Every finding on record at Henderson Nursing and Rehabilitation Center

Based on observation, interview, and review of the facility's policies, 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 for 1 of 6 sampled residents, Resident (R)79. The findings include: Review of the facility's policy titled, Medication Administration, revised 03/2026, revealed the purpose is for medications to be administered by licensed staff who will follow the established facility infection control procedures. Review of the facility's policy titled, Hand Hygiene Protocol, not dated, revealed hand hygiene means cleaning your hands by using either handwashing (washing hands with soap and water), antiseptic hand wash, antiseptic hand rub (i.e. alcohol-based hand sanitizer including foam or gel). Gloves may be used including but not limited to food and medication preparation areas. In addition, gloves changed, and hand hygiene performed before moving from a contaminated-body site to a clean-body site during resident care. Review of the facility's policy titled, Infection Control Policy, revised 03/2026, revealed the facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. Maintaining a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public. All personnel will be trained on our infection control policies and practices upon hire and periodically thereafter. The depth of employee training shall be appropriate to the degree of direct resident contact and job responsibilities. Observation on 06/03/2026 10:19 AM revealed (Kentucky Medication Aid) KMA 2 did not sanitize their hands after each resident medication administration. In addition, KMA 2 dropped Risperidone 0.5 mg on top of medication cart 1. KMA 2 picked up the pill with bare hands instead of discarding the pill, it was administered to 1 resident (R) 79. KMA 2 was observed to administer Flonase for R 79. She did not perform hand washing nor hand sanitizing before or after. During an interview with KMA 2 on 06/03/2026 at 10:31 AM, she stated per the facilities policy she sanitized after every third person she administered to. She stated she should have sanitized after each medication administration to prevent any transmission of infections. She stated she had discarded Risperidone 0.5 mg after it dropped on top of medication cart 1. However, after reflecting to the event, she stated you are right, I did not discard it. During an interview on 06/05/2026 at 2:30 PM with Infection Preventionist Nurse, she stated KMA are to hand wash after each resident when passing out medications, if possible, otherwise the use of hand sanitizer at the very least. She stated in-services related to hand hygiene were held each month. During an interview on 06/05/2026 at 3:34 PM with the Administrator, she stated her expectation was for staff to follow physician medication orders. She expected KMA to sanitize their hands in between residents at the very least if unable to wash their hands with soap and water. During an interview on 06/05/2026 at 3:42 PM with DON, she stated her expectation was for staff to wash their hands after each medication pass. She stated hand hygiene training was a yearly checkoff and impromptu training when there were concerns.

Based on observation, interview, record review, and review of facility policy, the facility failed to implement a comprehensive person centered care plan for 2 of 23 sampled residents, (Resident (R)50, and R42). 1. Review of R50's comprehensive person centered care plan revealed the resident was to wear left and right hand and knee splints daily for six days. However, observation on 05/13/2025 at 12:03 PM and 2:18 PM, on 05/14/2025 at 9:10 AM, 11:23 AM , on 05/15/2025 at 9:20 AM and 11:30 AM of R50, revealed two hand splints lying on the resident's bedside table; and observation on 05/16/2025 at 10:18 AM revealed the hand splints were located in R50's closet. Additionally, observation on 05/13/2025 at 12:03 PM and 2:18 PM, on 05/14/2025 at 9:10 AM, 11:23 AM revealed R50 lying on her bed with no knee splints in place and her knees drawn up to her chest. 2. Review of R42's comprehensive person centered care plan revealed the resident was not to have chips and was to be supervised with all (oral) intake. However, observation on 05/13/2025 at 11:42 AM and 2:48 PM, revealed R42 self-propelling throughout the facility while eating a bag of potato chips unsupervised. The findings include: Review of the facility policy, Comprehensive Care Plans, Standard of Practice, reviewed on 04/2025, revealed an individualized comprehensive care plan that included measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychosocial needs was to be developed for each resident. Continued review revealed, each resident's comprehensive care plan was designed to identify problem areas, reflect the resident's needs, reflect treatment goals, timetables and objectives. Per review, the comprehensive care plan was also to identify professional services that were responsible for each element of care, and aid in preventing or reducing declines in the residents. Further review revealed functional level care plans were reviewed and updated when there was a significant change in the resident's condition, when the desired outcome was not met, or when the resident was readmitted to the facility from a hospital stay and at least quarterly. 1. Review of the, admission Face Sheet for R50 revealed the facility admitted the resident on 06/29/2021, with diagnoses to include: persistent vegetative state; epilepsy, intractable, without status epilepticus: and encounter for attention to tracheostomy. Review further revealed R50 developed contractures to an unspecified joint of the left and right wrist on 02/20/2023. Review of the Significant Change in Status Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 04/20/2025, revealed under section B the facility assessed R50 as being in a persistent vegetative state. Further review revealed the Brief Interview for Mental Status (BIMS) assessment area had not been completed. Review of the Comprehensive Care Plan for R50 dated 06/13/2024, revealed the facility identified a focus problem that read splint and or brace assistance, the resident required the use of a splint/brace to prevent further contractures related to persistent vegetative state, anoxic brain damage, contracture of unspecified joint, and contracture of muscle. Per review, the interventions included: removing the Posey splints as needed to inspect skin; inspecting the splints for damage and reporting to therapy immediately; and removing splints as needed for ADL care. Continued review revealed the interventions also included: restorative nursing rehabilitation (rehab; for 90 days; and passive range of motion to bilateral lower extremities. Further review revealed the target goals dated 06/14/2024 were that the resident would tolerate resting hand splint to right hand without pain for five hours daily as resident allowed from 9:00 AM to 2:00 PM, six days a week through next review. In addition, review revealed the target goals also included: the resident would tolerate grip splint to left hand without pain for five hours daily as resident allowed from 9:00 AM to 2:00 PM, six days a week through next review. Review further revealed the target goals additionally noted the resident would tolerate Posey splints to bilateral knees without pain for six hours daily as resident allowed from 9:00 AM to 3:00 PM, six days a week through next review. However, observation on 05/13/2025 at 12:03 PM and 2:18 PM, on 05/14/2025 at 9:10 AM, 11:23 AM , on 05/15/2025 at 9:20 AM and 11:30 AM of R50, revealed two hand splints lying on R50's bedside table and the resident had no splints in place as per the care plan. Observation on 05/16/2025 at 10:18 AM, revealed the hand splints were located in R50's closet and the resident had no hand splints in place as per the care plan. Observation on 05/13/2025 at 12:03 PM and 2:18 PM, on 05/14/2025 at 9:10 AM, 11:23 AM also revealed R50 lying on her bed with no knee splints in place as per the care plan and she had her knees drawn up to her chest. In interview with Restorative Aide (RA) 8 on 05/16/2025 at 9:45 AM, she stated she was told that morning by the Director of Rehab (DoR) that R50 was to resume restorative services including the splinting next week. She reported when residents went on restorative programs she received training from the DoR and signed a paper. RA 8 said R50 was to have left and right hand splints and knee splints to both legs, and was to wear the splints six hours a day. She stated R50 received passive range of motion (ROM) to her extremities before the splints were applied. The RA further stated the restorative binder had all residents' restorative programs in it. In interview with Kentucky Medication Aide (KMA) 4 on 05/15/2025 at 9:57 AM, she stated she was providing care for R50 and the resident required total care. She stated resident information was located on the computer that information told staff what care a resident needed. KMA 4 said she did recall seeing R50's splints and assumed they were applied by therapy. When asked by the State Survey Agency (SSA) Surveyor about R50's knee splints and hand splints lying on the overbed table, she reported therapy was responsible for applying the splints. The KMA further stated she was not sure if R50 had restorative programs and she did not know who, other than therapy, would apply the resident's splints. In interview with the Unit Manager (UM)/Restorative Nurse on 05/16/2025 at 11:10 AM, she stated she just started overseeing the facility's Restorative Programs in April of this year. She stated therapy communicated with her when residents were given a restorative program. The UM/Restorative Nurse reported she updated the residents' care plans and included the restorative information in the restorative binder for staff. She said she had received R50's communication form just this week for the hand splints; however, had not received a form for the knee splints. The UM/Restorative Nurse explained therapy did splinting when residents were receiving their services. She said R50 had received splinting for a long time and that was why it was care planned. The UM/Restorative Nurse further stated as the restorative program had not been written the care plan was not being followed. 2. Review of the admission Facesheet for R42 revealed the facility admitted the resident on 03/13/2020, with diagnoses that included: Idiopathic Epilepsy; Dysphagia; and Profound Intellectual Disabilities. Review of the Quarterly MDS Assessment with an ARD of 02/11/2025, revealed the facility assessed R42 to have a BIMS score of zero out of 15, indicating the resident was rarely or never understood. Review of R42's comprehensive care plan revealed the facility had developed a dietary care plan with an implementation date of 06/19/2020, with interventions that included a regular diet with thin liquids advanced dysphagia consistency. Further review revealed the interventions further noted R42 was to have: supervision with all intake: have no chips, bread, whole potatoes, or caffeinated beverages; and finger foods as allowed. In interview with UM of unit 1 and 2 on 5/16/25 at 11:28 AM, she stated care plans were double checked in the morning meetings and clinical meeting to see if staff were implementing the care plans. She further stated she did not think staff would not follow R42's care plan and let her walk around with something that she should not have. In interview with the Director of Nursing (DON) on 05/16/2025 at 11:32 AM and at 11:40 AM, she stated her expectations for implementing residents' care plans was for the interventions to be placed into the facility's Resident Care Profile for the nursing assistants. She reported care plans were reviewed in the morning meetings and nurses could access the care plan interventions from the point of login in order to know how to provide care for the resident. The DON further stated any new orders put into the facility's computer system were to be included in the resident's care plan as well. In interview with the Administrator on 05/16/2025 at 11:56 AM, she stated she expected facility staff to follow residents' care plans and implement interventions.

Based on observation, interview, record review and review of facility policy, the facility failed to ensure residents with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion (ROM) for 1 of 23 sampled residents, (Resident (R)50). R50 was care planned with interventions to have left and right wrist and knee splints daily for six days. However, observation revealed two hand splints lying on R50's bedside table or located in the resident's closet. Additionally, observation revealed R50 did not have knee splints on while in bed and the resident's knees were drawn up to her chest. The findings include: Review of the facility policy, Restorative Nursing Standards of Practice, revised 12/2023, revealed the facility strived to promote a restorative nursing program that encourages all residents to attain or maintain their highest practical level of function. Per review, residents were to be evaluated for potential nursing restorative nursing needs on admission, quarterly, and with a change in condition. Continued review revealed a restorative nursing program might be developed independently by nursing. Further review revealed the dedicated restorative nursing process owner, a licensed nurse, was to complete a periodic evaluation of the resident's progress and goals at a minimum of quarterly, to determine any required changes to their restorative nursing program. In addition, review revealed a restorative program progress note was to be documented in the resident's medical record within the seven day assessment look back period. Review of R50's admission Face Sheet, revealed the facility admitted the resident on 06/29/2021, with diagnoses that included: encounter for attention to tracheostomy; persistent vegetative state; and epilepsy intractable, without status epilepticus. Review revealed R50 had developed contractures to an unspecified joint of the left and right wrist on 02/20/2023. Review of the Significant Change in Status Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 04/20/2025, revealed under section B the facility assessed R50 as being in a persistent vegetative state and the Brief Interview for Mental Status (BIMS) assessment was not completed. Review of the, Restorative Monthly Summary, dated 04/08/2025 and created on 05/16/2025, revealed, resident has bilateral posy splints to knees six hours daily for 90 days, and passive ROM to bilateral lower extremities (BLE) for 15 minutes daily for 90 days, passive ROM to BUE, left grip splint and right-hand resting hand splint. Continued review revealed, resident was progressing with splinting to bilateral knees and passive ROM to BLE with restorative programs. Further review revealed R50 continued with good progress, passive range of motion bilateral upper extremities, left grip splint, and right resting hand splint added to program. Review of the Restorative Monthly Summary dated 04/30/2025 and created on 05/16/2025, revealed, the bilateral posy splints to knees six hours daily for 90 days; passive ROM to BLE for 15 minutes daily for 90 days; and passive ROM to BUE, left grip splint, and right resting hand splint. Per review, R50 was progressing with splinting to bilateral knees and passive ROM to BLE restorative programs; passive ROM to BUE left grip splint and right resting hands splint. Review further revealed R50 continued with good progress. Resident tolerating well, will continue at this time. However, observation of R50 on 05/13/2025 at 12:03 PM and 2:18 PM, on 05/14/2025 at 9:10 AM, 11:23 AM , on 05/15/2025 at 9:20 AM and 11:30 AM, revealed two hand splints lying on the resident's bedside table and the resident had no splints in place. Observation on 05/16/2025 at 10:18 AM, also revealed hand splints located in R50's closet and the resident had no hand splints. Additionally, observation on 05/13/2025 at 12:03 PM and 2:18 PM, on 05/14/2025 at 9:10 AM, 11:23 AM also revealed the resident had her knees drawn up to her chest while lying on her bed with no knee splints in place. In interview on 05/16/2025 at 9:45 AM, Restorative Aide (RA) 8 stated she was responsible for the facility's resident restorative programs. She said the restorative program included ambulation, transfers, ROM and splinting. RA 8 explained the purpose of the restorative programs was to improve or maintain a resident's function. She stated R50 had been on restorative services for a year or more; however, had to the hospital and received therapy when she came back. RA 8 reported restorative staff were not currently doing the restorative programs or the splinting for R50. She said the Director of Rehab (DoR) had told her that morning that R 50 was to resume restorative services including splinting next week. The RA reported R50 got left and right hand splints and knee splints to both legs, and was to wear the splints six hours a day. She further stated R50 received passive ROM to her extremities before the splints were applied. In addition, she said she received training from the DoR when residents went on restorative programs and she signed a paper after the training. In interview on 05/16/2025 at 10:02 AM, the Physical Therapist (PT) stated R50 had been receiving PT services to manage her spasms and keep her knees from getting tight. She said R50 had knee splints and that she had been wearing them for a while. The PT reported R50's last therapy treatment day was 05/13/2025, and she had been responsible for applying the resident's knee splints while she was receiving therapy services. She stated at the end of treatment on 05/13/2025, she gave the Rehab Director a form with her recommendations for restorative services. The PT said she provided training to the RA's on applying and removing the splints. She further stated her expectation had been for the RA's to start the programs for R50 the next day, as there was a potential for the resident to decline due to her muscle tone. The PT additionally said the knee splints only controlled the knees and helped keep R50 out of a frog position. In interview on 05/16/2025 at 10:49, the Director of Rehab (DoR) stated R50 was not currently on their caseload and had been discharged from therapy services on 05/08/2025. She stated when residents were discharged from therapy services a discharge notice was given to the Restorative Nurse. She reported she expected restorative programs to start immediately, and discharge training was provided to the RA's on how to apply and remove any devices. The DoR said R50 had worn splints for years and there had been no changes made to her splinting programs. She stated she was responsible for applying R50's hand splints while she had been on the therapy case load. The DoR explained she had not been aware R50 had not been wearing the hand splints since she was discharged from therapy services. She further stated R50's hand splints had been maintaining and preventing her from declining. In interview on 05/16/2025 at 11:10 AM, the Unit Manager (UM)/Restorative Nurse stated she just started overseeing the facility's Restorative Programs in April of the current year. She said therapy made her aware of restorative programs through the Therapy to Restorative Communication form. The UM/Restorative Nurse explained a resident would not get restorative programs until the necessary information was placed in the restorative binder. She reported she had received R50's Communication form just this week regarding the hand splints; however, had not received a form for the resident's knee splints. The UM/Restorative Nurse said when residents were receiving therapy, therapy did residents' splinting. She further stated the RA's applied and removed residents' splints when on the restorative program. In interview on 05/16/2025 at 11:32 AM, the Director of Nursing (DON) stated she had been the facility's DON for one month. She said when a resident required a restorative program, therapy communicated with the UM/Restorative Nurse on what the program was for each resident and whether it was to be done by RA's or the staff on the floor. She stated she did not know how it was communicated to staff. The DON reported she expected restorative programs to be initiated timely so that programs could be started as the residents could potentially have negative outcomes.

