. Interview with RN #7 on 02/13/17 at 3:33 PM revealed she was given in report on afternoon shift on 02/07/17 that the resident had fallen from the lift. She stated when she assessed the resident that evening she assessed the resident's upper body down to his/her knees where the soft boots were located. She revealed she did take off the boots to view the lower leg and feet and she had not received any report from her staff of pain. Review of Nurse's Note, dated 02/08/17 at 5:25 AM, revealed Resident #1's left foot and ankle were swollen at three plus (3+). The area was warm to the touch with no temperature difference between other body parts. The resident was noted to have slight jerking motions on occasion and no distress noted or complaints voiced. A Nurse's Note on 02/08/17 at 5:43 AM revealed bruising on instep of the left foot, at ankle and lower extremity. Interview with CNA #3, on 02/14/17 at 9:10 AM, revealed when she came in to work on 02/08/18 at 5:00 AM, she gave Resident #1 a bed bath and dressed the resident; and she noticed when she touched the resident's left foot he/she tensed up, then jumped, and made a loud noise. She stated the resident's left foot was swollen as well as a portion of the leg and there was a small bruise to the leg so she reported it to the nurse. She revealed the resident had been in a brown sling and if the sling needs to be changed that would be reported to the nurse. Interview CNA #4, on 02/14/17 at 10:50 AM, revealed on 02/08/17 at around 5:00 AM he was called into Resident #1's room by CNA #3 and the resident was grimacing and he saw bruising to the resident's leg. Review of the Pain Assessment for joint and bone pain, dated 02/08/17 at 8:30 AM, revealed Resident #1 was moaning and groaning with facial grimacing, rigid, fists clenched, and unable to distract or reassure and was given a pain score of an eight (8) out of ten (10); thirty (30) minutes after the pain medication was administered the resident's pain assessment at 9:00 AM revealed a score of a seven (7). Reassessment two (2) hours after the medication was administered the pain scale was a four (4). However, review of the February 2017 Medication Administration Record (MAR) revealed there was no documented evidence the resident was administered pain medication. Interview with LPN #1 on 02/14/17 at 8:59 AM revealed she worked 6:00 AM-2:00 PM on 02/08/17 and was told by staff that the resident had facial expressions of pain and moaning while the staff cared for her while getting him/her dressed and moving his/her leg. She stated she gave the resident Tylenol for pain at 8:30 AM when she performed the pain assessment, but forgot to document on the MAR. Review of a Nurse's Note on 02/08/17 at 9:46 AM by Licensed Practical Nurse (LPN) #2 revealed new orders received for X-ray to the left foot, ankle, tibia/fibula due to bruising, edema, and pain. A Nurse's Note at 10:49 AM revealed Resident #1 had a fracture and it was reported to the attending physician and an ambulance was called for transport to the hospital. Interview with LPN #2, on 02/14/17 at 9:20 AM, revealed the midnight nurse reported that CNA #3 had reported Resident #1 had swelling and bruising to the left ankle. She stated when the physician office opened she called to request an X-Ray. She revealed after the X-Rays were ordered and read the resident was sent to the emergency room with a spiral fracture. Interview with Paramedic on 02/14/17 at 2:05 PM revealed the ambulance was dispatched to pick up a resident on 02/08/17 with a fractured leg. He stated the resident was non-verbal and staff said the resident had fallen the day before from a lift. He stated the resident grimaced with transfer to the stretcher and then at the hospital. Review of the Hospital emergency room Note, dated 02/08/17 at 1:42 PM, revealed the resident had been moved by a lift on 02/07/17 and the resident had a fall. The note revealed, X-Rays taken revealed an impacted metatarsal fracture of the left foot and spiral fracture of the distal left tibia and fibula. The resident's symptoms were severe earlier in the emergency room and were unchanged at 1:42 PM. The Note further revealed the physician documented decreased ROM, ecchymosis, pain, swelling, tenderness to the resident's lateral aspect of the left foot and the resident was contracted. The resident was admitted to the hospital for orthopedic consult. Interview with the emergency room Registered Nurse #1, on 02/13/17 at 12:50 PM, revealed the resident was non-verbal and was dressed in a shirt, pants and socks upon arrival to the hospital. She stated the resident revealed facial grimacing and was tight and rigid. She further stated the resident's left leg was floppy with slight swelling and bruising with some deformity to the left lower leg. She revealed the resident was administered Morphine and Zofran and the resident seemed to relax and was able to fall asleep. Interview with the emergency room Registered Nurse #2, on 02/13/17 at 1:10 PM, revealed upon the resident's arrival to the hospital the resident grimaced when transferred from the stretcher to the bed. He stated the resident was contracted and non-verbal. He revealed when the leg was splinted the leg was floppy. He stated the resident became more relaxed after he/she was administered pain medications. Interview with the emergency room Physician, on 02/13/17 at 1:25 PM, revealed he was very concerned when the resident was presented with a spiral fracture as a spiral fracture does not occur from a fall but from the leg being caught in something and then twisted. He stated even if a resident had osteoporosis a spiral fracture would not occur without a twisting of some kind. Review of the hospital's Operative Report, dated 02/10/17 at 4:56 PM, revealed the preoperative [DIAGNOSES REDACTED]. Further review of the report revealed an open reduction and internal fixation of the left tibia fracture with plate and screws was performed. The fibular fracture had been aligned due to the tibia fracture fixation Interview with the Hospital's Orthopedic Surgeon on 02/14/17 at 4:30 PM revealed the resident was demented with contractures. He stated the type of fracture that Resident#1 had was due to the foot being caught and the body kept going or someone trying to catch him/her when he/she fell . He further revealed the toe fracture was due to impact and was notable bruising. He stated she is osteopenic so the twist would not take much; however, since the lady was larger it would take more force of transmission. Observation of Resident #1 on 02/13/17 at 1:50 PM at the hospital revealed the resident was lying in the bed in a fetal position with legs up to his/her chest. Interview with the Resident #1's family member at the hospital, on 02/13/17 at 1:50 PM, revealed when the resident came to the hospital prior to surgery the resident would make face expressions and tighten his/her hands indicating he/she was in pain, but is doing much better now since surgery. Interview with the Hospital Floor Nurse Registered Nurse # 3 on 02/13/17 at 2:00 PM revealed the resident requires assist with all activities of daily living and has poor trunk control, which was the baseline of the resident before and after surgery. Interview with the Assistant Director of Nursing (ADON) on 02/14/17 at 11:17 AM revealed on the day of the incident on 02/07/17 she entered the room when the incident occurred and asked if the resident had hit his/her head. She stated the resident was lying on the left side; however, she did not pay attention to what color sling was being used at that time. She stated the MDS Coordinator performs the transfer assessment. She further revealed that therapy determines first if the resident needs a lift and then MDS determines the sling size. She further stated she was not sure why the transfer assessments were previously done quarterly and then stopped in 2014. She stated maybe the slings are now measured for length instead of weight. She revealed the care plan should have been followed with three (3) people for transfers for Resident #1 and she was not sure if there was a problem with lift sling placement. She further stated Resident #1 was ambulatory on admission and had become contracted to a fetal position within the last two (2) years. Interview with the Director of Nursing (DON) on 02/14/17 at 11:38 AM revealed she entered the room when the incident occurred on 02/07/17 and the resident was lying on his/her left side however due to an eye condition could not tell the color of the lift sling at a distance. She stated that the transfer assessments are completed on admissions and change. She further revealed the sling size is determined by length not weight, therefore no need to reassess. She stated she expected the nursing staff to provide the amount of supervision needed for Resident #1's transfers with lift which was three (3) staff and for the staff to use a blue lift sling. She stated she had determined the root cause of the fall to be improper lift sling placement by the staff, however had not determined the reason for the spiral fracture. Although, she felt maybe the heel boot caught on the floor and when the resident rotated in the lift the boot rotated his/her leg. She stated the immediate intervention was education to the two (2) staff members right away. She stated the facility has yearly lift training with competency. She further stated the MDS staff are responsible to determine what lift pad is appropriate for the resident. Interview with the Administrator on 02/13/17 at 11:35 AM revealed the facility does not perform a Fall Assessment after a fall, however, the fall is brought to the Quality Assurance (QA) meeting which is conducted every day after the morning meeting to determine the root cause and put interventions in place. She stated this particular resident was reviewed the day of the incident with the Director of Nursing (DON) and it was determined the resident was not in a reclined position and the lift sling was not placed properly under the resident while being transferred from the bed to the chair. She stated after the incident the two (2) CNAs involved were given verbal training and watched the lift videos, however, no return demonstration was conducted. Further interview on 02/13/17 at 3:30 PM, revealed a transfer assessment is only performed if there is a change in the resident. She stated the new hire employees go over the lift policy with a therapist but not a demonstration. She stated the new employee receives demonstration on the floor with the preceptor. Interview on 02/13/17 at 5:45 PM, revealed she expected the staff to know how to apply the lift sling appropriately and to use the correct pad as care planned. She revealed if something is not available to accommodate what the care plan states for use the CNAs should alert the charge nurse. She further stated after the incident all staff were required to attend a verbal inservice and watch the lift video. She revealed that now she believes the transfer assessments should have been completed annually and with changes as verified by reviewing other residents' transfer assessments in the facility that had an annual transfer assessment.