Based on observation, interview, record review, the facility failed to ensure residents received and consumed foods in the appropriate form or the appropriate nutritive content as prescribed for 1 of 23 sampled residents, (Resident (R)42). R42 had a diet order for supervision with all (oral) intake and to have no chips. However, observation on 05/13/2025 at 11:42 AM and 2:48 PM, revealed R42 self-propelling throughout the facility while eating a bag of potato chips unsupervised. The findings include: A policy was requested however, the Administrator stated the facility did not have a policy related to the deficient practice. Record review revealed the facility admitted R42 on 03/13/2020, with diagnoses that included Dysphagia, Idiopathic Epilepsy, and Profound Intellectual Disabilities. Review of the Quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 02/11/2025 for R42, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of zero out of 15, indicating the resident was rarely or never understood. Review of R42's Diet Order dated 02/05/2025, revealed the resident had a regular advanced Dysphagia diet ordered that required supervision with all intake, no chips, bread, whole potatoes, or caffeinated beverages. Review of R42's lunch meal tray card dated 05/13/2025, revealed the resident was to be supervised during meal times. Further review of the lunch meal tray card revealed R42 had diet restrictions that included no potato chips, bread, whole potatoes, or french fries. However, observation of Resident 42 on 05/13/2025 at 11:42 AM and at 2:48 PM, revealed R42 self-propelling a wheelchair throughout the facility while eating a bag of potato chips unsupervised. In interview on 05/16/2025 at 11:12 AM, Licensed Practical Nurse (LPN) 4 stated nursing placed residents' diet orders in the computer and dietary checked to make sure they matched what the resident received. She stated if a resident's meal tray and meal ticket were not correct they took the tray back to the kitchen and got them to fix it. LPN 4 said R42 had a history of grabbing things off the snack cart all the time. She reported R42 did not like it when you try to take things away from her and that might have been why she had the bag of chips. LPN 4 further stated if she saw R42 on the hall with something she tried to take it away from her for her own safety. In interview on 5/16/2025 at 11:28 AM, the Unit Manager (UM) of units 1 and 2 stated if Resident 42 picked things up sometimes it was very hard to get it back from her. She said sometimes staff tried to get the resident to trade the restricted item for something she could have. The UM stated sometimes that worked and sometimes it did not. She reported most likely someone might have tried to take the chips away from her but were unsuccessful. The UM stated she did not think staff would just let R42 walk around with something she was not supposed to have. She further stated a possible outcome of R42 having food she should not have, could be the resident getting strangled or choked and no one was supervising her. In interview on 05/16/2025 at 11:40 AM, the Director of Nursing (DON) stated they had to keep an eye on R42 because she was a wanderer and went in and out of other residents' rooms and took their things. She said the staff had to constantly take things away from R42 that she was not supposed to have. The DON reported a potential outcome for R42 having a restricted food item, was she could potentially have a choking episode and aspirate on the food, especially chips. She further stated R42 was supposed to be on increased supervision only if she was eating or drinking. In interview on 05/16/2025 at 11:56 AM, the Administrator stated one day R42 had a (chip) bag, but it had been empty. She stated R42 like to take things off of tables and desks because she liked the colors of the bags and was very sneaky. The Administrator said somehow R42 just gets a hold of things she should not have; however, she expected staff to follow residents' dietary orders and care plan.

Based on observation, interview, record review, and review of facility policy, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 5 residents sampled for wound care out of the total sample of 23 residents (Resident (R)21). Staff providing R21's wound care failed to utilize proper hand washing during the resident's wound care procedure. The findings include: Review of the facility policy, Hand Hygiene, undated, revealed hand hygiene meant cleaning your hands by using either handwashing (washing hands with soap and water) or using hand sanitizer. Per review, hand hygiene was to be performed; before and after glove use; and before and after having contact with blood, body fluids or excretions, mucous membranes, non-intact skin, or wound dressing. Review further revealed gloves were to be changed and hand hygiene performed before moving from a contaminated body site to a clean body site during resident care. Review of the Face Sheet for R21 revealed the facility admitted the resident on 11/13/2024, with diagnoses which included: pressure wound to right heel; asymptomatic human immunodeficiency virus (HIV) infection status; acute kidney failure; and anxiety disorder. Review of the Significant Change Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 04/11/2025, revealed the facility assessed R21 to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident's cognition was intact. During observation on 05/15/25 at 3:38 PM of wound care to R21's right heel revealed the Wound Care Nurse (WCN) failed to wash her hands after removing the soiled dressing. Per observation, the WCN rolled the soiled dressing up in the right hand glove. Continued observation revealed however, after placing the soiled glove containing the soiled dressing in the trash, the WCN donned another glove on her right hand. Observation revealed she then proceeded to cleanse the right heel wound. The Registered Nurse/MDS Nurse (who was assisting the WCN) picked up R21's foot after it was cleansed; however, placed the foot back on the soiled absorbent pad, then picked the resident's foot back up at the request of the WCN. Further observation revealed the clean wound dressing was applied without the nurses re-cleansing the wound. During interview on 05/15/2025 at 4:25 PM, with the RN/MDS Nurse she stated she thought she placed the foot back down on a clean area of the absorbent pad and not on dirty area. She further stated she should not have laid R21's foot down to ensure the foot stayed clean. During an interview with the WCN on 05/16/2025 at 9:05 AM, she stated she should have washed her hands after removing the soiled dressing and before donning new gloves. She further revealed she should always wash her hands before and after gloving. In interview with the Administrator on 05/16/2025 at 10:38 AM, she stated she expected staff to wash their hands prior to donning gloves. She stated she also expected staff to wash their hands after doffing their gloves. The Administrator further stated she expected staff to follow the facility policies as written. During an interview with the Director of Nursing (DON) on 05/16/25 at 10:43 AM, she stated she expected staff to wash their hands prior to donning gloves and between removal and donning new gloves. She said she also expected if a wound had been cleansed prior to the new dressing application, the wound should not be placed back on the soiled barrier. The DON reported if that occurred the wound would require re-cleaning. She further stated she expected staff to follow the facility's handwashing and wound care policies as written.

Based on interview and record review, it was determined the facility failed to ensure medical records were accurately documented for two of three (2 of 3) sampled residents (Resident #1 and #2). The findings include: Review of facility policy titled Resident Records, dated 10/2020 revealed, the facility would maintain medical records for each resident that are complete, accurately documented, readily accessible, and systematically organized. 1. Closed record review revealed Resident #1 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 discharged Against Medical Advice (AMA) on 07/26/2021. Continued review revealed a comprehensive Minimum Data Set (MDS) assessment was not completed. Review of form entitled Discharge Against Medical Advice, revealed the form was signed and dated by Resident #1 on 07/26/2021 and included signatures of two (2) witnesses. Review of Progress notes, dated 07/23/2021 at 6:33 PM, and signed by LPN #1, revealed Resident #1 was upset and did not want to be at the facility and wanted to leave against medical advice (AMA). Continued review revealed Resident #1 signed AMA paper and left the facility and began walking down the street. The Social Services Director encouraged Resident #1 to return to the facility and he/she agreed. Review of Progress Note dated, 07/25/2021 at 3:31 PM, and signed by LPN #1 revealed, Resident #1 had been on the call light all day as staff had answered call light over fifty times. Further review revealed Resident #1 was yelling at staff wanting to go smoke stated his/her rights had been taken away. Review of Progress Note dated, 07/26/2021 at 10:16 AM and signed by SSD, revealed he had discussed the importance of isolation and following the Center for Disease Control (CDC) guidelines. However, Resident #1 continued to complain about not being able to smoke. Resident #1 was offered a nicotine patch but refused. Resident #1 did agree to see Psych services. Review of Progress Note, dated 07/26/2021 at 2:06 PM and signed by the Director of Nursing (DON), revealed Resident #1 refused to allow staff to provide incontinent care after having an incontinent bowel movement (BM). Resident #1 was cursing and refusing help from staff. Resident #1 came out of room without a face covering multiple times and stated it wasn't fair that he/she was on isolation, and he/she should be able to smoke and leave room when they chose to. Resident #1 refused referrals to be sent to other facilities, refused facilities help with discharge planning and refused psych services. The DON documented asking Resident #1 about going to the hospital for evaluation and Resident #1 agreed. However, there was no documentation that the physician had been notified of Resident #1 leaving AMA or that Resident #1 was sent to the hospital for evaluation. Interview with Licensed Practical Nurse #1, on 06/09/2022 at 10:51 AM, revealed she could not recall if she notified the physician when Resident #1 signed AMA or that he/she was sent to the hospital. She revealed she sent Resident #1 to the hospital at his/her insistence. She further revealed she should have notified the physician that Resident #1 left AMA and was sent to the hospital. 2. Closed record review revealed Resident #2 admitted to the facility on [DATE] with the following diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Admission minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of eleven (11) indicating mild cognitive impairment. Resident #2 discharged Against Medical Advice on 11/06/2021. Review of form entitled Discharge Against Medical Advice revealed the form was signed and dated by Resident #2 on 11/05/2021 and included signatures of two (2) witnesses. Interview with Licensed Practical Nurse #1, on 06/09/2022 at 10:51 AM, revealed she could not recall if she notified the physician when Resident #2 signed AMA. She revealed she assumed the physician and Hospice Services were aware as Resident #2 was supposed to leave the day before. She further revealed she should have notified the physician and Hospice Nurse and documented in the medical record. Interview with Director of Nursing (DON), on 06/09/2022 at 1:53 PM, revealed Resident #1 did not want to be at the facility. She revealed Resident #1 wanted to leave AMA but he had no where to go. She revealed she reminded Resident #1 that he/she could go to the hospital for evaluation. She revealed she expected the nurse to document that the physician had been made aware when a resident discharges AMA or when being sent to the hospital. Interview with Administrator, on 06/09/2022 at 4:00 PM, revealed she expected the nurse to notify the physician and document in the progress notes when a resident is transferred and or discharged from the facility no matter the reason.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to ensure all residents' drugs and biologicals which were expired were removed from all medication administration areas in order to prevent possible administration to residents. The findings include: Review of the facility policy titled, Administering Oral Medications Level III Purpose, undated, revealed, staff were to check the expiration dates on all residents' medications and return any expired medications to the Pharmacy. Observation 04/29/2021 at 10:10 AM, of the refrigerator located in the facility's Medication Prep Room, revealed one (1) bottle of [MEDICATION(S)] Suspension 20 milligrams/milliliter (mg/ML) with an expiration date of 03/21/2021. Observation on 4/30/2021 at 9:18 AM of the Hall 1 medication carts #1, #2 and #3 and the Hall 2 medication carts #1, #2 and #3 revealed the following expired medications: [MEDICAL RECORD OR PHYSICIAN ORDER] *Ondansetron 4 mg tablets (tabs), 4 tabs with an expiration date of 02/15/2021 *Loperamide 2 mg, 13 tabs - with an expiration date of 02/08/2021 *Ibuprofen 800 mg, 8 tabs, with an expiration date of 04/17/2021 *Loperamide 2 mg, 23 tabs with an expiration date of 04/27/2021 *Loperamide 2 mg, 16 tabs with an expiration date of 09/10/2020 *Diphenhydramine 29 caps with an expiration date of 04/11/2021 *Acetaminophen 325 mg 7 tabs with an expiration date of 04/17/2021 *Ondansetron 4mg 11 tabs, with an expiration date of 11/21/2020 *Bisacodyl 5 mg, 5 tabs with an expiration date of 02/23/2021 and 14 tabs with an expiration date of 04/17/2021 *Acetaminophen 325 mg 14 tabs, with an expiration date of 02/09/2021 and 28 tabs with an expiration date of 02/16/2021 *Ondansetron 4 mg 31 tabs, with an expiration date of 04/01/2021 *Glucagon injectable 1mg - with an expiration date of 08/2020 *Ondansetron 4 mg 10 tabs with an expiration date of 03/08/2021 *Loperamide 4 mg 14 tabs with an expiration date of 04/11/2021 *Loperamide 2 mg - 18 tabs with an expiration date of 03/29/2021 *Acetaminophen 325 mg 6 tabs with an expiration date of 02/09/2021 *Acetaminophen 325 mg 18 tabs with an expiration date of 02/21/2021 *Acetaminophen 325 mg 10 tabs with an expiration date of 02/21/2021 and 30 tabs with an expiration date of 02/03/2021. Interview with Registered Nurse (RN) #4 on 04/29/2021 at 10:10 AM, revealed expired medications were to be removed from medication storage areas including the medication refrigerator. Interviews on 04/30/2021 with Kentucky Medication Aide (KMA) #11 at 9:18 AM, KMA #12 at 9:35 AM, and KMA #13 at 9:43 AM revealed all expired medications should have been removed from the carts to protect residents. Interview with Licensed Practical Nurse (LPN) #1 on 04/30/2021 at 11:05 AM, revealed medication carts were checked daily on the night shift. Per interview, all expired medications should have been removed from the medication carts when night shift checked the carts. Interview with LPN #2, the Unit Manager on 04/30/2021 at 11:22 AM, revealed she was not aware of a facility policy regarding expired resident medications. Per interview, the medication carts were checked weekly on Wednesday nights by the night shift nurses; however, she was unaware of expired medications being on the medication carts. Interview with the Interim Director of Nursing (DON) on 04/30/2021 at 11:38 AM, revealed the facility had recently changed to using a new Pharmacy as was new to her position, having been in it for only a few weeks. She stated therefore, she was not aware there were expired medications remaining on the carts from the previous Pharmacy. She revealed the new Pharmacy Consultant had been in the facility recently; however, the Interim DON was unable to provide documented evidence the Pharmacy Consultant had checked the medication carts for expired medications. She revealed she had not performed audits of the medication carts as of the time of the interview. Continued interview revealed the Interim DON had posted a document entitled, Night Shift Responsibilities, undated. Review of the Night Shift Responsibilities, document revealed it stated, Go thru med carts and remove any discontinued medications, expired meds and medications from discharged /deceased residents.

The facility failed to prepare, distribute and serve food in accordance with professional standards for food service safety as related to the kitchen floor not being clean. Review of facility policy titled, Environment, revision date of 09/2017, revealed All food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition. The Dining Services Director will ensure that the kitchen is maintained in a clean and sanitary manner, including floors, walls, ceilings, lighting and ventilation. Observation on 04/27/2021 at 9:51 AM, while on initial tour of the kitchen with the Dietician, it was noted the floors were dirty with dirt, debris and dirty paper towels noted in the floor. Interview with the District Manager of Dietary, on 04/30/2021 at 8:13 AM, revealed that the dietary staff are expected to keep the floor clean. States that they usually clean the floor between breakfast and lunch. He would expect the floor to be free from debris and dust.

Based on observation, interview, record review and facility policy review, it was determined the facility failed to revise the Comprehensive Care Plan for one (1) of twenty-four (24) sampled residents (Resident #3). The facility failed to ensure Resident #3's Comprehensive Care Plan was revised to include the intervention for bladder cycling related to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings include: Review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Manual dated 10/2018, revealed residents' care plans were to be reviewed and revised based on the resident's needs, changing goals, preferences and in response to current interventions. Record review revealed the facility admitted Resident #3 on 10/18/2020, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #3's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident was assessed to have a Brief Interview for Mental Status (BIMS) score of six (6) which indicated moderate cognitive impairment. Continued record review revealed Resident #3 had documentation dated 04/08/2021, related to a Urology appointment which noted a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #3's Comprehensive Care Plan, revealed a care plan for potential for alteration in bladder elimination due to obstructive and reflux (the backward flow of urine from the bladder in the kidneys) [CONDITION(S)] (a disorder involving the urinary tract) with an onset date of 10/19/2020. Continued review of the care plan revealed Resident #3 had a Suprapubic catheter, with an intervention dated 04/26/2021 for bladder cycling (bladder re-training after catheter use). However, record review revealed the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Therefore, Resident #3's care plan was not revised to include the bladder cycling intervention until sixteen (16) days after the order was received. Observations on 04/27/2021 at 10:50 AM and 3:17 PM, revealed Resident # 3 had a Suprapubic catheter which had the tubing clamped off. Interview on 04/27/2021 at 04:19 PM with Resident #3 revealed the resident used the toilet without assistance. Interview on 04/27/2021 at 04:07 PM, with Licensed Practical Nurse (LPN) #3, revealed Resident #3 was pretty independent and he/she had a Suprapubic catheter. Per interview, Resident #3 had been on a bladder cycling schedule since 04/15/2021, (seven [7] days after the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the LPN, the resident's catheter tubing was capped off as the Physician wanted Resident #3 to attempt urinating on his/her own. Interview on 04/29/2021 at 4:35 PM, with the Minimum Data Set (MDS) Coordinator revealed she had updated Resident #3's care plan with the intervention regarding bladder cycling on 04/26/2021. The MDS Coordinator and Unit Manager (UM) #1, who was also present during the interview, revealed they did not know why Resident #3's care plan update regarding the bladder cycling had been missed after the order was received. They stated however, the care plan should have been revised with the bladder cycling intervention on 04/09/2021, after the order for it was received on 04/08/2021. Further interview revealed the MDS Coordinator and UM #1 participated in the facility's daily Interdisciplinary Team (IDT) meeting during which resident's new physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An additional interview on 04/30/2021 at 1:35 PM with UM#1, revealed nursing staff and the facility's IDT oversaw residents' care plans and were to ensure the residents' care plans were revised, as necessary. Interviews on 04/29/2021at 4:41 PM and on 04/30/2021 at 11:35 AM, with the Director of Nursing (DON) revealed physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Per interview, the DON's expectation was that Resident #3's care plan would have been revised with the bladder cycling intervention on 04/09/2021, after the order was received on 04/08/2021. Further interview revealed the MDS Coordinator was to ensure residents' care plans were revised with the necessary interventions. The DON further revealed the MDS Coordinator was ultimately responsible for maintaining residents' care plans.

Based on observation, interviews, record review and facility policy review, it was determined the facility failed to ensure residents received the necessary care and services to promote healing and prevent infection for one (1) of twenty-four (24) sampled residents, Resident (#33). Observation of a dressing change for Resident #33 revealed the nurse failed to ensure reusable resident care equipment was cleaned and sanitized before and after each use. The findings include: Review of the facility policy titled, Cleaning and Disinfection of Resident-Care Items and Equipment, revised on 10/2018 revealed resident care equipment which included reusable items and durable medical equipment were to be cleaned and disinfected according to current Centers for Disease Control and Prevention (CDC) recommendations for disinfection and the Occupational Safety and Health Administration (OSHA) Bloodborne Pathogens Standard. Continued review revealed reusable items, such as stethoscopes and durable medical equipment, etc. were to be cleaned and disinfected or sterilized between resident use. Record review revealed Resident #33 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed the facility had assessed Resident 33's Brief Interview for Mental Status (BIMS) score as a three (3) indicating severe cognitive impairment. Continued review revealed the facility also assessed Resident #33 to require extensive assistance with all Activities of Daily Living (ADLs). Review of Resident #33's Physician Orders revealed an order dated 04/29/2021, which noted Santyl External Ointment (a [MEDICATION(S)] agent) 250 unit/gram was to be applied between 7:00 AM and 6:59 PM to the unstageable wounds on the resident's left and right heel and the Stage IV pressure ulcer wound on his/her right heel. Continued review of the Order revealed the Santyl order instructions included cleansing the wound, patting it dry, applying the Santyl Ointment to the wound bed and covering with a dry dressing. Observation of wound care for Resident #33 on 04/29/2021 at 10:34 AM, revealed Registered Nurse (RN) #1 retrieved scissors from her uniform pocket and without cleaning and sanitizing the scissors initiated cutting a hydrogel dressing. Observation revealed RN #1 placed the hydrogel dressing into the wound bed of Resident #33's right heel ulcer, then covered the heel with a dry dressing and secured it with tape. Further observation revealed RN #1 placed Resident #33's socks back on his/her feet, then placed the contaminated scissors back in her uniform pocket. Interview with RN #1 on 04/29/2021 at 11:08 AM, revealed she should have cleaned and sanitized her scissors before using them to prevent causing any type of infection for Resident #33. Per interview, she also should have cleaned and sanitized the scissors prior to replacing the scissors back into her uniform pocket. Interview with Unit Manager (UM) #1 on 04/30/2020 at 12:00 PM, revealed scissors and all reusable resident care items were to be cleaned and sanitized prior to each use to prevent the spread of infection. Per interview, the items were to also be cleansed and sanitized after each use. Interview with the Interim Director of Nursing (DON) on 04/30/2021 at 11:35 AM, revealed scissors and all other reusable resident care items were to be cleaned and sanitized before using them for cutting residents' wound dressings. Per interview, scissors and all other reusable resident care items were to be cleaned and sanitized after each use to prevent the spread of infection.

Based on observation, record review, interview and facility policy review, it was determined the facility failed to ensure all residents requiring a therapeutic diet prescribed by the Physician received the diet as ordered for one (1) of twenty-four (24) sampled residents (Resident #56). Resident #56 had a Physician ordered dietary change for a therapeutic diet which the facility failed to implement immediately. The findings include: Review of the facility policy entitled, Therapeutic Diets, revision date of 09/2017, revealed all residents were to have a Physician ordered diet which included regular, therapeutic and modified texture diets. Continued review revealed the licensed nurse accepting the diet order from the prescriber was to complete and sign the facility's Diet Requisition Form. Further review revealed the licensed nurse was to ensure the Diet Requisition Form included the diet ordered by the prescriber, any food allergies and specific food preference requests. In addition, review revealed all residents' diets were prepared in accordance with the guidelines in his/her individualized plan of care, and the facility's Diet Manual. Review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Manual dated 10/2018, page K-11 defines a therapeutic diet as a diet intervention ordered by a health care practitioner as part of the treatment for a disease or clinical condition manifesting an altered nutritional status, to eliminate, decrease, or increase certain substances in the diet (e.g., sodium, potassium) . Record review revealed the facility admitted Resident #56 on 11/25/2019, with diagnoses which included: End Stage Renal Disease with dependence on Renal [CONDITION(S)], Vitamin B12 and [CONDITION(S)] [CONDITION(S)], Supraventricular Tachycardia, and [NAME] (blood in stool). Review of the Annual Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #56 with a Brief Interview for Mental Status (BIMS) score of two (2) two which indicated the resident was severely cognitively impaired. Further review of the MDS Assessment revealed the facility assessed Resident #56 to require extensive assistance with all Activities of Daily Living (ADLs). Review of Resident #56's Comprehensive Care Plan revealed an alteration in fluid balance care plan was noted which was related to the resident's diagnoses of End Stage Renal Failure with dependence on [CONDITION(S)], Dysphagia, history of [CONDITION(S)] (CVA) with [CONDITION(S)]. Continued review of the care plan revealed the interventions included providing the diet and fluids for the resident as per the Medical Doctor's (MD's) order. Further review of the Comprehensive Care Plan revealed a care plan regarding nutrition alteration 04/27/2021, which was related to the resident's significant weight loss over the past thirty (30), sixty (60), ninety (90), and one hundred and eighty (180) days. Per review of this care plan the interventions included provision of dietary snacks or supplements as ordered by the MD, with a start date of 04/28/2021. Additional review revealed other interventions noted for Resident #56 were for the resident to receive double protein at meals, fortified oatmeal at breakfast, and fortified mashed potatoes at lunch. Review of Resident #56's Physician Orders revealed an order dated 04/28/2021, which noted the resident was to receive double protein with meals, fortified oatmeal at breakfast and fortified mashed potatoes at lunch. Review of Resident #56's Progress Notes revealed Notes dated 04/28/2021 at 12:16 PM and 1:18 PM documented by Unit Manager (UM) #1. Continued review revealed UM #1 had documented add fortified oatmeal at breakfast, fortified mashed potatoes at lunch, and double protein at meals. Further review revealed the Nurse Practitioner (NP) was notified of the new orders received, and the resident's Power of Attorney (POA) was also notified. Review of the Diet Requisition Form dated 04/28/2021 timed 12:30 PM for Resident #56, revealed it was signed by UM #1 and noted the Physician's Order for the resident to receive fortified oatmeal at breakfast, fortified mashed potatoes at lunch and double protein with meals. Observation on 04/29/2021 at 8:38 AM, revealed Certified Nursing Assistant (CNA) #14 was assisting Resident #56 with eating his/her breakfast meal. Interview with CNA #14, at the time of observation, revealed Resident #56 usually ate his/her meals well. Further observation revealed no fortified oatmeal or double protein present on Resident #56's meal tray. Review of the meal tickets dated from 04/28/2021 through 04/29/2021, revealed no documented evidence of the Physician ordered fortified oatmeal for breakfast, fortified mashed potatoes at lunch or double protein present on Resident #56's meal tray tickets. Interview with the facility's District Culinary Manager (DCM) on 04/29/2021 at 9:37 AM and 11:30 AM, revealed if a resident received recommendations or orders for a dietary change, staff were to complete the dietary form and ensure the dietary department received the form completed by nursing staff. Per interview, the dietary department was informed immediately by nursing staff of any dietary changes for residents. The DCM stated after receiving a resident's dietary change the facility's Dietary Manager or Assistant Dietary Manager made the necessary changes in the meal tracker program. The DCM stated he had not received any dietary change notification for Resident #56 and had checked for any resident dietary changes that morning (04/29/2021). Continued interview revealed dietary changes were noted on the residents' meal tray tickets and were to be implemented during the next meal which followed the dietary change notification. Per the DCM, he had checked for a Physician's Order or any new changes noted on Resident #56's meal tray tickets; however, had not found any dietary changes documented for the resident. The DCM further stated he could not track the time stamp of dietary changes on the residents' charts. In an additional follow-up interview on 04/30/2021 at 8:17 AM, with the DCM revealed on 04/29/2021, after discussion with the Surveyor, he had received the dietary changes of fortified foods and double protein for Resident #56. He stated the Physician ordered dietary changes Resident #56 had been implemented as soon as UM #1 sent the changes to the dietary department. Interview on 04/29/2021 at 9:40 AM, with the Assistant Dietary Manager (ADM) revealed she had not made any dietary changes for Resident #56 in the meal tracker program or on the resident's meal tray ticket that day. The ADM stated dietary changes were given to the dietary staff they. Further interview revealed however, she failed to look and see if any dietary changes had been made. Interview on 04/29/2021 at 9:47 AM, with UM #1 revealed when dietary changes were made the information was placed in the facility's computer system under the diet section, or the supplemental meds tab section depending on what the change was. Per interview, if the recommendation was from the Dietician, then a Physician Order was obtained for the recommendation. UM #1 stated the resident's family was notified of the dietary change(s), and a progress note made in the resident's medical record. Continued interview revealed a dietary requisition paper filled out and given to dietary staff. The UM stated nursing staff would follow up in the facility's Interdisciplinary Team (IDT) meeting to ensure the dietary change(s) had been made. Further interview revealed the IDT meeting had not occurred on 04/29/2021; however, Resident #56's dietary recommendations should have been put in place. The UM further revealed it had been a little crazy around there and that might have been why the resident's dietary recommendations had not been made. Interview on 04/29/2021 at 10:40 AM, with the Director of Nursing (DON) revealed when dietary changes were made for residents the process was for the dietary recommendation to be placed in the facility's computer system under the diet area, and the supplement meds tab if a medication was recommended. Per interview, if the dietary recommendations came from the Dietician, then a Physician's Order for the recommendation was obtained, and the resident's family notified of the change(s). The DON revealed nursing staff were to make a note in the Progress Notes section of the resident's medical record documenting the dietary changes. Further interview revealed nursing staff were also to complete a Dietary Requisition Form noting the dietary changes for the resident and ensure if was provided to dietary staff. In addition, the DON stated Resident #56's new dietary changes should have been done by now.