Based on interview, record review, and review of facility policies it was determined the facility failed to immediately consult with the physician when treatment was altered significantly for one of fifteen sampled residents (Resident #14). The facility failed to follow facility policies: Physician/Legal Representative Notification and Medication Administration-General Guidelines. The facility failed to notify the physician when licensed nurses judgement determined a need to alter Resident #14's diabetic treatment. Resident #14 had multiple [DIAGNOSES REDACTED]. sugar. From 09/01/10 through 01/13/11, the facility's licensed nurses failed to administer or hold (did not administer) insulin medication to Resident #14 in accordance to the physician's orders [REDACTED]. All alterations in the administration of insulin were completed without notification and/or consultation of the physician. As a result Resident #14 was at risk for severe hyperglycemic and hypoglycemic episodes. The facility's failure to notify and/or consult with the physician and failure to administer insulin in accordance with physician orders [REDACTED]. Immediate Jeopardy was determined to exist on 09/01/10 and the facility was notified, on 03/08/11. The findings include: A review of the facility's policy, Physician/Legal Representative Notification, revision date August 2006, revealed the facility was to immediately inform the resident, consult with the resident's attending physician: and if known, notify the resident's legal representative or an interested family member when there was a need to alter treatment significantly. The policy/procedure revealed the facility was to notify the physician when a need to alter treatment was indicated. The charge nurse was to make two attempts to notify the attending physician within a ten minute period. If unsuccessful, the charge nurse would notify the physician on call or the Medical Director. A review of the facility's policy entitled, "Medication Administration-General Guidelines," not dated, revealed medications were to be administered as prescribed in accordance with good nursing principles and practices. The procedure portion of the policy revealed medications were to be administered in accordance with written orders of the attending physician. If nursing staff considered a dose excessive, considering the resident's age and/or condition, the nurse was to call the prescriber for clarification. Interview with the Director of Nursing (DON), on 02/25/11 at 5:00 PM and on 03/08/11 at 1:05 PM, revealed the nurse should never alter any dose of medication based on nursing judgement, and if the licensed staff had a concern regarding the administration of any medication she would expect the staff to notify the physician of their concern and seek direction for administration. She expected the licensed staff to notify the physician for direction whenever there was a "HI" glucometer reading as there would be no blood sugar level to base the administration of sliding scale insulin. The facility admitted Resident #14, on 01/10/08, with [DIAGNOSES REDACTED]. Closed record review of the physician orders, dated 11/20/09, revealed an order to administer Humalog insulin per sliding scale based on the calculation of blood sugar minus 100 divided by 30. Subsequent physician orders, dated 06/01/10, revealed Resident #14 was to receive [MEDICATION NAME] 16 units at supper and to continue the same sliding scale insulin. On 09/20/10, the routine [MEDICATION NAME] was changed to 12 units in the afternoon. On 10/06/10, routine [MEDICATION NAME] was increased to 14 units every day. On 10/29/10, the routine [MEDICATION NAME] was changed from 4:00 PM to be administered at 7:00 AM and the sliding scale insulin was changed to blood sugar minus 100 divided by 40. A review of the pre-printed orders revealed sliding scale insulin was to be given for blood sugars greater than 250 mg/dl. Review of Diabetic Records for the months of September 2010, October 2010, November 2010, December 2010 and January 2011 revealed on 110 occasions licensed nursing staff altered the amount of sliding scale insulin administered, withheld both routine insulin and sliding scale insulin, administered sliding scale insulin of various amounts without a valid blood sugar result needed to calculate the dosage of insulin, altered the dosage and time of administration of the routine [MEDICATION NAME] all of which was not in accordance with the physician's orders [REDACTED]. The documentation revealed the licensed nursing staff withheld the resident's routine scheduled insulin (non sliding scale) six (6) times; withheld sliding scale insulin despite the physician's orders [REDACTED]. Additionally, there was no documented evidence that the charge nurse made two attempts to notify the attending physician within a ten minute period and when unsuccessful, notified the physician on call or the Medical Director regarding the need to alter Resident #14's diabetic treatment. (Refer to F333 for specific dates and diabetic medication dosage administered) Interviews with Licensed Practical Nurse (LPN) #1 through #9, on 03/08/11 at 10:20 AM, on 03/08/11 at 2:15 PM, on 03/08/11 at 11:15 AM, on 03/07/11 at 4:00 PM, on 03/07/11 at 4:15 PM, on 03/08/11 at 8:45 PM, on 03/08/11 at 9:15 AM, on 03/07/11 at 2:40 PM and on 03/07/11 at 3:00 PM, respectively, revealed the licensed staff routinely altered Resident #14's insulin based on nursing judgement and what each individual nurse felt was best for the resident to maintain an acceptable blood sugar level. The staff revealed they did not contact the physician when altering the resident's dose of insulin. The licensed staff revealed when the glucometer reading was "HI", the sliding scale insulin was administered based on the highest reading the glucometer registered; however, multiple nurses indicated the glucometer registered "HI" above 500 mg/dl, when in fact the glucometer registered up to 550 mg/dl. All licensed staff revealed with a "HI" reading, there was no actual figure to use to calculate the sliding scale insulin. Interview with Resident #14's attending physician, on 02/25/11 at 5:50 PM and on 03/08/11 at 1:30 PM, revealed he would expect the licensed staff to notify the physician when there was a "HI" glucometer reading and he was unaware the licensed staff were routinely altering the dose of insulin administered to Resident #14. He revealed the staff should have notified himself or the physician on-call anytime there was concern with the administration of any medication and never base administration on nursing judgement without contacting a licensed physician for direction. An acceptable Allegation of Compliance (AoC) was received on 03/16/11 and detailed as follows: Criteria #1: Resident #14 no longer resides at the facility. An audit was completed by the Assistant Director of Nursing (ADON) of the diabetes management interventions documented for Resident #14, with investigation of the circumstances in which insulin administration was not consistent with the MD (physician) orders. The facility disciplinary action policy was has been implemented for the licensed nursing staff identified to have insulin administration inconsistent with MD orders, in the form of a final written warning with further non-compliance to result in disciplinary action up to and including termination. Criteria #2: An audit has been completed by the ADON on 03/09/11 of the facility residents with the [DIAGNOSES REDACTED]. Addendum to the audit was made on 03/15/11 by the ADON identifying the error of administering sliding scale insulin without having an actual glucose reading, instead basing the calculation on a reading of "HIGH." The DON and Administrator reviewed these findings. All identified discrepancies involving inaccurate insulin dosage administration were identified as significant medication errors and were reviewed with and acknowledged by the attending physician to discuss the residents current status and review current insulin orders. No new physician orders [REDACTED]. MD orders for parameters for reporting of high and low glucose levels were obtained for residents receiving insulin injections. The [MEDICAL CONDITION] policy was provided and acknowledged by the facility attending physicians and Medical Director. Criteria #3: The facility policy/procedure for Diabetes Management, including management of [MEDICAL CONDITION] was reviewed/revised to address the following: A. Obtaining, interpreting, and reporting of glucose finger sticks in accordance with physician orders [REDACTED]. B. Assessment of the resident with abnormal glucose finger stick results, with documentation and reporting of the findings. C. Administration of insulin in accordance with physician orders [REDACTED]. The facility has implemented a new Diabetic Record to be used for the documentation of glucose finger stick results, insulin dosage orders, and administration. The DON received in-service education as provided by the nursing consultant by telephone conversations on 03/08/11 and 03/09/11, prior to the in-service for the licensed staff on the following: A. The F-157 regulatory requirements for physician notification, including notification of the MD for finger stick glucose results in accordance with MD ordered parameters, and MD notification of assessment findings related to resident change in status, especially as associated with [MEDICAL CONDITION]. B. Administration of insulin in accordance with MD orders, and the need to notify the physician if the residents status denotes that insulin order changes may be indicated. C. Review of the facility Diabetes Management Policies and Procedures and revisions, including the new Diabetic Record; physician ordered parameters for the reporting of glucose finger stick results; the calculation of sliding scale insulin dosage in accordance with MD orders; and the administration of insulin in accordance with physician orders. D. The protocol for two nurses to verify and initial routine and sliding scale insulin doses administered to residents. The DON received in-service education as provided by the nursing consultant on 03/15/11, prior to the in-service for the licensed nursing staff on the following: A. Revisions to the Diabetic Management-[MEDICAL CONDITION] policy. B. Administration of insulin in accordance with MD orders, and the need to notify the physician if the resident's status denotes that insulin order changes may be indicated. Utilizing the employee listing, licensed nursing staff have received in-service education provided by the DON on 03/09/11, on 03/15/11 and on 03/16/11 regarding Diabetes Management interventions, including but not limited to the following: A. The F-157 regulatory requirements for physician notification, including notification of the MD for finger stick glucose results in accordance with MD ordered parameters, and MD notification of assessment findings related to resident change in status, especially as associated with [MEDICAL CONDITION]. B. Administration of insulin in accordance with MD orders to prevent a significant medication error, and the need to notify the physician if the residents status denotes that insulin order changes may be indicated. C. Review of the facility Diabetes Management Policies and Procedures and revisions, including the new Diabetic Record; physician ordered parameters for the reporting of glucose finger stick results; the calculation of sliding scale insulin dosage in accordance with MD orders; and the administration of insulin in accordance with physician orders. D. The protocol for two nurses to verify and initial routine and sliding scale insulin doses administered to residents. Licensed nursing staff were administered a written medication administration test which included questions pertaining to insulin, as provided by the DON on 03/09/11, on 03/15/11 and on 03/16/11. Licensed nurses will be provided the in-service information referenced above as part of the facility orientation process, and will have completion of the Diabetes Management Skills Checklist as provided by the DON or designee. The Administrator has reviewed all in-service information and verified attendance of licensed nursing staff on 03/17/11. Criteria #4: Two (2) licensed nursing staff will verify and initial routine and sliding scale insulin doses administered to residents. The CQI indicator for the monitoring of compliance with the facility policy/procedure and MD orders for Diabetes Management will be utilized monthly X 2 months, and then quarterly thereafter under the supervision of the DON. The Administrator will review the completed CQI indicator to determine compliance and to determine if an action plan is indicated for any identified issues. The DON and/or Nurse Consultant will review all facility Diabetic Records weekly X 1 month, and then five chosen randomly on a monthly basis thereafter to determine compliance with the facility policies/procedures and MD orders. The CQI indicator for the monitoring of the effectiveness of the QA process will be utilized monthly X 2 months and then quarterly under the supervision of the Administrator. The Corporate Consultant will review the completed CQI indicator to determine if an action plan is indicated for any identified issues. A Diabetes Management skills check list is being completed on two licensed nursing staff daily for two weeks, and then weekly for four weeks, and then monthly for three months, and then quarterly thereafter by the DON/Pharmacy Consultant/Administrative Nursing/Nursing Consultant during observations of finger stick glucose testing and insulin preparation/administration to determine compliance with these procedures and accurate insulin administration. Criteria #5: March 17, 2011. During the extended survey, on 03/16/11 through 03/18/11, verification of the removal of Immediate Jeopardy was completed as follows: Interviews with Registered Nurse (RN) #1, RN #2, RN #3, LPN #8, LPN #9, LPN #10, LPN #11, LPN #12 and LPN #13, on 03/17/11 at 2:25 PM, on 03/18/11 at 9:00 AM, on 03/17/11 at 11:35 AM, on 03/17/11 at 2:17 PM, on 03/18/11 at 9:30 AM, on 03/17/11 at 1:55 PM, on 03/17/11 at 10 :35 AM, on 03/17/11 at 3:00 PM and on 03/17/11 at 1:50 PM respectively, revealed the licensed staff were educated regarding notification of the physician for finger stick glucose results in accordance with physician ordered parameters, physician notification of assessment findings related to resident change in status, administration of insulin in accordance with physician orders [REDACTED]. The interviews revealed the staff understood the content of the inservice and individual responsibility. Observations of RN #1, LPN #11 and LPN #13, on 03/17/11 between 11:00 AM and 11:45 AM, revealed staff obtained accuchecks on five residents and administered insulin to four residents. Insulin doses were verified by two licensed staff as directed by the AoC. Both routine insulin and sliding scale insulin was administered in accordance with the written physician order. A record review, on 03/17/11 at 10:30 AM, revealed the facility had initiated Diabetic Management check lists for all licensed nursing staff on 03/11/11 and had completed 16 competency checks at the time of review with the process continuing until all licensed nursing staff had been checked off. A record review, on 03/17/11 at 10:35 AM, revealed all licensed nursing staff had completed a written test on medication administration and review of the test revealed questions pertained to Diabetes, insulin and insulin administration including questions requiring the staff to calculate sliding scale insulin doses. A review of all residents records with the [DIAGNOSES REDACTED]. Record review also revealed four residents with the [DIAGNOSES REDACTED]. A review of the facility's audit of other residents with the potential to be affected by the deficient practice revealed the facility identified other residents affected by the practice and notified the physician of each resident affected by the deficient practice. A review of sign-in sheets for all in-services the facility provided in response to the Immediate Jeopardy revealed all licensed staff had attended the training sessions except one staff member who was hospitalized . An interview with the DON, on 03/17/11 at 2:00 PM, revealed the DON would monitor the Continuous Quality Improvement (CQI) by auditing all diabetic records weekly for one month and then five chosen randomly on a monthly basis thereafter to determine compliance with the facility policy/procedure and physician orders. The DON stated the audit would include whether the resident had Diabetes identified through the care plan process, monitoring of the diabetic record to ensure accuracy and completion, parameters for [DIAGNOSES REDACTED] and [MEDICAL CONDITION] were listed on both the Diabetic Record and the physician orders [REDACTED]. She stated all hypo and hyperglycemic events would be reviewed to ensure all protocols were followed. The DON stated if audits do not demonstrate at least 95 percent compliance, an action plan would be developed immediately to address any identified problems. An interview with the Administrator, on 03/18/11 at 11:15 AM, revealed he would be completing a check list after reviewing audits completed by the DON to ensure policy and procedure was followed correctly and if any problem were to be identified regarding audits not being completed as directed by the AoC, he would initiate disciplinary action. Based on the above observations, interviews and review of records, it was determined the Immediate Jeopardy was removed, effective 03/17/11, as alleged in the AoC with the scope and severity lowered to an "E", based on the need to continue to evaluate the implementation of changes and quality assurance activities.

Based on interview, record review, and review of facility policy and procedures it was determined the facility failed to immediately notify the physician when there was a need to alter the treatment related to a clinical symptom for one resident (#4) in the selected sample of nine residents. Resident #4 had written orders to notify the physician of any blood sugar levels less than 70 milligrams/deciliter (mg/dl) or greater than 300 mg/dl. The facility failed to notify the physician of Resident #4's blood sugar level of 54 mg/dl on 05/04/11. The findings include: A review of the facility's policy, Physician/Legal Representative Notification, dated revised August 2006, revealed the facility would immediately inform the resident, consult with the resident's attending physician, and if known, notify the resident's legal representative or an interested family member when there was a need to alter treatment significantly. The policy/procedure revealed the facility would notify the physician when a need to alter treatment was indicated. The charge nurse would make two attempts to notify the attending physician within a ten minute period. If unsuccessful, the charge nurse would notify the physician on call or the Medical Director. A record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the resident's diabetic record, dated May 2011, revealed, on 05/04/11 at 6:00 AM, the resident's blood sugar level was 54 mg/dl. Record review revealed no documented evidence the resident's physician was notified of the resident's blood sugar level. Interviews, on 05/19/11 at 3:00 PM and on 05/20/11 at 11:55 AM with Registered Nurse (RN) #1 who obtained Resident #4's blood sugar level on 05/04/11, revealed she did not contact the physician about the blood sugar level. She stated the Director of Nursing (DON) brought the error to her attention two days later, on 05/06/11. However, she received no instructions to notify the physician of the blood sugar level at that time, and she failed to notify the physician of the blood sugar level, on 05/06/11. Interviews with the DON, on 05/19/11 at 2:05 PM and on 05/20/11 at 1:30 PM, revealed she identified the failure to notify the physician of the blood sugar level as a result of an informal audit she conducted on Resident #4's diabetic record on 05/06/11. Per interview, she failed to instruct the staff member to notify the physician when the error was discovered. The DON revealed she expected staff to notify the physician at the time the blood sugar level was obtained if the level was outside of the established parameters for the resident. An interview with Resident #4's attending physician, on 05/20/11 at 10:50 AM, revealed the orders written on 03/07/11 established parameters for notification regarding blood sugar levels so the facility would have set guidelines to contact him when levels were outside of the established parameters.

Based on interviews, record review, and review of the facility's policy and procedures it was determined the facility failed to ensure licensed staff provided services that met professional standards of quality, for one of ten sampled residents (Resident (#8). On 03/24/11, licensed staff administered 16 units of [MEDICATION NAME]to Resident #8. Record review revealed no documented evidence there was an order for [REDACTED]. The findings include: A review of the facility's "Medication Administration-General Guidelines" policy and procedure, not dated, revealed medications were to be administered in accordance with written orders of the attending physician. A record review revealed Resident #8 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. Furhter review of the physician's orders [REDACTED]. A review of a Diabetic Record revealed Resident #8's blood sugar was 418 on 03/24/11 at 11:30 AM and 16 units of [MEDICATION NAME]was administered. A review of the physician's orders [REDACTED]. An interview with Licensed Practical Nurse (LPN) #1, on 04/14/11 at 9:30 AM, revealed she called the Physician and made him aware Resident #8's blood sugar was 418. She stated the Physician gave an order to give 16 units of [MEDICATION NAME] insulin. She stated she must have forgotten to write the physician's orders [REDACTED]. An interview with the Director of Nursing, on 04/14/11 at 10:00 AM, revealed the Nurse should have called the Physician and wrote the physician's orders [REDACTED]. Interview with Resident #8's Physician, on 04/14/11 at approximately 2:00 PM, revealed he could not recall if the Nurse called him related to Resident #8's blood sugar of 418 or if he had given an order to administer 16 units of [MEDICATION NAME] insulin. He stated 16 units of [MEDICATION NAME] sounded like the amount he would of ordered if Resident 8's B/S was 418. Review of the twenty-four hour report, dated 03/24/11, revealed a note the Physician was contacted on 03/24/11 with new orders received; however, the insulin dosage was not indicated and there was no evidence in Resident #8's clinical record the order for 16 units of [MEDICATION NAME] had been received.

Based on interview and record review it was determined the facility failed to ensure services provided or arranged by the facility met professional standards of quality related to failure to carry out the written physician's orders [REDACTED].#4), in the selected sample of nine residents. The facility failed to follow the physician's orders [REDACTED]. Resident #4's blood sugar level was 54 mg/dl on 05/04/11. The findings include: A record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].#4's physician orders, dated 03/07/11, revealed an order to notify the physician for blood sugar levels less than 70 mg/dl or greater than 300 mg/dl. A review of the resident's diabetic record, dated May 2011, revealed on 05/04/11 at 6:00 AM the resident's blood sugar level was 54 mg/dl. Interviews with Registered Nurse (RN) #1, on 05/19/11 at 3:00 PM and on 05/20/11 at 11:55 AM, revealed RN #1 had obtained Resident #4's blood sugar level at 6:00 AM on 05/04/11 and the result was 54 mg/dl. RN #1 revealed she did not contact the physician about the blood sugar level. She stated the Director of Nursing (DON) brought the error to her attention two days later, on 05/06/11. RN #1 revealed she received no instructions to notify the physician of the blood sugar level on 05/06/11 when the error was brought to her attention.. Interviews with the DON, on 05/19/11 at 2:05 PM and on 05/20/11 at 1:30 PM, revealed she identified the failure to notify the physician of the blood sugar level as a result of an informal audit she conducted on Resident #4's diabetic record on 05/06/11. She revealed RN #1 received disciplinary action as a result of the failure to notify the physician, but failed to instruct the staff member to notify the physician when the error was discovered. The DON revealed she expected staff to carry out the physician's orders [REDACTED]. An interview with Resident #4's attending physician, on 05/20/11 at 10:50 AM, revealed the orders written on 03/07/11 established parameters for notification regarding blood sugar levels so the facility would have set guidelines to contact him when levels were outside of the established parameters.