Based on interview, record review, hospital discharge summary review, and facility policy review, it was determined the facility failed to revise the Comprehensive Care Plan for one (1) of three (3) sampled residents (Resident #1) to reflect the care and/or supervision the resident was to receive to try to prevent further falls. Record review revealed Resident #1 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 sustained ten (10) falls between 07/01/2020 thru 11/12/2020, and seven (7) of the falls were a result of the resident ambulating to bathroom without the facility assessed need of staff assistance. However, review of the Comprehensive Care Plan revealed the facility failed to revise the care plan per facility policy with interventions related to the resident's need of increased supervision or more frequent toileting assistance to prevent further falls. On 11/12/2020, the resident was left unattended in the hall and was found on the floor in front of his/her wheelchair. The resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed upon return to the facility, the care plan was not revised to include an intervention to prevent further falls after the 11/12/2020 fall; per facility policy. The facility's failure to revise the falls care plan with interventions to address the resident getting up without staff assistance has caused or was likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 11/20/20 and determined to exist on 11/12/20. The facility was notified of the Immediate Jeopardy on 11/20/20. An acceptable Allegation of Compliance (AoC) was received on 11/25/20. The State Survey Agency validated the AoC and determined Immediate Jeopardy was removed on 11/24/2020. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Interview with the Administrator, on 11/18/2020 at 2:02 PM, revealed the facility utilized the Resident Assessment Instrument (RAI) Manual as their guide for care plans. He stated the facility's intent was to develop an individualized plan of care based on the identified needs, strengths and preferences of the resident. Review of the facility policy titled, Falls Standard of Practice, dated July 2020, revealed an investigation should be initiated at the time of a fall to implement interventions to try to prevent further falls. The resident's care plan is to be updated with implemented intervention(s). The Clinical Quality Assurance (QA) Interdisciplinary Team (IDT) would review and discuss any fall from the prior day in the morning clinical meeting. The care plan would be updated to reflect any changes to risk factors or needed interventions. Residents experiencing falls were reviewed to determine the effectiveness of current interventions or to identify potential new approaches. Record review revealed the facility admitted Resident #1 on 10/30/2018 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) assessment, dated 06/23/2020, revealed the facility assessed Resident #1's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of seven (7), which indicated the resident was not interviewable. Further review of the MDS revealed the facility assessed the resident required extensive assist of two (2) staff for transfers and toileting, assist of one (1) staff for ambulation, and the resident's balance was unsteady and required staff assistance for balance. Review of the Quarterly MDS assessment dated [DATE] revealed the facility assessed Resident #1's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of seven (7), which indicated the resident was not interviewable. Further review revealed the resident was assessed to require extensive assist of one (1) staff for transfers and toileting; and assist of one (1) for ambulation. The resident's balance remained unsteady requiring staff assistance. Review of facility Fall Management tools, dated 07/01/2020, 07/19/2020 and 07/26/2020, revealed Resident #1 had falls in the bathroom with minor injuries on 07/01/2020 at 9:00 AM and again at unknown time, on 07/19/2020 at 12:30 PM, and 07/26/2020 at 6:40 AM. Interventions put in place after the resident's first fall, in which he/she tried to self toilet on 07/01/2020, was a low bed and laboratory studies. The second fall on 07/01/2020, the resident tried to lay down in the bed without staff assistance, interventions put in place was for staff to provide first aid and apply anti-tippers and anti-rollbacks to wheelchair. On 07/19/2020, the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . On 07/26/2020, the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . However, review of the Comprehensive Care Plan, dated 04/30/2020, revealed there was no revisions to address the resident's need for increased supervision or more frequent toileting assistance to prevent further falls due to the resident getting up without assistance to go to the bathroom; per facility policy. Review of Fall Management tools revealed Resident #1 fell while self ambulating from the bathroom with minor injuries on 08/26/2020 at 10:30 PM and on 10/13/2020 at 7:15 AM. Further review of the tools revealed an intervention was put in place for first aid after the 08/26/2020 fall and lab studies after the 10/13/2020 fall, however, review of the care plan revealed there were still no revisions to address the resident's need for increased supervision or more frequent toileting assistance to prevent further falls, per facility policy. Review of a Fall Management tool revealed on 10/20/2020 at 9:00 PM, a State Registered Nurse Aide (SRNA) responded to Resident #1's call light and when she assisted the resident back to bed she noted a large dark purple bruise to the lower left hip and buttocks. An intervention was placed to educate staff to keep this resident's door to room open at all times to visually be able to see the resident due to decreased safety awareness. However, further review of the Comprehensive Care Plan, dated 04/30/2020, revealed the facility failed to revise the care plan to include this intervention, per facility policy. Review of a Fall Management tool revealed Resident #1 fell on [DATE] at 6:15 PM, while ambulating without assistance in his/her room and sustained a skin tear. Interventions were developed to include First Aid, activities, maintaining visualization of resident while up in wheelchair. and to perform neurological checks. However, further review of the Comprehensive Care Plan, dated 04/30/2020 revealed there the facility failed to revise the care plan to include the intervention to maintain visualization of resident while up in wheelchair, per facility policy. Review of a Fall Management tool revealed Resident #1 self transferred to the bathroom and fell on [DATE] at 9:45 AM, with no injury noted. The interventions developed were to apply a new pair of gripper socks and to encourage the resident to ask for assistance with ambulating to restroom even though the facility had assessed the resident's cognition as severely impaired. Review of a Nursing Progress Note and Fall Management Tool, dated 11/12/2020 at 6:10 PM, revealed Resident #1 was found by Registered Nurse (RN) #1 face down in front of the wheelchair. The resident's wheelchair was upright at the resident's feet, the resident had shoes on, and the resident's glasses were found on the floor several feet away. Resident #1 was responsive to name but was unable to turn self over; and, there was an open area above the left eye and bleeding from the nose. The resident was sent to the hospital for evaluation. The documented interventions on the Fall tool were to send the resident to the hospital and a drug regimen review. Review of the Hospital Discharge Summary dated 11/14/2020 revealed Resident #1 was diagnosed with an Acute Cervical Fracture at the seventh level, Bilateral Subdural Hemorrhages, a Nasal Bone Fracture, Right Orbital Fracture and a Left Maxillary Fracture. Further review of the Comprehensive Care Plan revealed the facility failed to revise the care plan when Resident #1 returned to the facility from the hospital after the 11/12/2020 fall. Interview with Licensed Practical Nurse (LPN) #1, on 11/19/2020 at 11:01 AM, and at 2:30 PM, revealed Resident #1 had fallen frequently, and his/her cognition was not there (the resident was not always oriented), and his/her condition had deteriorated. LPN #1 stated staff would put the resident at the nurse's desk or in his/her room to watch television. The resident was unable to comprehend the use of the call light and would get up randomly as the resident was forgetful. She revealed the resident self propelled in the wheelchair and she had staff watch the resident more frequently. She stated she was the nurse that was present for the 11/01/2020 fall; and, was aware the resident's door was to be kept open so staff could see the resident. She stated staff saw the resident get up and fall in his/her room on 11/01/2020. She stated she developed the intervention to keep resident in sight when in the wheelchair, after the 11/01/2020 fall. She revealed she was trained on how to update the care plan and in the past she had put an intervention in the computer and hit the wrong key causing the intervention to be deleted. She stated she was not sure why the visualization intervention did not make it from the fall investigation to the Fall care plan or SRNA care plan. She stated if the resident were to fall again it could be bad due to the condition he/she was in now. Interview with the LPN Unit Manager, on 11/19/2020 at 9:15 AM and at 4:09 PM, revealed the MDS nurse or the nurses on the floor update care plans. The LPN, Unit Manager stated Resident #1 was impulsive but sometimes he/she could follow instructions. The LPN Unit Manager initiated the Fall Management forms for the two (2) falls on 07/01/2020 and 10/13/2020, and provided input on the form for the fall on 11/08/2020. The LPN Unit Manager placed interventions for a low bed and to obtain laboratory tests after the fall, on 07/01/2020 at 9:00 AM. She also placed interventions after the fall on 10/13/2020, to provide first aid and to obtain [MEDICATION(S)] level. She stated it was the resident's right to get up, walk, and fall, but staff tried to keep the resident as safe as possible. She revealed all falls were screened by therapy and reviewed in the IDT meetings; and, the effectiveness of interventions were discussed in IDT meetings and changed if not appropriate. She stated she felt they had addressed the resident's toileting needs. Interview with Registered Nurse (RN) #1, on 11/16/2020 at 12:58 PM, revealed she was the nurse that responded to Resident #1 after the fall on 11/12/2020; and she also completed the Fall Management tool. RN #1 stated she was aware the resident was supposed to be in sight of staff when up in wheelchair. She revealed she stepped across the hall to obtain a pulse oximeter and the SRNA's were providing care to other residents at the time of the fall. She stated she walked by the nurses desk, and she saw the resident lying face down on the floor with blood around the head. The wheelchair was behind the resident sitting in an upright position. She stated the intervention put in place after this fall was to send the resident to the hospital and she did not determine the root cause of the fall or put an intervention in place to prevent further falls. Interview with the Therapy Department Director, on 11/18/2020 at 3:44 PM, and on 11/19/2020 at 4:09 PM, revealed Resident #1 had received Occupational Therapy (OT) and Physical Therapy (PT) at some point. The Therapy Department Director stated residents were assessed by therapy after each fall. She stated the last intervention placed by therapy was for anti-tippers and anti-rollbacks to wheelchair. She further revealed she was a member of the IDT and Resident #1 had a number of falls. She stated the IDT discussed care plans for falls and if the IDT determined an intervention put in place was not appropriate, the IDT would change it to a better intervention. She revealed she thought the interventions put in place were appropriate and she had not received any education on root cause analysis. Interview with the Director of Nursing (DON), on 11/20/2020 at 9:10 AM, revealed she was hired as the MDS Nurse in July 2020 and had been the DON since the end of October, first part of November 2020. The DON stated she was working covering another unit on 11/12/2020, and was there when Resident #1 fell . She revealed she had seen the resident sitting in the wheelchair across from the nurses desk prior to the fall. She was the nurse that called the ambulance for the resident to be transported to the hospital. The DON revealed IDT members discussed resident falls and assessed the interventions for effectiveness in IDT meetings. The DON revealed that she has been trained on Root Cause Analysis in the past and was a member of the IDT team. She stated that the IDT team determined the Root Cause as a team and changed interventions as needed. The DON felt the interventions placed were appropriate for the resident and addressed the root cause of the falls. She revealed resident falls were reviewed in QA. She stated Resident #1's 11/12/2020 fall had not been discussed in a QA meeting because the next meeting was not until 11/23/2020. She stated the 11/01/2020 fall intervention to visualize the resident when up in wheelchair did not make it to the care plan She revealed it was the nurses responsibility to update the care plan. She stated she was not sure if agency staff were educated on entering care plan interventions and was not sure how the breakdown occurred. Interview with the facility Administrator, on 11/18/2020 at 3:10 PM, revealed the MDS Nurse or nursing manager should discontinue/update care plan intervention as they change. The Administrator stated staff had not discussed Resident #1's most recent fall in QA as they did not have a QA meeting in October 2020, due to various conflicts. He revealed the IDT performed the root cause analysis as a team and the LPN/Unit Manager was responsible to close the root cause analysis out, as well as the Incident report. He reported the facility did not have a policy on root cause analysis. He revealed the resident had a BIMS of seven (7) and telling the resident to use the call light would not be an effective intervention. Further interview with the facility Administrator, on 11/19/2020 at 2:05 PM, and and at 4:21 PM, revealed there had been no education for root cause analysis since he had been at the facility (July 2019). He stated the former DON's last day was 10/23/2020 and the MDS Nurse took over as DON, on 10/24/2020; and was still assisting with MDS until the new MDS person was trained. He stated there was also a floating MDS person. He revealed the IDT reviewed care plans and falls; and if intervention were put in place that were not appropriate, the IDT would change the intervention. He stated nurses were asked to place an immediate/new intervention after a fall into the care plan and notify care staff. The facility implemented the following to remove the Immediate Jeopardy: 1. Resident #1 was readmitted to the facility COVID Unit on 11/14/2020. A fall assessment was completed and care plan interventions were re-instated to support the needs of the resident on the COVID unit, including bed against wall, low bed with scoop mattress, and mat beside bed. 2. The Assistant Director of Nursing (ADON) and Nurse Unit Manager (UM) completed fall risk assessments for all residents on 11/20/2020. 3. The ADON and Nurse Unit Manager reviewed care plans for residents identified with risk factors for falls on 11/20/2020, to ensure interventions were in place to address the resident risk factors. 4. Nursing Management including the Director of Nursing (DON), ADON, Nursing UM's, and Staff Development Coordinator (SDC) reviewed all resident falls in the past thirty (30) days to ensure that care plans had been revised with interventions to reduce the risk of further falls. Any identified concerns were addressed at the time of discovery. This was completed on 11/20/20 - 11/23/2020. 5. The Regional Program Manager (RPM) provided education to the Administrator (ADM) the DON, the ADON, and the LPN UM on 11/20.2020 regarding F657 and F689. Specifically, this education included: A comprehensive care plan must be developed within seven (7) days after completion of the comprehensive assessment, prepared by an IDT, and reviewed and revised by the IDT after each assessment, including both the comprehensive and quarterly review assessments. The care plan should also be evaluated and revised as needed. An example included, but not limited to, the need to revise a care plan after a fall to reflect the care and/or supervision a resident was to receive to try to prevent further falls. Interventions to reduce fall risk based on certain resident behaviors, such as attempting to transfer self independently when assessed to require assist, should be included in the plan of care. The facility must ensure the resident's environment remained as free of accident hazards as was possible. Each resident receives adequate supervision and assistive devices to prevent accidents. This included identifying hazard(s) and risk(s), evaluating and analyzing hazard(s) and risk(s), implementing interventions to reduce hazard(s) and risk(s) and monitoring for effectiveness and modifying interventions when necessary. Examples included, but was not limited to identifying the supervision needs of the resident identified as a fall risk, evaluating a fall risk resident to create a system to reduce the likelihood of further falls, and evaluating the needs of resident with poor safety awareness to reduce the likelihood of further falls. 6. Verbal acknowledgement of understanding, along with signed education and post-test was obtained after education. 7. The above education was then provided to the nursing staff (including contracted/agency nursing staff) by the DON, ADON, SDC and/or LPN UM on 11/20/2020-11/23/2020. 8. Verbal acknowledgement of understanding, along with signed education and post -test was obtained after education. 9. Any new nursing hire (including contracted/agency) would received this education prior to assuming duties. 10. An ad hoc Quality Assurance Process Improvement (QAPI) meeting was held 11/20/2020, to review the summary of Immediate Jeopardy finding and discuss the development of action items to be completed. This meeting included the Administrator, DON, ADON, UM, Social Services Director (SSD), Activities Director, Dietary Manager, Business Office Manager, Therapy Director, and Medical Director. 11. The DON, ADON, SDC, and/or LPN UM educated licensed nurses (including contracted/agency nurses) on 11/20/2020 through 11/23/2020. The licensed nurses were educated that anytime there was a resident fall incident, the DON or the designated on-call licensed nurse was to be notified, at which time the incident would be reviewed and applicable immediate interventions(9) would be added to the plan of care and the Resident Care Profile. This notification process began 11/20/2020. 12. Effective 11/21/2020 and continuing on-going, the prior 24-hour falls incident would be reviewed daily and again reviewed to see that the care plan and the Resident Care Profile was updated with fall prevention intervention(s). The intervention(s) would be reviewed to see if any changes may be warranted to the immediate intervention(s). The falls would be reviewed weekdays in the morning clinical meeting by the DON, ADON, Therapy Director, Administrator, and/or UM; and, on weekends, by the SDC and/or Weekend Supervisor Nurse. 13. Effective the week of 11/23/2020, continuing weekly on-going, members of the IDT including DON, ADON, Therapy Director, Social Services, Activities Director, Dietary Manager, UM, and Administrator, would review weekly residents experiencing falls to include risk assessments, the incident investigation post fall, effectiveness of current interventions or the need to identify a new approach. 14. A second ad hoc QAPI meeting was held on 11/23/2020 to review the status of the education and audits. This meeting included the Administrator, DON, ADON, UM, Social Services Director (SSD), Activities Director, Dietary Manager, Business Office Manager, Therapy Director, and Medical Director. 15. The monitoring results would be followed in the facility monthly QAPI meeting a minimum of three (3) months for review of recommendation if indicated. The monthly QAPI is attended by, but not limited to the Adm, DON, ADON, UM, Social Services Director (SSD), Activities Director, Dietary Manager, Business Office Manager, Therapy Director, and Medical Director a minimum of quarterly The State Survey Agency validated the corrective action taken by the facility as follows: 1. Review of the Fall Risk Assessment, dated 11/14/2020 revealed Resident #1 was assessed and it was determined the resident was at an increased risk for falls with a score of twenty-one (21). Review of Resident #1's Comprehensive Care Plan, revealed the resident's care plan was reinstated when he/she returned from the hospital and included interventions for bed against wall, low bed with scoop mattress, and mat beside bed. 2. Review of Fall Risk Assessments dated 11/20/2020 revealed all residents were assessed for falls risk by LPN Unit Manager and the ADON. Interviews with the LPN Unit Manager and the ADON on 12/03/2020 at 1:46 PM and 2:09 PM verified they had completed the Fall Assessments for all residents. 3. Review of care plans of residents identified at risk for falls, revealed the Unit Manager and the ADON reviewed the care plans of resident's identified at risk for falls to ensure accuracy of the fall interventions on 11/23/2020. 4. Review of a written statement revealed the care plans were reviewed on 11/23/2020 by the LPN Unit Manager, ADON, DON and the SDC. Interviews on 12/03/2020 at 1:46 PM, 2:09 PM, 1:01 PM and 12:28 PM with the Unit Manager, ADON, and the SDC revealed they reviewed the care plans of residents with falls in the past thirty (30) days to ensure appropriate interventions were implemented with no concerns identified. 5. Review of the attendance roster dated 11/20/2020, revealed the Regional Quality Manager (RQM) educated the Administrator, DON, ADON, and Unit Managers regarding the timing and revision of Care Plans. Interview with the RQM, on 12/03/2020 at 1:43 PM, revealed education was provided to the Administrator, DON, ADON and Unit Managers regarding the timing and revision of Care Plans. Interviews on 12/03/2020 with the Administrator at 9:45 AM, DON at 1:01 PM, ADON at 2:09 PM, LPN Unit Manager at 1:46 PM, and Unit Manager #2 at 2:03 PM, revealed they received education from the RQM regarding Care Plan timing and revisions and were able to verbalize what they learned. 6. Review of Post Test and the signed attendance roster revealed the Administrator, DON, ADON, LPN Unit Manager and Unit Manager #2, signed and passed the post test on 11/20/2020. 7. Review of attendance rosters dated 11/20/2020 through 11/23/2020, revealed all nursing staff were provided care plan education by the DON, ADON and LPN Unit Manager. Interviews on 12/03/2020 with SRNA #3 at 11:59 AM, SRNA # 4 at 12:12 PM, RN #1 at 12:28 PM, LPN #2 at 12:47 PM, RN #2 at 12:51 PM, SRNA #5 at 1:36 PM, SRNA #6 at 1:57 PM; and, on 12/11/2020 (Post Survey) with LPN #3 at 3:41 PM and LPN #4 at 3:45 AM revealed the staff reported they were educated on care plan timing and revision, Free of Accidents and Hazards, Supervision and devices. 8. Review of signed education roster and post tests dated 11/20/2020 revealed all nursing staff signed the education roster and completed a post test which determined they understood the education. 9. Review of attendance roster with content covered revealed New Agency hires (SRNA #5 on 11/24/2020, SRNA #6 on 11/25/2020, SRNA #7 on 11/27/2020 and Certified Medication Aide (CMA) on 11/28/2020) were educated before they could work. 10. Review of attendance roster indicated the QAPI team met on 11/20/2020 with names of those in attendance listed which included, the Administrator, DON, ADON, UM, SSD, Activities Director, Dietary Manager, Business Office Manager, Therapy Director and the Medical Director. Further review revealed care plans and falls were discussed. Interviews with the Administrator on 11/18/2020 at 3:10 PM, the LPN Unit Manager on 11/19/2020 at 9:15 AM, the Dietary Manager on 11/20/2020 at 8:44 AM, the DON on 11/20/2020 at 9:10 AM, and ADON on 12/03/2020 at 2:03 PM revealed that they participated in QAPI team meetings. 11. Review of the inservice training guide, dated 11/20/2020 through 11/23/2020, revealed the DON, ADON and LPN Unit Manager educated licensed staff on the notification process that was put into place. Education was provided either in person or by telephone. Interviews on 12/03/2020 with RN #1 at 12:28 PM, LPN #2 at 12:47 PM, RN #2 at 12:51 PM; and, on 12/11/2020 (Post Survey) with LPN #3 at 3:41 PM and LPN #4 at 3:45 AM revealed they received education on the notification process. 12. Review of Fall Incident Review document, dated 11/21/2020 through 12/03/2020 revealed all falls were reviewed with no concerns identified. The review sheet contained the following information about the fall: Resident room number, name, progress note, Doctor notification, Family notification, dated care plan intervention, pain intervention as applicable, falls assessment, resident care profile updated and fall management form completion. Interview with the DON, on 12/03/2020 at 1:01 PM revealed she was reviewing the review sheet daily Monday - Friday and delegated to other staff on the weekends. 13. Review of the Inservice sign in sheet revealed members of the IDT including DON, ADON, Therapy Director, Social Services, Activities Director, Dietary Manager, UM, and Administrator, reviewed weekly residents experiencing falls to include risk assessments, the incident investigation post fall, effectiveness of current interventions or the need to identify a new approach. There no concerns identified. Interview with the Administrator, on 12/03/2020 at 9:45 AM, revealed the IDT team would continue to review risk assessment, incident investigation post fall, and the effectiveness of current interventions or the need to identify a new intervention, for residents who have had falls each week. 14. Review of QAPI sign in sheet dated 11/23/2020 indicated the QAPI team met to review the status of the education and audits. Interview with the facility Administrator, on 12/03/2020 at 9:45 AM, revealed they had a QAPI meeting on 11/23/2020 and a roster of those in attendance was provided. 15. Interview with the facility Administrator on 12/03/2020 at 9:45 AM, revealed the monitoring results will be followed in the facility monthly QAPI meeting for a minimum of three (3) months.