Based on interview, record review, and review of facility policies it was determined the facility failed to ensure one of fifteen sampled residents (Resident (#14) was free of significant medication errors. The facility failed to ensure policy and procedures related to medication administration were followed. Resident #14 had multiple [DIAGNOSES REDACTED]. sugar. Record review revealed from 09/01/10 through 01/13/11, the facility's licensed nurses failed to administer or hold (did not administer) insulin medication to Resident #14 in accordance to the physician's orders [REDACTED]. The documentation revealed the licensed nursing staff withheld the resident's routine scheduled insulin (non sliding scale) six (6) times; withheld sliding scale insulin despite the physician's orders [REDACTED]. Immediate Jeopardy was determined to exist on 09/01/10 and the facility was notified, on 03/08/11. The findings include: A review of the facility's policy entitled, "Medication Administration-General Guidelines," not dated, revealed medications were to be administered as prescribed in accordance with good nursing principles and practices. The procedure portion of the policy revealed medications were to be administered in accordance with written orders of the attending physician. If nursing staff considered a dose excessive, considering the resident's age and/or condition, the nurse was to call the prescriber for clarification. Interviews with Licensed Practical Nurse (LPN) #1 through #9, on 03/08/11 at 10:20 AM, on 03/08/11 at 2:15 PM, on 03/08/11 at 11:15 AM, on 03/07/11 at 4:00 PM, on 03/07/11 at 4:15 PM, on 03/08/11 at 8:45 PM, on 03/08/11 at 9:15 AM, on 03/07/11 at 2:40 PM and on 03/07/11 at 3:00 PM, respectively, revealed the licensed staff routinely altered Resident #14's insulin based on nursing judgement and what each individual nurse felt was best for the resident to maintain an acceptable blood sugar level. The staff interviews revealed they did not contact the physician when altering the resident's dose of insulin. Staff interviews revealed the dose administered was based on such things as food consumption, history, and staff knowledge of the resident. Per interview, the calculated sliding scale insulin requirement was always rounded down to the nearest unit. The licensed staff revealed when the glucometer result was "HI", the sliding scale insulin was administered based on the highest reading the glucometer could register. Interview with LPN #2, #4, #5, #7, and #8 revealed if the glucometer registered "HI" the resident's blood sugar would be above 500 milligrams per deciliter (mg/dl). However, based on the manufacture's instructions a "HI" reading indicated the blood sugar level was greater than 550 mg/dl. Further interview with the licensed staff revealed when the glucometer registered "HI", there was no actual blood sugar reading to calculate the needed dosage of sliding scale insulin. Closed record review revealed Resident #14 was admitted , on 01/10/08, with [DIAGNOSES REDACTED]. 1. A review of the physician orders, dated 11/20/09, revealed an order to administer Humalog insulin (fast acting insulin) per sliding scale based on the calculation of the resident's blood sugar results minus 100 divided by 30. Subsequent physician orders, dated 06/01/10, revealed Resident #14 was to receive [MEDICATION NAME] (long acting insulin) 16 units at supper and to continue the same sliding scale insulin. Review of the resident's Diabetic Record from 09/01/10 through 09/18/10, and interviews with licensed staff revealed the following significant medication errors: On 09/01/10 at 4:00 PM, Resident #14's accucheck result was 413 mg/dl. LPN #5 did not follow the physician's orders [REDACTED]. The resident should have received 10 units of Humalog. On 09/02/10 at 4:00 PM, Resident #14's accucheck result was 470 mg/dl. LPN #2 gave the resident 16 units of [MEDICATION NAME], per the physician's orders [REDACTED]. The nurse should have administered 12 units of Humalog regular insulin in accordance with the calculation per the physician's orders [REDACTED]. On 09/03/10 at 5:00 AM, Resident #14's accucheck result was 335 mg/dl. LPN #7 administered 5 units of Humalog insulin. In accordance with the calculation per physician order, the LPN should have administered 7 units of Humalog regular insulin. On 09/03/10 at 4:00 PM, Resident #14's accucheck result was 386 mg/dl. LPN #5 administered the resident's [MEDICATION NAME] per physician's orders [REDACTED]. LPN #5 should have administered 9 units of Humalog regular insulin per the ordered calculation. On 09/04/10 at 2:30 AM, Resident #14's accucheck result was 440 mg/dl. LPN #7 administered 8 units of Humalog insulin. In accordance with the ordered calculation, LPN #7 should have administered 11 units of Humalog regular insulin. On 09/04/10 at 5:00 AM, Resident #14's accucheck result was 218 mg/dl. LPN #7 administered 10 units of Humalog insulin. In accordance with physician's orders [REDACTED]. Additionally, LPN #7 administered 16 units of [MEDICATION NAME] which was not ordered to be administered at 5:00 AM. On 09/06/10 at 4:00 PM, Resident #14's accucheck result was "HI", which indicated the result was above 550 mg/dl and the actual results could not be determined per the glucometer. LPN #2 administered 16 units of [MEDICATION NAME] and 10 units of Humalog insulin. However, due to the "HI" glucometer result, the resident's actual blood sugar was not determined and the resident's needed dosage of Humalog insulin could not be calculated. On 09/07/10 at 4:00 PM. Resident #14's accucheck result was 236 mg/dl. LPN #6 administered 8 units of [MEDICATION NAME]. In accordance with physician's orders [REDACTED]. On 09/08/10 at 4:00 PM, Resident #14's accucheck result was "HI". LPN #5 administered 8 units of [MEDICATION NAME] and 5 units of sliding scale Humalog insulin. However, per the physician's orders [REDACTED]. Due to the "HI" glucometer result, Resident #14's actual blood sugar was undetermined and the resident's needed dosage of Humalog insulin could not be calculated. On 09/09/10 at 5:00 AM, Resident #14's accucheck result was 449 mg/dl. LPN #7 administered 6 units of Humalog insulin. In accordance with the ordered calculation, LPN #7 should have administered 11 units of Humalog insulin. On 09/09/10 at 4:00 PM, Resident #14's accucheck result was 419 mg/dl. LPN #14 administered 16 units of [MEDICATION NAME] and 6 units of sliding scale Humalog insulin. In accordance with the ordered calculation, LPN #14 should have administered 10 units of Humalog insulin. On 09/10/10 at 4:00 PM, Resident #14's accucheck result was 467 mg/dl. LPN #2 administered 16 units of [MEDICATION NAME] and 5 units of the sliding scale Humalog insulin. In accordance with the ordered calculation, LPN #2 should have administered 12 units of Humalog insulin. On 09/12/10 at 4:00 PM, Resident #14's accucheck result was 184 mg/dl. LPN #4 withheld 16 units of [MEDICATION NAME], without consultation with the resident's physician. LPN #4 should have administered 16 units of [MEDICATION NAME] as ordered. On 09/13/10 at 4:00 PM, Resident #14's accucheck result was "HI". An unidentified LPN administered 16 units of [MEDICATION NAME] and 10 units of the sliding scale Humalog insulin. Resident #14's blood sugar result was undetermined and therefore, the amount of Humalog insulin needed could not be calculated as ordered. On 09/15/10 at 4:00 PM, Resident #14's accucheck result was "HI". LPN #5 administered 16 units of [MEDICATION NAME] and 10 units of sliding scale Humalog insulin. Resident #14's blood sugar result was undetermined and therefore, could not be calculated as ordered. On 09/16/10 at 4:00 PM, Resident #14's accucheck result was 468 mg/dl. LPN #2 administered 16 units of [MEDICATION NAME] and 5 units of sliding scale Humalog insulin. In accordance with the ordered calculation, LPN #2 should have administered 12 units of Humalog insulin. On 09/17/10 at 4:00 PM, Resident #14's accucheck result was 544 mg/dl. LPN #5 administered 16 units of [MEDICATION NAME] and 7 units of the sliding scale Humalog insulin. In accordance with the ordered calculation, LPN #5 should have administered 14 units of the sliding scale Humalog insulin. On 09/18/10 at 4:00 PM, Resident #14's accucheck result was 151 mg/dl. LPN #5 withheld the [MEDICATION NAME], without consulting with the resident's physician. LPN #5 should have administered 16 units of [MEDICATION NAME] as ordered. 2. Review of the physician's orders [REDACTED]. Review of the resident's Diabetic Record from 09/20/10 through 10/05/10 and follow-up interviews with licensed staff revealed the following significant medication errors: On 09/20/10 at 4:00 PM, Resident #14's accucheck result was "HI". LPN #2 administered 12 units of [MEDICATION NAME] and 10 units of the sliding scale Humalog insulin. Resident #14's actual blood sugar was undetermined and the amount of Humalog insulin need could not be calculated. On 09/21/10 at 4:00 PM, Resident #14's accucheck result was "HI". LPN #5 administered 12 units of [MEDICATION NAME] and 10 units of the sliding scale Humalog insulin. Resident #14's actual blood sugar undetermined and the resident's needed dosage of Humalog insulin could not be calculated. On 09/22/10 at 4:00 PM, Resident #14's accucheck result was "HI". LPN #5 administered 12 units of [MEDICATION NAME] and 10 units of the sliding scale Humalog insulin. Resident #14's actual blood sugar was undetermined and the resident's needed dosage of Humalog insulin could not be calculated. On 09/24/10 at 4:00 PM, Resident #14's accucheck result was "HI". LPN #5 administered 12 units of [MEDICATION NAME] and 10 units of the sliding scale Humalog insulin. Resident #14's actual blood sugar was undetermined and the resident's needed dosage of Humalog insulin could not be calculated. On 09/25/10 at 5:00 AM Resident #14's accucheck was "HI". LPN #7 administered 8 units of Humalog insulin. Resident #14's actual blood sugar was undetermined and the resident's needed dosage of Humalog insulin could not be calculated. On 09/27/10 at 4:00 PM, Resident #14's accucheck result was "HI". LPN #9 administered 12 units of [MEDICATION NAME] and 10 units of the sliding scale Humalog insulin. Resident #14's actual blood sugar was undetermined and the resident's needed dosage of Humalog insulin could not be calculated. On 09/28/10 at 4:00 PM, Resident #14's accucheck was 537 mg/dl. LPN #8 administered administered 12 units [MEDICATION NAME] and 7 units of Humalog insulin. In accordance with the ordered calculation, LPN #8 should have administered 14 units of Humalog insulin. On 09/29/10 at 4:00 PM, Resident #14's accucheck result was "HI". LPN #8 administered 12 units of [MEDICATION NAME] and 10 units of the sliding scale Humalog insulin. Resident #14's actual blood sugar was undetermined and the resident's needed dosage of Humalog insulin could not be calculated. On 09/30/10 at 4:00 PM, Resident #14's accucheck result was "HI". LPN #8 administered 12 units of [MEDICATION NAME] and 10 units of the sliding scale Humalog insulin. Resident #14's actual blood sugar was undetermined and the resident's needed dosage of Humalog insulin could not be calculated. On 10/01/10 at 4:00 PM, Resident #14's accucheck result was "HI". LPN #1 administered 12 units of [MEDICATION NAME] and 10 units of the sliding scale Humalog insulin. Resident #14's actual blood sugar was undetermined and the resident's needed dosage of Humalog insulin could not be calculated. On 10/04/10 at 4:00 PM, Resident #14's accucheck was 367 mg/dl. LPN #6 administered 12 units of [MEDICATION NAME] and 5 units sliding scale Humalog insulin. In accordance with the ordered calculation, LPN #6 should have administered 8 units of Humalog insulin. On 10/05/10 at 4:00 PM, Resident #14's accucheck was 331 mg/dl. LPN #5 administered 12 units of [MEDICATION NAME] and no sliding scale Humalog insulin. In accordance with the ordered calculation, LPN #5 should have administered 7 units of Humalog insulin. 