Based on interview, record review, review of facility policy, and review of Trauma Surgeon's Discharge Summary, it was determined the facility failed to ensure one (1) of three (3) sampled residents assessed as a falls risk (Resident #1), received adequate supervision to prevent accidents. Record review revealed Resident #1 had a diagnosis of Dementia and was noted to have poor safety awareness. Resident #1 had a total of ten (10) falls since 07/01/2020 and would get up from the wheelchair and/or bed frequently. On 11/01/2020, the facility determined the resident needed to be in sight of staff when in wheelchair. However, on 11/12/2020, staff left the resident seated in the wheelchair unattended in the hallway and found the resident face down on the floor in front of his/her wheelchair with face in a pool of blood. The resident was transported to the emergency room . The resident sustained an Acute Cervical Fracture at level seven, bilateral Subdural Hemorrhages, Nasal Bone Fracture, right Orbital Fracture, and Maxillary Fracture. The resident returned to the facility and was made a DNR and placed on Hospice Care. In addition, the facility had failed to analyze or evaluate the resident's falls to ensure a system was in place to reduce the likelihood of falls, per facility policy. The facility's failure to provide adequate supervision to prevent accidents has caused or was likely to cause serious injury, harm, impairment, or death to a resident, Immediate Jeopardy was identified on 11/20/20 and determined to exist on 11/12/2020. The facility was notified of the Immediate Jeopardy on 11/20/2020. An acceptable Allegation of Compliance (AoC) was received on 11/25/20. The State Survey Agency validated the AoC and determined Immediate Jeopardy was removed on 11/24/2020. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility policy titled, Falls Standard of Practice, dated July 2020, revealed the facility would ensure that the resident environment remains as free of accident hazards as was possible and each resident receives adequate supervision and assistance devices to prevent accident. At the time of a fall, after assessing and caring for the resident, an Incident Report and investigation should be initiated to determine appropriate intervention(s). The residents care plan was to be updated with implemented intervention(s). The Clinical Quality Assurance (QA) Interdisciplinary Team (IDT) would review and discuss any fall from the prior day in the morning clinical meeting. The care plan would be updated to reflect any changes to risk factors or needed interventions. Residents experiencing fall were reviewed to determine the effectiveness of current interventions or to identify potential new approaches. Record review revealed the facility admitted Resident #1 on 10/30/2018 with diagnoses which included Diabetes, Transient Cerebral Ischemic Attack (TIA), [CONDITION(S)], Hypertension and [CONDITION(S)] (GERD). Review of the Quarterly Minimum Data Set (MDS) assessment, dated 06/23/2020 , revealed the facility assessed Resident #1's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of seven (7), which indicated the resident was not interviewable. Further review of the MDS revealed the facility assessed Resident #1 required extensive assist of two (2) staff for transfers and toileting, assist of one (1) staff for ambulation, and the resident's balance was unsteady and required staff assistance for balance. Review of the Fall Management tools for Resident #1 revealed Resident #1 sustained falls on 07/01/2020 at 9:00 AM, and again at an unknown time. The resident fell on [DATE] at 12:30 AM, 07/26/2020 at 6:40 AM, 08/26/2020 at 10:30 PM, 10/13/2020 at 7:15 AM, and on 11/08/2020 at 9:45 AM, as a result of the resident transferring from wheelchair/bed, ambulating to and from restroom, and toileting without the facility assessed need for staff assistance. Further review of the Fall Management tools revealed there was no documented evidence the facility analyzed or evaluated the resident's falls to identify the root cause of the 07/01/2020, 07/26/2020 and 10/13/2020 falls, per facility policy. Review of Resident #1's Comprehensive Care Plan for Falls, dated 04/30/2020, revealed interventions directed staff to ensure urinal/personal belongings were at bedside in reach of the resident, attempt to identify root cause for falls, ensure appropriate footwear when out of bed, place grab bars around the toilet, and non skid strips in front of bathroom door/toilet, and beside bed. In addition, there were interventions for call bell to be in reach, educate the resident if urinal on the floor to ask for assistance, educate resident to ask for assistance as needed, encourage nonskid socks, and place the call light to gown when in bed even though the facility had assessed the resident's cognition to be severely impaired. Review of the Resident Care Profile (SRNA care plan), dated 10/16/2020 had interventions to use call light, keep wheelchair close to resident as possible, and offer to take the resident to the bathroom after meals. In addition, the resident was on Restorative Program and received ambulation with Active Range of Motion to Bilateral lower extremities. Further review of the Fall Management tools, dated 07/01/2020 at 9:00 AM, and again at an unknown time, 07/19/2020, 07/26/2020, 08/26/2020, 10/13/2020, and 11/08/2020, revealed interventions put in place after the falls were a low bed, anti-tippers and anti-rollbacks to wheelchair, activities, resident medication review, first aid, lab studies to include an [MEDICATION(S)] level, a new pair of gripper socks, and to encourage the resident to ask for assistance with ambulating to restroom even though the resident's cognition was severely impaired. However, none of the interventions implemented addressed the need of increased supervision to ensure staff were aware when the resident was attempting to transfer/ambulate without assistance; or, to provide more frequent toileting assistance; to prevent further falls per facility policy. Review of a Fall Management tool revealed Resident #1 fell , on 11/01/2020 at 6:15 PM, while ambulating without assistance in his/her room and sustained a skin tear. The root cause was identified as the resident was ambulating without assistance in the room and stumbled and fell . Interventions included First Aid, activities, maintaining visualization of resident while up in wheelchair, and to perform neurological checks. Review of the Nursing Progress Note, dated 11/12/2020 at 6:10 PM revealed Resident #1 was found on the floor by Registered Nurse (RN) #1. The resident was noted to be face down on the floor with blood surrounding his/her head. The resident's wheelchair was upright at the resident's feet, the resident had shoes on, and the resident's glasses were found on the floor several feet away. The resident was responsive to name but was unable to turn self over. The RN assisted the resident to roll to his/her side while providing support to the neck. The resident was noted to have an open area above the left eye and to be bleeding from the nose. The RN applied pressure to the open area and held pressure to the resident's nose to slow the bleeding. Another staff member called 911 to have the resident transferred to the hospital for care. It was noted in the note the SRNA had seen the resident approximately five (5) minutes before the fall and the resident was sitting in the hallway quietly. The RN noted in the notation that the resident does have a history of falls due to a decreased safety awareness. Further review of the note revealed the Director of Nursing (DON) and Administrator were notified of the fall at 6:20 PM, the ambulance arrived to transport the resident at 6:35 PM, the Nurse Practitioner was notified at 6:40 PM, and the guardian was notified at 6:50 PM. Review of a Fall Management tool, dated 11/12/2020, regarding the 11/12/2020 at 6:10 PM fall, revealed there was no evidence the facility identified the resident was not in view of staff at the time of the fall. In addition, the intervention put in place after the fall to prevent further falls was to send the resident to the hospital. Review of Trauma Surgeon Discharge Summary, dated 11/14/2020, revealed the resident was admitted to the hospital on 11/12/2020. The reason listed for admission was resident found down at the nursing home, presumed fallen from wheelchair. Patient has dementia and was unable to give any history. The laceration was repaired The patient was admitted to the trauma Intensive Care Unit (ICU) after presenting as a trauma. In addition to the trauma consult, there were also consults for Neurosurgery and Ears, Nose, Throat (ENT). It was determined the patient was not a candidate for surgery. The patient had an extensive past medical history including liver failure. Given his/her medical conditions and clinical decline it was felt the best way to proceed with the patient's care was a transition to a Do Not Resuscitate (DNR) to allow for a natural death. The trauma surgeon personally discussed the case with the patient's guardian. It was determined the patient had an Acute Cervical level seven (7) Fracture, Bilateral Subdural Hemorrhages, Nasal Bone Fracture, Right Orbital Fracture, and a Left Maxillary Fracture. Interview with State Registered Nurse Aide (SRNA) #1, on 11/18/2020 at 4:38 PM, revealed Resident #1 falls a lot. SRNA #1 stated he was working when the resident fell on [DATE], but did not witness the fall. He revealed there was an intervention in place to have the resident in the area near the nurses desk in case he/she tried to get up and he was aware the resident was supposed to be in sight of staff. He stated also the resident's room was near the nurses station so the resident could be seen in room if the door was open. He stated staff would do every two (2) hour rounds, and were told to toilet the resident every hour. The resident was oriented to name, and would get really confused later in the shift. He stated the SRNA's have a kiosk with interventions and updates were provided by managers/nurses. Interview with SRNA #2, on 11/19/2020 at 10:47 AM, revealed she was working on 11/12/2020 when Resident #1 fell but she was providing care to another resident at the time of Resident #1's fall. She stated the resident thought he/she could do everything on his/her own, was not able to use the call light to call for assistance, and was quick and would get up unassisted. She revealed one of the interventions was to place the resident near the nurses station when up in the wheelchair. The SRNA stated the resident was to be kept in sight. She stated the resident was able to self propel in the wheelchair and was difficult to redirect. Interview with Registered Nurse (RN) #1, on 11/16/2020 at 12:58 PM, revealed she walked by the nurses desk and saw Resident #1 lying face down on the floor with blood around his/her head. She stated the wheelchair was not tipped, the resident was wearing shoes, and the resident's glasses were on the floor. She revealed the resident responded to his/her name being called and she supported the resident's neck to get the resident's face out of the blood that had pooled. She stated a SRNA went to get another nurse in the building to assist her in calling the ambulance. The RN revealed she had seen the resident less than five (5) minutes before she found the resident on the floor. She stated she had went to get a oxygen saturation monitor from across the hall and the SRNA's were providing care to other residents. She stated there was no particular staff member assigned to keep the resident in sight. Interview with the Licensed Practical Nurse (LPN) Unit Manager, on 11/19/2020 at 9:15 AM, and on 11/19/2020 at 4:09 PM, revealed the facility was no longer doing Bowel/Bladder patterning for the resident. She stated toileting was assessed on admission or as needed; and staff had done everything needed to address any toileting needs for Resident #1. Resident #1's last bladder and bowel pattern was completed in February 2020 for three (3) days. She revealed the resident was care planned to receive incontinent care as needed and required the assist of one staff for toileting. She also revealed the resident had a urinal and could use it. She further revealed Resident #1 was very impulsive and kept on getting up. She stated she thought the resident had adequate supervision. She stated the resident had the right to get up, walk, and fall but they tried to keep the resident as safe as possible. All falls were screened by therapy. She stated falls and the effectiveness of interventions were discussed in IDT meetings and interventions were changed if not appropriate. She revealed she thought the staff were keeping the resident as safe as possible. She revealed the root cause of the falls was determined in the IDT meetings and Resident #1's falls were discussed in the QA committee. However, there was no root cause identified for the fall on 11/12/2020. Interview with the Trauma Surgeon, on 11/19/2020 at 12:36 PM, revealed the injuries Resident #1 sustained were as reported in his hospital notes. He stated that the resident was not a candidate for surgery. He further revealed the reasons for the Do Not Resuscitate (DNR) order was due to the resident's condition after the fall and also the resident's other medical problems. Interview with the Director of Nursing (DON), on 11/20/2020 at 9:10 AM, revealed after a resident sustained a fall, it was the responsibility of the nurse caring for the resident to initiate the Fall Management form and to determine interventions post fall. The DON stated the nurse should initiate new orders and update the residents care plan and alert staff to any changes in care. She stated she was working on the floor on 11/12/2020 when Resident #1 fell . She revealed the facility does not utilize alarms and root causes were determined by the IDT. She revealed she was new to the position and had not been the one to monitor the root cause of falls nor had she been in the position to identify and monitor interventions. The DON stated due to staff not keeping the resident in site, the resident suffered harm from 11/12/2020 fall. Interview with the facility Administrator, on 11/16/2020 at 2:09 PM and 11/18/2020 at 2:02 PM, revealed the facility does not use alarms, nor do they utilize 1:1 supervision after falls. He stated the facility was a restraint free building. He revealed most of Resident #1's falls were related to the bathroom and staff conducted a toileting program in February of 2020 but no pattern was determined. He stated non-skid strips and grab bars were placed around the toilet. He reported the resident's falls were tracked and trended. He stated he was aware that the care plan interventions do not match the fall investigations and he was not sure if there were any other care plans that reflect the interventions noted in the falls investigations. The facility implemented the following to remove the Immediate Jeopardy: 1. Resident #1 was readmitted to the facility COVID Unit on 11/14/2020. A fall assessment was completed and care plan interventions were re-instated to support the needs of the resident on the COVID unit, including bed against wall, low bed with scoop mattress, and mat beside bed. 2. The Assistant Director of Nursing (ADON) and Nurse Unit Manager (UM) completed fall risk assessments for all residents on 11/20/2020. 3. The ADON and Nurse Unit Manager reviewed care plans for residents identified with risk factors for falls on 11/20/2020, to ensure interventions were in place to address the resident risk factors. 4. Nursing Management including the Director of Nursing (DON), ADON, Nursing UM's, and Staff Development Coordinator (SDC) reviewed all resident falls in the past thirty (30) days to ensure that care plans had been revised with interventions to reduce the risk of further falls. Any identified concerns were addressed at the time of discovery. This was completed on 11/20/20 - 11/23/2020. 5. The Regional Program Manager (RPM) provided education to the Administrator (ADM) the DON, the ADON, and the LPN UM on 11/20.2020 regarding F657 and F689. Specifically, this education included: A comprehensive care plan must be developed within seven (7) days after completion of the comprehensive assessment, prepared by an IDT, and reviewed and revised by the IDT after each assessment, including both the comprehensive and quarterly review assessments. The care plan should also be evaluated and revised as needed. An example included, but not limited to, the need to revise a care plan after a fall to reflect the care and/or supervision a resident was to receive to try to prevent further falls. Interventions to reduce fall risk based on certain resident behaviors, such as attempting to transfer self independently when assessed to require assist, should be included in the plan of care. The facility must ensure the resident's environment remained as free of accident hazards as was possible. Each resident receives adequate supervision and assistive devices to prevent accidents. This included identifying hazard(s) and risk(s), evaluating and analyzing hazard(s) and risk(s), implementing interventions to reduce hazard(s) and risk(s) and monitoring for effectiveness and modifying interventions when necessary. Examples included, but was not limited to identifying the supervision needs of the resident identified as a fall risk, evaluating a fall risk resident to create a system to reduce the likelihood of further falls, and evaluating the needs of resident with poor safety awareness to reduce the likelihood of further falls. 6. Verbal acknowledgement of understanding, along with signed education and post-test was obtained after education. 7. The above education was then provided to the nursing staff (including contracted/agency nursing staff) by the DON, ADON, SDC and/or LPN UM on 11/20/2020-11/23/2020. 8. Verbal acknowledgement of understanding, along with signed education and post -test was obtained after education. 9. Any new nursing hire (including contracted/agency) would received this education prior to assuming duties. 10. An ad hoc Quality Assurance Process Improvement (QAPI) meeting was held 11/20/2020, to review the summary of Immediate Jeopardy finding and discuss the development of action items to be completed. This meeting included the Administrator, DON, ADON, UM, Social Services Director (SSD), Activities Director, Dietary Manager, Business Office Manager, Therapy Director, and Medical Director. 11. The DON, ADON, SDC, and/or LPN UM educated licensed nurses (including contracted/agency nurses) on 11/20/2020 through 11/23/2020. The licensed nurses were educated that anytime there was a resident fall incident, the DON or the designated on-call licensed nurse was to be notified, at which time the incident would be reviewed and applicable immediate interventions(9) would be added to the plan of care and the Resident Care Profile. This notification process began 11/20/2020. 12. Effective 11/21/2020 and continuing on-going, the prior 24-hour falls incident would be reviewed daily and again reviewed to see that the care plan and the Resident Care Profile was updated with fall prevention intervention(s). The intervention(s) would be reviewed to see if any changes may be warranted to the immediate intervention(s). The falls would be reviewed weekdays in the morning clinical meeting by the DON, ADON, Therapy Director, Administrator, and/or UM; and, on weekends, by the SDC and/or Weekend Supervisor Nurse. 13. Effective the week of 11/23/2020, continuing weekly on-going, members of the IDT including DON, ADON, Therapy Director, Social Services, Activities Director, Dietary Manager, UM, and Administrator, would review weekly residents experiencing falls to include risk assessments, the incident investigation post fall, effectiveness of current interventions or the need to identify a new approach. 14. A second ad hoc QAPI meeting was held on 11/23/2020 to review the status of the education and audits. This meeting included the Administrator, DON, ADON, UM, Social Services Director (SSD), Activities Director, Dietary Manager, Business Office Manager, Therapy Director, and Medical Director. 15. The monitoring results would be followed in the facility monthly QAPI meeting a minimum of three (3) months for review of recommendation if indicated. The monthly QAPI is attended by, but not limited to the Adm, DON, ADON, UM, Social Services Director (SSD), Activities Director, Dietary Manager, Business Office Manager, Therapy Director, and Medical Director a minimum of quarterly The State Survey Agency validated the corrective action taken by the facility as follows: 1. Review of the Fall Risk Assessment, dated 11/14/2020 revealed Resident #1 was assessed and it was determined the resident was at an increased risk for falls with a score of twenty-one (21). Review of Resident #1's Comprehensive Care Plan, revealed the resident's care plan was reinstated when he/she returned from the hospital and included interventions for bed against wall, low bed with scoop mattress, and mat beside bed. 2. Review of Fall Risk Assessments dated 11/20/2020 revealed all residents were assessed for falls risk by LPN Unit Manager and the ADON. Interviews with the LPN Unit Manager and the ADON on 12/03/2020 at 1:46 PM and 2:09 PM verified they had completed the Fall Assessments for all residents. 3. Review of care plans of residents identified at risk for falls, revealed the Unit Manager and the ADON reviewed the care plans of resident's identified at risk for falls to ensure accuracy of the fall interventions on 11/23/2020. 4. Review of a written statement revealed the care plans were reviewed on 11/23/2020 by the LPN Unit Manager, ADON, DON and the SDC. Interviews on 12/03/2020 at 1:46 PM, 2:09 PM, 1:01 PM and 12:28 PM with the Unit Manager, ADON, and the SDC revealed they reviewed the care plans of residents with falls in the past thirty (30) days to ensure appropriate interventions were implemented with no concerns identified. 5. Review of the attendance roster dated 11/20/2020, revealed the Regional Quality Manager (RQM) educated the Administrator, DON, ADON, and Unit Managers regarding the timing and revision of Care Plans. Interview with the RQM, on 12/03/2020 at 1:43 PM, revealed education was provided to the Administrator, DON, ADON and Unit Managers regarding the timing and revision of Care Plans. Interviews on 12/03/2020 with the Administrator at 9:45 AM, DON at 1:01 PM, ADON at 2:09 PM, LPN Unit Manager at 1:46 PM, and Unit Manager #2 at 2:03 PM, revealed they received education from the RQM regarding Care Plan timing and revisions and were able to verbalize what they learned. 6. Review of Post Test and the signed attendance roster revealed the Administrator, DON, ADON, LPN Unit Manager and Unit Manager #2, signed and passed the post test on 11/20/2020. 7. Review of attendance rosters dated 11/20/2020 through 11/23/2020, revealed all nursing staff were provided care plan education by the DON, ADON and LPN Unit Manager. Interviews on 12/03/2020 with SRNA #3 at 11:59 AM, SRNA # 4 at 12:12 PM, RN #1 at 12:28 PM, LPN #2 at 12:47 PM, RN #2 at 12:51 PM, SRNA #5 at 1:36 PM, SRNA #6 at 1:57 PM; and, on 12/11/2020 (Post Survey) with LPN #3 at 3:41 PM and LPN #4 at 3:45 AM revealed the staff reported they were educated on care plan timing and revision, Free of Accidents and Hazards, Supervision and devices. 8. Review of signed education roster and post tests dated 11/20/2020 revealed all nursing staff signed the education roster and completed a post test which determined they understood the education. 9. Review of attendance roster with content covered revealed New Agency hires (SRNA #5 on 11/24/2020, SRNA #6 on 11/25/2020, SRNA #7 on 11/27/2020 and Certified Medication Aide (CMA) on 11/28/2020) were educated before they could work. 10. Review of attendance roster indicated the QAPI team met on 11/20/2020 with names of those in attendance listed which included, the Administrator, DON, ADON, UM, SSD, Activities Director, Dietary Manager, Business Office Manager, Therapy Director and the Medical Director. Further review revealed care plans and falls were discussed. Interviews with the Administrator on 11/18/2020 at 3:10 PM, the LPN Unit Manager on 11/19/2020 at 9:15 AM, the Dietary Manager on 11/20/2020 at 8:44 AM, the DON on 11/20/2020 at 9:10 AM, and ADON on 12/03/2020 at 2:03 PM revealed that they participated in QAPI team meetings. 11. Review of the inservice training guide, dated 11/20/2020 through 11/23/2020, revealed the DON, ADON and LPN Unit Manager educated licensed staff on the notification process that was put into place. Education was provided either in person or by telephone. Interviews on 12/03/2020 with RN #1 at 12:28 PM, LPN #2 at 12:47 PM, RN #2 at 12:51 PM; and, on 12/11/2020 (Post Survey) with LPN #3 at 3:41 PM and LPN #4 at 3:45 AM revealed they received education on the notification process. 12. Review of Fall Incident Review document, dated 11/21/2020 through 12/03/2020 revealed all falls were reviewed with no concerns identified. The review sheet contained the following information about the fall: Resident room number, name, progress note, Doctor notification, Family notification, dated care plan intervention, pain intervention as applicable, falls assessment, resident care profile updated and fall management form completion. Interview with the DON, on 12/03/2020 at 1:01 PM revealed she was reviewing the review sheet daily Monday - Friday and delegated to other staff on the weekends. 13. Review of the Inservice sign in sheet revealed members of the IDT including DON, ADON, Therapy Director, Social Services, Activities Director, Dietary Manager, UM, and Administrator, reviewed weekly residents experiencing falls to include risk assessments, the incident investigation post fall, effectiveness of current interventions or the need to identify a new approach. There no concerns identified. Interview with the Administrator, on 12/03/2020 at 9:45 AM, revealed the IDT team would continue to review risk assessment, incident investigation post fall, and the effectiveness of current interventions or the need to identify a new intervention, for residents who have had falls each week. 14. Review of QAPI sign in sheet dated 11/23/2020 indicated the QAPI team met to review the status of the education and audits. Interview with the facility Administrator, on 12/03/2020 at 9:45 AM, revealed they had a QAPI meeting on 11/23/2020 and a roster of those in attendance was provided. 15. Interview with the facility Administrator on 12/03/2020 at 9:45 AM, revealed the monitoring results will be followed in the facility monthly QAPI meeting for a minimum of three (3) months. ,

Based on observation, interview, record review, facility policy review, and review of The Lippincott's Textbook for Nursing Assistants, it was determined the facility failed to treat two (2) of twenty-one (21) sampled residents with respect and dignity (Residents #44 and #39). Observation on 10/30/19 revealed Certified Nurse Aide (CNA) #3 failed to keep Resident #44's upper body covered while providing incontinent care. In addition, staff failed to ensure Resident #39's facial hair was removed. The findings include: Review of the facility policy titled, Quality of Life-Dignity, not dated revealed each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Residents shall be treated with dignity and respect at all times. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. Residents shall be groomed as they wish to be groomed (hair styles, nails, facial hair, etc.). 1. Record review revealed the facility admitted Resident #44 on 09/08/19 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 09/17/19 revealed the facility assessed Resident #44's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of six (6) which indicated the resident was not interveiwable. Further review of the MDS revealed the resident required total assist of two (2) for hygiene and toileting. Observation on 10/30/19 at 1:59 PM revealed Resident #44's door was slightly open, and after knocking on the door and entering the room, surveyor observed the privacy curtain was not pulled and Resident #44 was lying in bed with only a brief on, completely exposed with the bed sheet and cover lying around the resident's ankles. Further observation revealed Resident #44 was attempting to cover the chest area with his/her crossed arms. Interview with CNA #3 on 10/30/19 at 2:15 PM revealed she guessed the door had been left open by another CN[NAME] CNA #3 stated if the resident had been covered and the curtain drawn, the resident would not have been exposed. She stated she gets in a hurry at times. Interview with the Staff Development Coordinator (SDC) on 10/31/19 at 1:00 PM revealed when giving resident care, the door should be shut, the curtain pulled, and the resident covered to provide privacy at all times. The SDC stated she did annual competencies and monthly education that covers this. Interview with the Director of Nursing (DON) on 10/31/19 at 1:50 PM, revealed she expected the privacy curtain to be pulled closed, and the resident to be covered during care to protect their privacy and dignity. 2. Record review revealed the facility admitted Resident #35 on 11/07/18 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 09/13/19 revealed the facility assessed Resident #35's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of six (6) which indicated the resident was not interviewable. Observation of Resident #35 on 10/29/19 at 2:37 PM and 10/31/19 at 9:04 AM revealed there was facial hair to chin and upper lip. Interviews with the resident at these times revealed he/she would like to get rid of it but he/she has no razor, and the hair on his/her face made him/her feel dirty and he/she wanted to hide from others because of the hair. Interview with Resident #35's Power of Attorney (POA) by phone, on 10/31/19 at 10:15 AM revealed she has asked the nurses, the people that come into the resident's room, and the people who sit at the front and back nurses stations, time and time again to cut the resident's facial hair but no one does it. The POA further revealed she told them that she would pay the beautician to have it done but no one calls and she bought the resident a $20 dollar shaver to keep in his/her room but someone stole it. She stated the resident would be so upset if his/her mind was all there and he/she realized he/she had long whiskers on his/her face. Interview with CNA #5 on 10/31/19 at 9:07 AM revealed he was caring for Resident #35 that day and could shave Resident #35, but he had never done it before. He stated could shave the resident later in the day, but not at this time. Interview with Unit Manager on 10/31/19 at 9:16 AM revealed staff could remove the hair for Resident #35 but the resident may not agree because he/she likes to stay to him/herself in room. The Unit Manager interviewed Resident #35 with surveyor present and he/she stated he/she had no money to pay for shave. The Unit Manager told the resident no money was needed, it would be free. Interview with the DON and Regional Nurse on 10/31/19 at 11:17 AM revealed the DON would have someone come down and shave Resident #35's chin to remove facial hair. The DON stated the residents should be shown respect and dignity which included making sure the resident's are properly groomed including removal of facial hair.