3. Review of the physician's orders [REDACTED]. Review of the resident's Diabetic Record from 10/06/10 through 10/28/10 and follow-up interviews with licensed staff revealed the following significant medication errors: On 10/06/10 at 7:00 AM, LPN #1 administered 4 units of sliding scale Humalog insulin based on Resident #14's accucheck of 227 mg/dl, which was obtained at 5:00 AM. Based on the physician's orders [REDACTED]. LPN #1 should not have administered any sliding scale Humalog insulin. On 10/07/10 at 7:00 AM, LPN #1 administered 4 units of sliding scale Humalog insulin based on Resident #14's accucheck of 232 mg/dl, which was obtained at 5:00 AM. Based on the physician's orders [REDACTED]. LPN #1 should not have administered any sliding scale Humalog insulin. On 10/07/10 at 4:00 PM, Resident #14's accucheck result was "HI". LPN #5 administered 14 units of [MEDICATION NAME] and 10 units of the sliding scale Humalog insulin. Resident #14's actual blood sugar was undetermined and the resident's needed dosage of Humalog insulin could not be calculated. On 10/08/10 at 4:00 PM, Resident #14's accucheck result was 463 mg/dl. LPN #5 administered 14 units of [MEDICATION NAME] and 10 units of the sliding scale Humalog insulin. In accordance with the ordered calculation, LPN #5 should have administered 12 units of Humalog insulin. On 10/09/10 at 4:00 PM, Resident #14's accucheck was 302 mg/dl. LPN #3 administered 14 units of [MEDICATION NAME] and no sliding scale Humalog insulin. In accordance with the ordered calculation, LPN #3 should have administered 6 units of Humalog insulin. On 10/10/10 at 4:00 PM, Resident #14's accucheck was 468 mg/dl. LPN #5 administered 14 units of [MEDICATION NAME] and 10 units of sliding scale Humalog insulin. In accordance with the ordered calculation, LPN #5 should have administered 12 units of Humalog insulin. On 10/11/10 at 4:00 PM, Resident #14's accucheck was 503 mg/dl. LPN #5 administered 14 units of [MEDICATION NAME] and 10 units of sliding scale Humalog insulin. In accordance with the ordered calculation, LPN #5 should have administered 13 units of Humalog insulin. On 10/13/10 at 4:00 PM, Resident #14's accucheck result was 133 mg/dl. LPN #5 withheld 14 units of [MEDICATION NAME], without consultation with the resident's physician. LPN #5 should have administered 14 units of [MEDICATION NAME] as ordered. On 10/14/10 at 5:00 AM, Resident #14's accucheck was 326 mg/dl. LPN #7 failed to administer any sliding scale Humalog insulin. In accordance with the ordered calculation, LPN #7 should have administered 7 units of Humalog insulin. On 10/14/10 at 4:00 PM, Resident #14's accucheck was 333 mg/dl. LPN #8 administered 14 units of [MEDICATION NAME] and no sliding scale Humalog insulin. In accordance with the ordered calculation, LPN #8 should have administered 7 units of Humalog insulin. On 10/15/10 at 4:00 PM, Resident #14's accucheck was 523 mg/dl. LPN #2 administered 14 units of [MEDICATION NAME] and no sliding scale Humalog insulin. In accordance with the ordered calculation, LPN #2 should have administered 14 units of Humalog insulin. On 10/16/10 at 4:00 PM, Resident #14's accucheck was 345 mg/dl. LPN #5 administered 14 units of [MEDICATION NAME] and no sliding scale Humalog insulin. In accordance with the ordered calculation, LPN #5 should have administered 8 units of Humalog insulin. On 10/17/10 at 4:00 PM, Resident #14's accucheck was 280 mg/dl. Unknown licensed staff failed to administer either the scheduled 14 units of [MEDICATION NAME] or the 6 units of sliding scale Humalog insulin, which was indicated in accordance with the ordered calculation. On 10/18/10 at 4:00 PM, Resident #14's accucheck result was "HI". LPN #8 administered 14 units of [MEDICATION NAME] and 8 units of the sliding scale Humalog regular insulin. Resident #14's actual blood sugar was undetermined and the resident's needed dosage of Humalog insulin could not be calculated. On 10/19/10 at 4:00 PM, Resident #14's accucheck was 440 mg/dl. LPN #2 administered 14 units of [MEDICATION NAME] and no sliding scale Humalog insulin. In accordance with the ordered calculation, LPN #2 should have administered 11 units of Humalog insulin. On 10/20/10 at 4:00 PM, Resident #14's accucheck was 491 mg/dl. LPN #5 administered 14 units of [MEDICATION NAME] and 10 units of sliding scale Humalog insulin. In accordance with the ordered calculation, LPN #5 should have administered 13 units of Humalog insulin. On 10/21/10 at 5:00 AM, Resident #14's accucheck was 376 mg/dl. LPN #7 administered 7 units of sliding scale Humalog insulin. In accordance with the ordered calculation, LPN #7 should have administered 9 units of Humalog insulin. On 10/21/10 at 4:00 PM, Resident #14's accucheck result was "HI". LPN #5 administered 14 units of [MEDICATION NAME] and 10 units of the sliding scale Humalog regular insulin. Resident #14's actual blood sugar was undetermined and the resident's needed dosage of Humalog insulin could not be calculated. On 10/23/10 at 5:00 AM, Resident #14's accucheck was 333 mg/dl. LPN #7 failed to administer any sliding scale Humalog insulin. In accordance with the ordered calculation, LPN #7 should have administered 7 units of Humalog insulin. On 10/23/10 at 4:00 PM, Resident #14's accucheck result was "HI". LPN #4 administered 14 units of [MEDICATION NAME] and 10 units of the sliding scale Humalog insulin. Resident #14's actual blood sugar was undetermined and the resident's needed dosage of Humalog insulin could not be calculated. On 10/23/10 at 10:00 PM, Resident #14's accucheck result was "HI". LPN #6 administered 10 units of the sliding scale Humalog insulin. Resident #14's actual blood sugar was undetermined and the resident's needed dosage of Humalog insulin could not be calculated. On 10/25/10 at 4:00 PM, Resident #14's accucheck result was "HI". LPN #9 administered 14 units of [MEDICATION NAME] and 8 units of the sliding scale Humalog insulin. Resident #14's actual blood sugar was undetermined and the resident's needed dosage of Humalog insulin could not be calculated. On 10/28/10 at 4:00 PM, Resident #14's accucheck was 461 mg/dl. LPN #5 administered 14 units of [MEDICATION NAME] and 8 units of the sliding scale Humalog insulin. In accordance with the ordered calculation, LPN #5 should have administered 12 units of Humalog insulin. 4. Review of the physician's orders [REDACTED]. A review of the pre-printed orders revealed sliding scale insulin was to be given for blood sugar results greater than 250 mg/dl. Review of the resident's Diabetic Record from 11/01/10 through 01/09/11 and follow-up interviews with licensed staff revealed the following significant medication errors: On 11/01/10 at 4:00 PM, Resident #14's accucheck was 493 mg/dl. LPN #2 administered 8 units of the sliding scale Humalog insulin. In accordance with the ordered calculation, LPN #2 should have administered 9 units of Humalog insulin. On 11/03/10, Resident #14's accucheck was 161 mg/dl at 6:00 AM. LPN #1 failed to administer Resident #14's scheduled dose of 14 units [MEDICATION NAME] at 7:00 AM as ordered. LPN #1 administered the 14 units of [MEDICATION NAME] at 11:00 AM. On 11/03/10 at 4:00 PM, Resident #14's accucheck result was "HI". LPN #5 administered 10 units of the sliding scale Humalog insulin. Resident #14's actual blood sugar was undetermined and the resident's needed dosage of Humalog insulin could not be calculated. On 11/04/10 at 4:00 PM, Resident #14's accucheck result was "HI". LPN #5 administered 10 units of the sliding scale Humalog insulin. Resident #14's actual blood sugar was undetermined and the resident's needed dosage of Humalog insulin could not be calculated. On 11/05/10 at 5:00 AM, Resident #14's accucheck was 414 mg/dl. LPN #7 administered 5 units of the sliding scale Humalog insulin. In accordance with the ordered calculation, LPN #7 should have administered 7 units of Humalog insulin. On 11/08/10 at 5:00 AM, Resident #14's accucheck was 280 mg/dl. LPN #6 failed to administer any sliding scale Humalog insulin. In accordance with the ordered calculation, LPN #6 should have administered 4 units of Humalog insulin. On 11/08/10 at 4:00 PM, Resident #14's accucheck result was "HI". LPN #5 administered 10 units of the sliding scale Humalog regular insulin. Resident #14's actual blood sugar was undetermined and the resident's needed dosage of Humalog insulin could not be calculated. On 11/09/10 at 4:00 PM, Resident #14's accucheck result was "HI". LPN #5 administered 10 units of the sliding scale Humalog regular insulin. Resident #14's actual blood sugar was undetermined and the resident's needed dosage of Humalog insulin could not be calculated. On 11/10/10 at 4:00 PM, Resident #14's accucheck was 502 mg/dl. LPN #5 administered 14 units of [MEDICATION NAME] and 7 units of sliding scale Humalog insulin. LPN #5 should not have administered the 14 units of [MEDICATION NAME] as the time of administration had been changed to 7:00 AM on 10/29/10. In accordance with the ordered calculation, LPN #5 should have administered 10 units of Humalog insulin. On 11/11/10 at 