Based on observation, interview, record review, and review of the Resident Assessment Instrument (RAI) Manual, it was determined the facility failed to ensure the facility must develop or implement a comprehensive person-centered care plan for two (2) of twenty-one (21) sampled residents (Resident #39, and #49). Resident #39 and the Resident's Power of Attorney wanted the resident facial hair removed when groomed by staff; however, the care plan did not address the removal of the resident's facial hair. In addition, Resident #49 was care planned for extensive assist of two (2) persons for transfers; however, observation on 10/31/19 revealed only one staff transferred the resident from chair to bed and bed to chair. The findings include: Interview on 10/31/19 at 11:17 AM with the Director of Nursing (DON) revealed the facility did not have a Comprehensive Care Plan policy; however, the RAI manual was used for a guideline for Comprehensive Care Plans. Review of the RAI Manual As required at 42 CFR 483.21(b), the comprehensive care plan is an interdisciplinary communication tool. It must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The care plan must be reviewed and revised periodically, and the services provided or arranged must be consistent with each resident's written plan of care. Good assessment is the starting point for good clinical problem solving and decision making and ultimately for the creation of a sound care plan. The CAA's provide a link between the MDS and care planning. The care plan should be revised on an ongoing basis to reflect changes in the resident and the care that the resident is receiving. 1. Record review revealed the facility admitted Resident #39 on 11/07/18 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 09/13/19 revealed the facility assessed Resident #39's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of six (6) which indicated the resident was able to answer simple questions without difficulty. Further review of the MDS revealed the resident required extensive assist of one person for grooming. Observation of Resident #35 on 10/29/19 at 2:37 PM and 10/31/19 at 9:04 AM revealed there was facial hair to chin and upper lip. Interviews with the resident at these times revealed he/she would like to get rid of it but he/she has no razor, and the hair on his/her face made him/her feel dirty and he/she wanted to hide from others because of the hair. In addition, interview by phone with Resident #35's Power of Attorney (POA) on 10/31/19 at 10:15 AM revealed she asked the nurses, the people that come into the resident's room, and the people who sit at the front and back nurses stations, time and time again to cut the resident's facial hair but no one does it. The POA further revealed she told them that she would pay the beautician to have it done but no one calls and she bought the resident a $20 dollar shaver to keep in his/her room but someone stole it. However, review of the Self Care Deficit Comprehensive Care Plan and Certified Nurse Aide (CNA) Care Plan , both dated 12/27/18, revealed no interventions to address the removal of facial hair. Interview with CNA #5 on 10/31/19 at 9:07 AM revealed he was caring for Resident #35 that day and could shave Resident #35, but he had never done it before. Interview with the DON and Regional Nurse on 10/31/19 at 11:17 AM revealed the DON expected the resident's ADL Comprehensive Care Plan to include the removal of facial hair. She further revealed the staff go by the Practice Standards in removing facial hair from residents. 2. Record review revealed the facility admitted Resident #49 on 09/18/19 with [DIAGNOSES REDACTED]. Review of the Admission MDS assessment, dated 09/25/19 revealed no BIMS was attempted since the resident was rarely or never understood. Further review revealed the facility assessed the resident's cognitive skills for daily decision making were severely impaired. Review of the Comprehensive Care Plan for Self Care Deficit dated 10/01/19 revealed an intervention for transfers: extensive assist of two. Observation on 10/31/19 at 8:53 AM revealed CNA #5 held Resident #49 in front of the wheelchair with his arms under the resident's arms and CNA #4 was behind the resident and wheelchair with a brief in her hand. The resident would not stand up and CNA #5 said lets put him/her in the bed. They proceeded to sit the resident back in the wheel chair, rolled the resident to the bed, and then CNA #5 picked the resident up from under his/her arms and pivoted the resident to the bed without the assistance of CNA #4. Peri care was completed and then CNA #5 picked him/her up again by himself and placed him/her back into the chair. The staff was not talking with the resident and the resident was lashing out trying to grab onto something. He/She appeared out of control/flaying about. Interview with CNA #5 on 10/31/19 at 1:05 PM revealed he knew the resident was a two assist and that there were two CNA's in the room; however, only one CNA assisted in transferring the resident. Interview with the DON on 10/31/19 at 11:53 PM revealed the staff should follow the Comprehensive Care Plan according to the transfer status. The DON stated the transfer status is also listed on the CNA care plans for each resident. She revealed the care plan is in several places to include the kiosk (computer system) and a book on the nursing station desk.