7:00 AM, Resident #14's accucheck result was 137 mg/dl. LPN #1 withheld the [MEDICATION NAME], without consulting with the resident's physician. LPN #1 should have administered 14 units of [MEDICATION NAME] as ordered. On 11/12/10 at 4:00 PM, Resident #14's accucheck result was "HI". LPN #6 administered 10 units of the sliding scale Humalog regular insulin. Resident #14's actual blood sugar was undetermined and the resident's needed dosage of Humalog insulin could not be calculated. On 11/13/10 at 4:00 PM, Resident #14's accucheck result was "HI". LPN #5 administered 10 units of the sliding scale Humalog regular insulin. Resident #14's actual blood sugar was undetermined and the resident's needed dosage of Humalog insulin could not be calculated. On 11/14/10 at 5:00 AM, Resident #14's accucheck was 302 mg/dl. LPN #6 failed to administer any sliding scale Humalog insulin. In accordance with the ordered calculation, LPN #6 should have administered 5 units of Humalog insulin. On 11/14/10 at 4:00 PM, Resident #14's accucheck result was "HI". LPN #5 administered 10 units of the sliding scale Humalog insulin. Resident #14's actual blood sugar was undetermined and the resident's needed dosage of Humalog insulin could not be calculated. On 11/15/10 at 12:00 AM, Resident #14's accucheck result was "HI". LPN #6 administered 10 units of the sliding scale Humalog insulin. Resident #14's actual blood sugar was undetermined and the resident's needed dosage of Humalog insulin could not be calculated. On 11/15/10 5:00 AM, Resident #14's accucheck was "HI". LPN #6 failed to administer the sliding scale Humalog insulin. Resident #14's actual blood sugar was undetermined and the resident's needed dosage of Humalog insulin could not be calculated. On 11/15/10 at 4:00 PM, Resident #14's accucheck result was "HI". LPN #2 administered 10 units of the sliding scale Humalog insulin. Resident #14's actual blood sugar was undetermined and the resident's needed dosage of Humalog insulin could not be calculated. On 11/16/10 at 4:00 PM, Resident #14's accucheck result was "HI". LPN #5 administered 10 units of the sliding scale Humalog insulin. Resident #14's actual blood sugar was undetermined and the resident's needed dosage of Humalog insulin could not be calculated. On 11/17/10 at 4:00 PM, Resident #14's accucheck result was "HI". LPN #5 administered 10 units of the sliding scale Humalog regular insulin. Resident #14's actual blood sugar was undetermined and the resident's needed dosage of Humalog insulin could not be calculated. On 11/19/10 at 5:00 AM, Resident #14's accucheck was 268 mg/dl. LPN #7 failed to administer any sliding scale Humalog insulin. In accordance with the ordered calculation, LPN #7 should have administered 4 units of Humalog insulin. On 11/21/10 at 5:00 AM, Resident #14's accucheck was 326 mg/dl. LPN #6 failed to administer any sliding scale Humalog insulin. In accordance with the ordered calculation, LPN #6 should have administered 5 units of Humalog insulin. On 11/22/10 at 4:00 PM, Resident #14's accucheck result was "HI". LPN #5 administered 10 units of the sliding scale Humalog regular insulin. Resident #14's actual blood sugar was undetermined and the resident's needed dosage of Humalog insulin could not be calculated. On 11/24/10 at 4:00 AM, Resident #14's accucheck was 274 mg/dl. LPN #5 failed to administer any sliding scale Humalog insulin. In accordance with the ordered calculation, LPN #5 should have administered 4 units of Humalog insulin. On 11/26/10 at 4:00 PM, Resident #14's accucheck result was "HI". LPN #2 administered 10 units of the sliding scale Humalog insulin. Resident #14's actual blood sugar was undetermined and the resident's needed dosage of Humalog insulin could not be calculated. On 11/27/10 at 5:00 AM, Resident #14's accucheck result was "HI". LPN #7 administered 8 units of the sliding scale Humalog insulin. Resident #14's actual blood sugar was undetermined and the resident's needed dosage of Humalog insulin could not be calculated. On 11/27/10 at 4:00 PM, Resident #14's accucheck result was "HI". LPN #5 administered 10 units of sliding scale Humalog regular insulin. Resident #14's blood sugar could not be determined and the resident's needed dosage of Humalog insulin could not be calculated. On 11/29/10 at 4:00 PM, Resident #14's accucheck result was 367 mg/dl. LPN #5 administered 5 units of sliding scale Humalog insulin. In accordance with the ordered calculation, LPN #5 should have administered 6 units of Humalog insulin. On 12/01/10 at 4:00 PM, Resident #14's accucheck was 256 mg/dl. LPN #5 did not administer sliding scale Humalog insulin. In accordance with the ordered calculation, LPN #5 should have administered 3 units of Humalog insulin. On 12/10/10 at 5:00 AM, Resident #14's accucheck was 361 mg/dl. LPN #7 did not administer sliding scale Humalog insulin. In accordance with the ordered calculation, LPN #7 should have administered 6 units of Humalog insulin. On 12/12/10 at 4:00 PM, Resident #14's accucheck was 509 mg/dl. LPN #7 administered 5 units of sliding scale Humalog insulin. In accordance with the ordered calculation, LPN #5 should have administered 10 units of Humalog insulin. On 12/13/10 at 4:00 PM, Resident #14's accucheck was 411 mg/dl. LPN #9 administered 4 units of sliding scale Humalog insulin. In accordance with the ordered calculation, LPN #9 should have administered 7 units of Humalog insulin. On 12/14/10 at 4:00 PM, Resident #14's accucheck was 476 mg/dl. LPN #2 administered 5 units of sliding scale Humalog insulin per nursing judgment. In accordance with the ordered calculation, LPN #2 should have administered 9 units of Humalog insulin. On 12/15/10 at 4:00 PM, Resident #14's accucheck was 377 mg/dl. LPN #2 administered 5 units of sliding scale Humalog insulin. In accordance with the ordered calculation, LPN #2 should have administered 6 units of Humalog insulin. On 12/16/10 at 4:00 PM, Resident #14's accucheck was 383 mg/dl. LPN #2 administered 5 units of sliding scale Humalog insulin. In accordance with the ordered calculation, LPN #2 should have administered 7 units of Humalog insulin. On 12/17/10 at 4:00 PM, Resident #14's accucheck result was "HI". LPN #2 administered 10 units of sliding scale Humalog regular insulin. Resident #14's blood sugar could not be determined and the resident's needed dosage of Humalog insulin could not be calculated. On 12/19/10 at 4:00 PM, Resident #14's accucheck result was "HI". LPN #4 administered 10 units of sliding scale Humalog regular insulin. Resident #14's blood sugar could not be determined and the resident's needed dosage of Humalog insulin could not be calculated. On 12/20/10 at 4:00 PM, Resident #14's accucheck result was "HI". LPN #1 administered 10 units of sliding scale Humalog regular insulin. Resident #14's blood sugar could not be determined and the resident's needed dosage of Humalog insulin could not be calculated. On 12/21/10 at 5:00 AM, Resident #14's accucheck result was 270 mg/dl. LPN #15 did not administer sliding scale Humalog insulin. In accordance with the ordered calculation, LPN #15 should have administered 4 units of Humalog insulin. On 12/22/10 at 4:00 PM, Resident #14's accucheck result was "HI". LPN #1 administered 10 units of sliding scale Humalog regular insulin. Resident #14's blood sugar could not be determined and the resident's needed dosage of Humalog insulin could not be calculated. On 12/23/10 at 5:00 AM, Resident #14's accucheck result was "HI". LPN #7 administered 7 units of sliding scale Humalog insulin. Resident #14's blood sugar could not be determined and the resident's needed dosage of Humalog insulin could not be calculated. On 12/23/10 at 4:00 PM, Resident #14's accucheck result was "HI". LPN #2 administered 10 units of sliding scale Humalog insulin. Resident #14's blood sugar could not be determined and the resident's needed dosage of Humalog insulin could not be calculated. On 12/23/10 at 8:00 PM, Resident #14's accucheck result was "HI". LPN #7 administered 5 units of sliding scale Humalog insulin. Resident #14's blood sugar could not be determined and the resident's needed dosage of Humalog insulin could not be calculated. On 12/24/10 at 5:00 AM, Resident #14's accucheck result was 377 mg/dl. LPN#7 did not administer sliding scale Humalog insulin. In accordance with the ordered calculation, LPN #7 should have administered 6 units of Humalog insulin. On 12/24/10 at 4:00 PM, Resident #14's accucheck result was "HI". An unidentified LPN administered 10 units of sliding scale Humalog regular insulin. Resident #14's blood sugar could not be determined and the resident's needed dosage of Humalog insulin could not be calculated. On 12/25/10 at 12:00 AM, Resident #14's accucheck result was "HI". LPN #7 administered 5 units of sliding scale Humalog insulin. Resident #14's blood sugar could not be determined and the resident's needed dosage of Humalog insulin could not be calculated. On 12/25/10 at 5:00 AM, Resident #14's accucheck result was 344 mg/dl. LPN #7 did not administer sliding scale Humalog insulin. In accordance with the ordered calculation, LPN #7 should have administered 6 units of Humalog insulin. On 12/27/10 at 6:00 AM, Resident #14's accucheck result was 211 mg/dl LPN #1 administered 10 units of [MEDICATION NAME]. LPN #1 should have administered 14 units of [MEDICATION NAME] as ordered. On 12/27/10 at 4:00 PM, Resident #14's accucheck result was "HI". LPN #2 administered 10 units of sliding scale Humalog insulin. Reside

Based on interview, record review, and review of facility policies, it was determined the facility failed to ensure the quality assessment and assurance committee was effective in identifying and correcting quality of care issues related to the inappropriate administration of insulin for one resident (#14) in the selected sample of fifteen residents. The facility failed to ensure policy and procedures related to medication administration were followed and resident's were free from significant medication errors. Resident #14 had multiple [DIAGNOSES REDACTED]. sugar. Record review revealed from 09/01/10 through 01/13/11, the facility's licensed nurses failed to administer or hold (did not administer) insulin medication to Resident #14 in accordance to the physician's order a total of one hundred and ten (110) times. The documentation revealed the licensed nursing staff withheld the resident's routine scheduled insulin (non sliding scale) six (6) times; withheld sliding scale insulin despite the physician's order to administer the insulin based on the resident's elevated blood sugar level twenty-four (24) times; and, altered the dosage of sliding scale insulin that was not in accordance with the physician order for [REDACTED].#14 was at risk for severe hyperglycemic and hypoglycemic episodes. The facility's failure to identify quality of care issues related to the inappropriate administration of insulin resulted in a situation that was likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy was determined to exist on 09/01/10 and the facility was notified, on 03/08/11. The findings include: A review of the facility policy entitled, Quality Assurance Program, with an effective date of January 1996 and a revision date of May 2004, revealed the facility's Quality Assurance Program was a comprehensive program designed to monitor all departments and the physical plant in order to identify areas in which there are problems or opportunities for improvement. The Executive Quality Assurance Committee is responsible for the implementation of the program through development of appropriate plans of action that support and encourage quality care and correct identified quality deficiencies. The Policy further states that the Director of Nursing is the Quality Assurance Coordinator. The facility admitted Resident #14, on 01/10/08, with [DIAGNOSES REDACTED]. Closed record review of the resident's Diabetic Records for the months of September 2010, October 2010, November 2010, December 2010 and January 2011 revealed on 110 occasions licensed nursing staff altered the amount of sliding scale insulin administered, withheld both routine insulin and sliding scale insulin, administered sliding scale insulin of various amounts without a valid blood sugar result needed to calculate the dosage of insulin, altered the dosage and time of administration of the routine [MEDICATION NAME] all of which was not in accordance with the physician's orders for Resident #14. The documentation revealed the licensed nursing staff withheld the resident's routine scheduled insulin (non sliding scale) six (6) times; withheld sliding scale insulin despite the physician's order to administer the insulin based on the resident's elevated blood sugar level twenty-four (24) times; and, altered the dosage of sliding scale insulin that was not in accordance with the physician order for [REDACTED].#14's medical record revealed no documented evidence that the licensed nurses notified the physician when a need to alter treatment was indicated. Additionally, there was no documented evidence that the charge nurse made two attempts to notify the attending physician within a ten minute period and when unsuccessful, notified the physician on call or the Medical Director regarding the need to alter Resident #14's diabetic treatment. (Refer to F333 for Resident #14's physician orders related to diabetic management and for specific detail of dates of the facility administering diabetic medications not in accordance with the physician's orders) The facility could provide no evidence that their Quality Assurance program had identified or implemented a plan of correction related to their licensed nursing staff routinely altering Resident #14's diabetic treatment without notifying the physician (attending/on call/medical director). Interviews with the Director of Nursing (DON) designated as the Quality Assurance Coordinator, on 02/25/11 at 5:00 PM and on 03/08/11 at 1:05 PM, revealed the nurse should never alter any dose of medication based on nursing judgement, and if the licensed staff had a concern regarding the administration of any medication she would expect the staff to notify the physician of their concern and seek direction for administration. She further revealed that had never identified this practice occurring in this facility. An interview with the facility's former administrator (04/01/02 through 01/28/11), on 03/18/11 at 9:20 AM, revealed the Continuous Quality Improvement (CQI) committee met at least quarterly to discuss identified problems or concerns and develop action plans to address any identified areas. She stated she was unaware the licensed nursing staff was not administering insulin in accordance with written physician's orders, but felt it was a problem she should have been aware of through the CQI process. An interview with the facility Medical Director, on 03/18/11 at 10:25 AM, revealed the CQI committee met at least quarterly and more often as needed. He stated the CQI process should, hopefully, identify an issue such as improper insulin administration but he was unaware of the problem until identified through the survey process. An interview with the facility's current administrator and the facility owner, on 03/18/11 at 11:15 AM, revealed care issues were identified through the CQI process by review of quality indicators, review of audits completed for each department, concerns brought to managements attention from either staff members, residents or resident's families and from rounds conducted to observe care. While the facility identifies quality concerns through these methods, they could not provide evidence that their CQI process had identified these failures in improper insulin administration. An acceptable Allegation of Compliance (AoC) was received on 03/16/11 and detailed as follows: Criteria #1: Resident #14 no longer resides at the facility. An audit was completed by the Assistant Director of Nursing (ADON) of the diabetes management interventions documented for Resident #14, with investigation of the circumstances in which insulin administration was not consistent with the MD (physician) orders. The facility disciplinary action policy was has been implemented for the licensed nursing staff identified to have insulin administration inconsistent with MD orders, in the form of a final written warning with further non-compliance to result in disciplinary action up to and including termination. Criteria #2: An audit has been completed by the ADON on 03/09/11 of the facility residents with the [DIAGNOSES REDACTED]. Addendum to the audit was made on 03/15/11 by the ADON identifying the error of administering sliding scale insulin without having an actual glucose reading, instead basing the calculation on a reading of "HIGH." The DON and Administrator reviewed these findings. All identified discrepancies involving inaccurate insulin dosage administration were identified as significant medication errors and were reviewed with and acknowledged by the attending physician to discuss the residents current status and review current insulin orders. No new physician orders were indicated or determined by the physicians. MD orders for parameters for reporting of high and low glucose levels were obtained for residents receiving insulin injections. The [MEDICAL CONDITION] policy was provided and acknowledged by the facility attending physicians and Medical Director. Criteria #3: The facility policy/procedure for Diabetes Management, including management of [MEDICAL CONDITION] was reviewed/revised to address the following: A. Obtaining, interpreting, and reporting of glucose finger sticks in accordance with physician orders and physician ordered result parameters. B. Assessment of the resident with abnormal glucose finger stick results, with documentation and reporting of the findings. C. Administration of insulin in accordance with physician orders to avoid significant medication errors. The facility has implemented a new Diabetic Record to be used for the documentation of glucose finger stick results, insulin dosage orders, and administration. The DON received in-service education as provided by the nursing consultant by telephone conversations on 03/08/11 and 03/09/11, prior to the in-service for the licensed staff on the following: A. The F-157 regulatory requirements for physician notification, including notification of the MD for finger stick glucose results in accordance with MD ordered parameters, and MD notification of assessment findings related to resident change in status, especially as associated with [MEDICAL CONDITION]. B. Administration of insulin in accordance with MD orders, and the need to notify the physician if the residents status denotes that insulin order changes may be indicated. C. Review of the facility Diabetes Management Policies and Procedures and revisions, including the new Diabetic Record; physician ordered parameters for the reporting of glucose finger stick results; the calculation of sliding scale insulin dosage in accordance with MD orders; and the administration of insulin in accordance with physician orders. D. The protocol for two nurses to verify and initial routine and sliding scale insulin doses administered to residents. The DON received in-service education as provided by the nursing consultant on 03/15/11, prior to the in-service for the licensed nursing staff on the following: A. Revisions to the Diabetic Management-[MEDICAL CONDITION] policy. B. Administration of insulin in accordance with MD orders, and the need to notify the physician if the resident's status denotes that insulin order changes may be indicated. Utilizing the employee listing, licensed nursing staff have received in-service education provided by the DON on 03/09/11, on 03/15/11 and on 03/16/11 regarding Diabetes Management interventions, including but not limited to the following: A. The F-157 regulatory requirements for physician notification, including notification of the MD for finger stick glucose results in accordance with MD ordered parameters, and MD notification of assessment findings related to resident change in status, especially as associated with [MEDICAL CONDITION]. B. Administration of insulin in accordance with MD orders to prevent a significant medication error, and the need to notify the physician if the residents status denotes that insulin order changes may be indicated. C. Review of the facility Diabetes Management Policies and Procedures and revisions, including the new Diabetic Record; physician ordered parameters for the reporting of glucose finger stick results; the calculation of sliding scale insulin dosage in accordance with MD orders; and the administration of insulin in accordance with physician orders. D. The protocol for two nurses to verify and initial routine and sliding scale insulin doses administered to residents. Licensed nursing staff were administered a written medication administration test which included questions pertaining to insulin, as provided by the DON on 03/09/11, on 03/15/11 and on 03/16/11. Licensed nurses will be provided the in-service information referenced above as part of the facility orientation process, and will have completion of the Diabetes Management Skills Checklist as provided by the DON or designee. The Administrator has reviewed all in-service information and verified attendance of licensed nursing staff on 03/17/11. Criteria #4: Two (2) licensed nursing staff will verify and initial routine and sliding scale insulin doses administered to residents. The CQI indicator for the monitoring of compliance with the facility policy/procedure and MD orders for Diabetes Management will be utilized monthly X 2 months, and then quarterly thereafter under the supervision of the DON. The Administrator will review the completed CQI indicator to determine compliance and to determine if an action plan is indicated for any identified issues. The DON and/or Nurse Consultant will review all facility Diabetic Records weekly X 1 month, and then five chosen randomly on a monthly basis thereafter to determine compliance with the facility policies/procedures and MD orders. The CQI indicator for the monitoring of the effectiveness of the QA process will be utilized monthly X 2 months and then quarterly under the supervision of the Administrator. The Corporate Consultant will review the completed CQI indicator to determine if an action plan is indicated for any identified issues. A Diabetes Management skills check list is being completed on two licensed nursing staff daily for two weeks, and then weekly for four weeks, and then monthly for three months, and then quarterly thereafter by the DON/Pharmacy Consultant/Administrative Nursing/Nursing Consultant during observations of finger stick glucose testing and insulin preparation/administration to determine compliance with these procedures and accurate insulin administration. Criteria #5: March 17, 2011. During the extended survey, on 03/16/11 through 03/18/11, verification of the removal of Immediate Jeopardy was completed as follows: Interviews with Registered Nurse (RN) #1, RN #2, RN #3, LPN #8, LPN #9, LPN #10, LPN #11, LPN #12 and LPN #13, on 03/17/11 at 2:25 PM, on 03/18/11 at 9:00 AM, on 03/17/11 at 11:35 AM, on 03/17/11 at 2:17 PM, on 03/18/11 at 9:30 AM, on 03/17/11 at 1:55 PM, on 03/17/11 at 10 :35 AM, on 03/17/11 at 3:00 PM and on 03/17/11 at 1:50 PM respectively, revealed the licensed staff were educated regarding notification of the physician for finger stick glucose results in accordance with physician ordered parameters, physician notification of assessment findings related to resident change in status, administration of insulin in accordance with physician orders to prevent a significant medication error; the need to notify the physician if the residents status denotes that insulin order changes may be indicated; physician ordered parameters for the reporting of glucose finger stick results; the calculation of sliding scale insulin dosage in accordance with physician orders; and the protocol for two nurses to verify and initial routine and sliding scale insulin doses administered to residents. The interviews revealed the staff understood the content of the inservice and individual responsibility. Observations of RN #1, LPN #11 and LPN #13, on 03/17/11 between 11:00 AM and 11:45 AM, revealed staff obtained accuchecks on five residents and administered insulin to four residents. Insulin doses were verified by two licensed staff as directed by the AoC. Both routine insulin and sliding scale insulin was administered in accordance with the written physician order. A record review, on 03/17/11 at 10:30 AM, revealed the facility had initiated Diabetic Management check lists for all licensed nursing staff on 03/11/11 and had completed 16 competency checks at the time of review with the process continuing until all licensed nursing staff had been checked off. A record review, on 03/17/11 at 10:35 AM, revealed all licensed nursing staff had completed a written test on medication administration and review of the test revealed questions pertained to Diabetes, insulin and insulin administration including questions requiring the staff to calculate sliding scale insulin doses. A review of all residents records with the [DIAGNOSES REDACTED]. Record review also revealed four residents with the [DIAGNOSES REDACTED]. A review of the facility's audit of other residents with the potential to be affected by the deficient practice revealed the facility identified other residents affected by the practice and notified the physician of each resident affected by the deficient practice. A review of sign-in sheets for all in-services the facility provided in response to the Immediate Jeopardy revealed all licensed staff had attended the training sessions except one staff member who was hospitalized . An interview with the DON, on 03/17/11 at 2:00 PM, revealed the DON would monitor the Continuous Quality Improvement (CQI) by auditing all diabetic records weekly for one month and then five chosen randomly on a monthly basis thereafter to determine compliance with the facility policy/procedure and physician orders. The DON stated the audit would include whether the resident had Diabetes identified through the care plan process, monitoring of the diabetic record to ensure accuracy and completion, parameters for [DIAGNOSES REDACTED] and [MEDICAL CONDITION] were listed on both the Diabetic Record and the physician orders and documentation of evening snacks provided to Diabetic residents. She stated all hypo and hyperglycemic events would be reviewed to ensure all protocols were followed. The DON stated if audits do not demonstrate at least 95 percent compliance, an action plan would be developed immediately to address any identified problems. An interview with the Administrator, on 03/18/11 at 11:15 AM, revealed he would be completing a check list after reviewing audits completed by the DON to ensure policy and procedure was followed correctly and if any problem were to be identified regarding audits not being completed as directed by the AoC, he would initiate disciplinary action. Based on the above observations, interviews and review of records, it was determined the Immediate Jeopardy was removed, effective 03/17/11, as alleged in the AoC with the scope and severity lowered to an "E", based on the need to continue to evaluate the implementation of changes and quality assurance activities.

Based on interview, record review, and review of the facility's policy and procedures, facility's Compliance Checklist, and Plan of Correction (PoC) it was determined the facility failed to implement their PoC to identify quality concerns related to following physician's orders for one resident of ten sampled residents (Resident #8). Review of the facility's PoC revealed the DON and/or Nurse Consultant would review all facility Diabetic Records weekly times one month (03/12/11-04/01/11) to determine compliance with the facility's policies and procedures and physician's orders. Review of Resident #8's Diabetic Record for 03/24/11 revealed the resident's blood sugar was 418 and 16 units of [MEDICATION NAME]was given. However, review of the Physician's orders revealed there was no Physician order to administer [MEDICATION NAME] 16 units. (Refer to F281) A review of the facility's monitoring information indicated Resident #8's Diabetic Record had been reviewed on 03/25/11 and 04/01/11 and there was no evidence any concerns were identified related to Resident #8. The findings include: A review of the facility's "Quality Assurance Program" policy, last revised May 2004, revealed the facility's Quality Assurance Program was a comprehensive Program designed to monitor all departments and the physical plant in order to identify areas in which there were problems or opportunities for improvement. The Executive Quality Assurance Committee was responsible for the implementation of the program through development of appropriate plans of action that support and encourage quality care and correct identified quality deficiencies. The policy further stated the Director of Nursing (DON) was the Quality Assurance Coordinator. A review of the facility's PoC, dated 03/18/11, revealed the DON and/or Nurse Consultant would review all Diabetic Records weekly times one month (03/12/11-04/01/11), then five chosen randomly on a monthly basis thereafter to determine compliance with the facility's policy and procedures and Physician's orders. A record review revealed Resident #8 resided on Hall 100. A review of the Physician's orders, dated 02/04/11 and 03/07/11, revealed [MEDICATION NAME] 100 units/milliliter vial, Sliding scale insulin, with the following parameters: blood sugar minus 100 divided by 30 equals number of insulin units if blood sugar (B/S) greater than 200. The Physician was to be notified if the B/S was below 50 or above 400. A review of a Diabetic Record revealed Resident #8's BS was 418 on 03/24/11 at 11:30 AM and 16 units of [MEDICATION NAME]was administered. Review of the Nurse's Notes and Physician's orders revealed there was no order for the 16 units of insulin. A review of the facility's Compliance Checklist revealed the Diabetic Records of all residents with Diabetes were checked on 03/12/11, 03/18/11, 03/25/11, and 04/01/11. There was no evidence that any concerns were identified with any of the records. An interview with the DON, Assistant Director of Nursing (ADON), and Corporate Consultant, on 04/14/11 at 10:00 AM, revealed the check marks on the Compliance Checklist indicated that all Diabetic Records on the 100 Hall were reviewed by the DON. The DON stated the check marks indicated the Diabetic Sheets were reviewed and all concerns identified were corrected immediately. The DON revealed she did not recall finding any concerns with any of the Diabetic monitoring on Hall 100. When the DON was made aware of the concerns with Resident #8's Diabetic Flow Sheet, she stated she would have to check her notes and see if she had found anything. Further interview with the DON on 04/14/11 at 11:00 AM, revealed she had identified this discrepancy at the time of the audit, but failed to document the information. Per the DON, she had made the Nurse aware of the identified concerns for Resident #8 at the time of the audit, and the Nurse was supposed to correct them. The DON stated she did not follow up to ensure the corrections were made. However, interview with LPN #1, on 04/14/11 at 9:30 AM, revealed she was not aware she had forgotten to write the Physician's order and document in the Nurse's Note until after surveyor intervention.