Based on observation, interview, record review, facility policy review, and review of The Lippincott's Textbook for Nursing Assistants, it was determined the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good grooming for one (1) of twenty-one (21) sampled residents (Resident #39). Resident #39 and the resident's Power of Attorney (POA) both want the resident's facial hair removed when groomed; however, observations on 10/29/19 and 10/31/19 revealed the resident had facial hair on chin and upper lip. The findings include: Review of the facility policy,Quality of Life-Dignity, not dated revealed, each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Residents shall be treated with dignity and respect at all times. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. Residents shall be groomed as they wish to be groomed (hair styles, nails, facial hair, etc.). Review of The Lippincott's Textbook for Nursing Assistants, A Humanistic Approach to Caregiving, not dated, in Unit 3 Basic Patient/Resident Care; Assisting with Shaving revealed, some women experience the growth of coarse facial hair as they age and may request your help with removing this unwanted hair. If a woman is unable to shave her legs, armpits, or face and wants to do so, you should help her as necessary. Record review revealed the facility admitted Resident #35 on 11/07/18 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 09/13/19 revealed the facility assessed Resident #35's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of six (6) which indicated the resident was not interviewable. Further review of MDS revealed the resident needed extensive assist of one for grooming. Review of the Self Care Deficit Comprehensive Care Plan dated 12/27/18 for assist of one with Activity of Daily Living related to dementia, anxiety and depression with additional risk for decline secondary to impaired cognition, revealed no interventions for facial hair removal. Observation of Resident #35 on 10/29/19 at 2:37 PM revealed there was facial hair to chin and upper lip. Interview with the resident at the time revealed he/she would like to get rid of it but he/she has no razor. He/she stated there was a friend on another hall that would probably do that for me. Observation on 10/31/19 at 9:04 AM revealed Resident #35 was sitting in room looking at newspaper. He/She still had facial hair and stated she wanted it removed. He/She revealed the hair on his/her face made him/her feel dirty and he/she wanted to hide from others because of the hair. Interview with Resident #35's PoA by phone, on 10/31/19 at 10:15 AM revealed she has asked them time and time again to cut the resident's facial hair and trim his/her nails but no one does it. She stated she has requested this of all the nurses and the people that come into his/her room. She revealed she did not know who the DON was so she had not told her but she had told the people that sit at the front and back nurses stations. The POA further revealed she told them that she would pay the beautician to have it done but no one calls. She stated she bought the resident a $20 dollar shaver to keep in his/her room but someone stole it. She revealed she would really appreciate the surveyor's help in getting the resident's facial hair removed. She stated the resident would be so upset if his/her mind was all there and he/she realized he/she had long whiskers on his/her face. Interview with Certified Nurse Aide (CNA) #5 who was caring for Resident #35, on 10/31/19 at 9:07 AM, revealed he could shave Resident #35, but he had never done it before. He stated he could get to the resident later in the day, but not right at this time. Interview with Unit Manager on 10/31/19 at 9:16 AM revealed staff could remove the hair for Resident #35 but the resident may not agree because he/she likes to stay to him/herself in room. The Unit Manager interviewed Resident #35 with surveyor present and he/she stated he/she had no money to pay for shave. The Unit Manager told the resident no money was needed, it would be free. Interview with the Director of Nursing (DON) and Regional Nurse on 10/31/19 at 11:17 AM revealed the DON expected the resident's care plan to be person centered. The DON stated she would have someone come down and shave Resident #35's chin to remove facial hair. The DON stated the residents should be shown respect and dignity which included making sure the resident's are properly groomed including removal of facial hair.

Based on observation, interview, and record review, it was determined the facility failed to ensure a resident who is fed by enteral means receives the appropriate treatment and services, for one (1) of three (3) tube fed residents, in a selected sample of twenty-one (21) residents (Resident #19). Observation on 10/29/19 revealed Resident #19's bottle of Two Cal and bag of water were being administered per feeding tube; however, further observation revealed the bag of water and bottle of two cal were not labeled with the resident's name, date, and time. The findings include: Interview with the Administrator on 10/31/19 at 1:24 PM revealed the facility did not have a policy related to changing and labeling enteral feeding bottles and water bags. Record review revealed the facility admitted Resident #19 on 02/24/16 with [DIAGNOSES REDACTED].#19's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of zero (0) which indicated the resident was not interveiwable. Observation on 10/29/19 at 11:03 AM revealed Resident #19 had a [DEVICE] feeding running at sixty-three (63) milliliters (ml) per hour with a bag of water and a bottle of Two cal (feeding) hanging. Further observation revealed the bottle and bags were almost empty, and neither had a resident's name, room number, date, or time documented on them Interview with Licensed Practical Nurse (LPN) #1 on 10/29/19 at 11:15 AM revealed she agreed there was no documentation on the feeding bottle or water bag to indicate the resident's name, room number, start date, time, or the nurse that hung the feeding. LPN #1 stated there was an identification sticker on there but guessed it had fell off. Further observation of the bottle of Two cal at this time revealed a place on the bottle to write the resident's name and room number, the start date and time, and infusion rate, but was left blank. Interview with the Staff Developmental Coordinator (SDC) on 10/31/19 at 1:03 PM revealed an enteral feeding was good for twenty-four( 24) hours, so the new bottle should include the resident's name, room number, date, time, and rate of delivery. She stated the nurses are taught this during nursing orientation, and it is standard practice. Interview with the Director of Nursing (DON) on 10/31/19 at 1:47 PM revealed it was night shift's responsibility to change out the tubing and water bottle, but whoever changes the empty bottle of feeding is responsible for putting the resident's name, date, and time, on the new bottle.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to ensure drugs and biological's used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable related to one (1) Triceba Insulin pen found on one (1) of four (4) medication carts, that was not dated when opened. The findings include: Review of the facility policy, titled Labeling of Medication Containers, not dated, revealed all multi-dose vials should be labeled with the date they were opened. Observation of four (4) medication storage carts, on 10/29/19 at 4:15 PM, revealed the split hall medication cart #1 had one pen of Triceba Insulin with no date when it was opened. Interviews on 10/31/19 with the Director of Nursing (DON) at 1:47 PM, Staff Development Coordinator (SDC) at 2:00 PM, and Licensed Practical Nurse (LPN) #3 at 2:02 PM, revealed any multi-dose vial of medication should be dated when opened by whoever opened it.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure staff used proper hand hygiene during incontinent care for one (1) of twenty-one (21) sampled residents (Resident #18). Observation of Resident #18's incontinent care provided on 10/29/19 revealed Certified Nurse Aides (CNA's) #1 and #2 failed to remove gloves and wash hands after providing incontinent care and failed to wash the wheelchair prior to placing the resident back in the wheelchair after he/she had a urinary incontinent episode in it. The findings include: Review of facility policy titled, Perineal Care, not dated, revealed the purpose of the procedure was to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. The policy further revealed Procedure steps include wet a wash cloth and apply soap or cleansing agent. Wash the entire perineal area and inner thighs, rinse and dry. Instruct or assist the resident to turn to his/her side, and wash and rinse the rectal area thoroughly Discard disposable items, remove gloves and discard, wash and dry hands thoroughly. Reposition the bed covers and make the resident comfortable. Record review revealed the facility admitted Resident #18 on 06/22/19 with [DIAGNOSES REDACTED]. Observation of Resident #18's incontinent care by CNA #1 and CNA #2, on 10/29/19 at 3:33 PM, revealed the CNA's transferred the resident from his/her wheelchair due to him/her being wet from being incontinent. The CNA's then removed the resident's wet clothing, and washed the peri area and stool from the rectum. Further observation revealed CNA #2 applied a clean brief and clothing and the two (2) CNA's assisted the resident back to his/her wheel chair, without changing their gloves, washing their hands, or washing the wheel chair seat prior to returning the resident back to the seat. Interview with CNA #1 and CNA #2, on 10/29/19 at 3:50 PM, revealed they were unable to recall what step was left out with the procedure. When CNA #2 was told by surveyor they failed to change gloves, wash hands or clean wheelchair, he stated he was nervous and just forgot. Interview with the Staff Development Coordinator, on 10/31/19 at 1:06 PM, revealed she educated staff constantly on following the facility Infection Control policy and to always wash hands and change gloves whenever going from a dirty area to a clean area. Interview with the Director of Nursing (DON), on 10/31/19 at 1:53 PM, revealed she expected staff to wash their hands, especially when going from dirty to clean.

Based on interview, record review and review of facility policy, it was determined the facility failed to ensure one (1) of three (3) sampled residents received [MEDICAL TREATMENT] services as ordered (Resident #1). On 07/18/19, the facility failed to ensure Resident #1 had transportation to his/her [MEDICAL TREATMENT] center for treatment. The [MEDICAL TREATMENT] treatment had to be rescheduled for the next day. The findings include: Interview with the Director of Nursing (DON), on 07/26/19 at 10:04 AM, revealed there was no specific policy for [MEDICAL TREATMENT]. Record review revealed the facility admitted Resident #1 on 07/11/19 with [DIAGNOSES REDACTED]. There was no Minimum Data Set (MDS) completed due to the brief time of admission to the facility. Review of physician's orders [REDACTED].#1 was to have [MEDICAL TREATMENT] three (3) days a week. Review of the Interim Care Plan, dated 07/12/19; and Daily Care Guide, not dated; revealed Resident #1 was to have [MEDICAL TREATMENT] on Tuesdays, Thursdays and Saturdays. Review of the Hospital emergency room Chart dated 07/19/19, revealed Resident #1 arrived at the hospital after the [MEDICAL TREATMENT] center reported the resident had mental status changes and [MEDICAL CONDITION]. The resident was placed on a non-re-breather mask and when an attempt was made to change to a nasal cannula, the resident's oxygen saturations dropped into the 70's, requiring intubation by the physician. The resident was subsequently admitted with [DIAGNOSES REDACTED]. Interview with the [MEDICAL TREATMENT] Center Administrator, on 07/26/19 at 9:35 AM, revealed Resident #1 missed a treatment on 07/18/19 but it was rescheduled for the following day (07/19/19) after notifying the physician for the order. Interview with the transportation driver for the transportation service, on 07/26/19 at 3:36 PM, revealed he would go to the door each time and ring the bell. He stated no one came to the door on 07/18/19 and he waited five (5) minutes then had to leave to pick up his next appointment. Interview with the Director of Nursing (DON), on 07/26/19 at 10:04 AM, revealed Resident #1 did miss a [MEDICAL TREATMENT] treatment on 07/18/19 but the appointment was rescheduled for the following day by the [MEDICAL TREATMENT] Center after a problem occurred with transportation. The DON stated there was a problem with the transportation service set up by the [MEDICAL TREATMENT] unit and the facility would no longer be using that service as they will not enter the building to secure the resident. She revealed the resident was sitting in the lobby area by the door to be picked up that morning but no one ever came. She stated the temperatures were entirely too hot to have the resident sit out on the porch in the heat. She further revealed no one ever came to the door to get the resident.

Based on interview, record review, personnel record review, and review of the facility's Abuse and Neglect Policy, it was determined the facility failed to ensure twelve (12) of fifteen (15) sampled residents (Resident #4, #3, #13, #1, #2, #5, #6, #7, #8 and #9, #11, and #12), and twenty-six (26) of thirty (30) unsampled residents had the right to be free from neglect (Unsampled Residents M, N, R, O, S, I, U, A, C, D, F, G, J, H, L, P, T, V, W, X, Y, Z, AA, BB, CC, and DD). The facility failed to ensure residents were free from neglect when they failed to ensure State Registered Nurse Assistant (SRNA) #1 was qualified to administer medications prior to assigning him to administer medications to a total of thirty-eight (38) residents on three (3) of four (4) halls over three (3) days (03/21/16, 04/03/16 and 04/18/16). SRNA #1 administered medications such as narcotics (sedatives, antianxiety, anti-[MEDICAL CONDITION] and pain medication), antihypertensive, [MEDICATION NAME], antipsychotics, diuretics, muscle relaxer and potassium replacement therapy. SRNA #1 failed to provide treatments, failed to obtain blood pressures prior to administering blood pressure medication per physician's orders [REDACTED].; and, failed to ensure pain pumps were monitored for functioning. The facility's failure to ensure residents were free from neglect has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 03/22/16 and determined to exist on 03/21/16, 04/03/16 and 04/18/16. The facility was notified of the Immediate Jeopardy on 04/22/16. An acceptable Allegation of Compliance (AoC) was received on 05/04/16 alleging the removal of the Immediate Jeopardy on 04/25/16. The State Survey Agency validated, on 05/06/16, the Immediate Jeopardy was removed on 05/06/16. The scope and severity was lowered to an E while the facility develops and implements the Plan of Correction (PoC), and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy titled, Abuse and Neglect, not dated, revealed neglect was the failure to provide goods or services necessary to avoid physical harm, mental anguish or mental illness. Review of SRNA #1's Personnel Record revealed he was hired as an SRNA on 10/15/13 and had a current SRNA Certification which would expire on 06/30/16. However, further personnel record review revealed there was no documented evidence he received education or passed the test to work as a Kentucky Medication Aide (KMA). Review of his employment history revealed he had not been employed as a Medication Aide (MA) with any previous employer. Review of the March and April Medication Administration Records (MAR) revealed SRNA #1 administered medications to a total of thirty-eight (38) residents on 03/21/16, 04/03/16, and 04/18/16. For example, SRNA #1 administered [MEDICATION NAME] (anti-hypertensive), Potassium ER (Potassium Replacement therapy), and [MEDICATION NAME] DN ( Vasodialator) to Unsampled Resident M; [MEDICATION NAME] ER (anti-hypertensive) and Klonopin (Sedative) to Unsampled Resident R; [MEDICATION NAME] (anti-hypertensive), [MEDICATION NAME] (Imsomnia) and [MEDICATION NAME] (Antianxiety) to Unsampled Resident N; Sodium [MEDICATION NAME] ( pH [MEDICATION NAME]), Tamsulosin HCL (Urinary flow), [MEDICATION NAME] (anti-Alzheimer's), [MEDICATION NAME] (anti-depressant), and [MEDICATION NAME] ( anti-psychotic) to Unsampled Resident S, and [MEDICATION NAME] (anti-hypertensive) to Resident I. In addition, SRNA #1 failed to ensure blood pressures were checked prior to B/P medication being administered to Resident N, Resident R and Resident M; failed to obtain an oxygen saturation level on Resident U; and, failed to ensure pain pumps were functioning for Resident #4 and Unsampled Resident O. Interview with SRNA #1, on 04/21/16 at 8:12 AM, revealed he passed medications in the facility on three (3) occasions. He stated the Administrator called him at home to come in on 03/21/16 to work as a KMA on the medication cart from 7:00 PM to 7:00 AM and the Administrator told one (1) of the Unit Managers (UM) to tell him to pass medication for eight (8) hours on 04/03/16. SRNA #1 revealed the Director of Nursing (DON) asked him to cover the medication cart for four (4) hours on 04/18/16. He stated he did not have proof he had a certification during the times he passed medications and he made the Administrator aware three (3) times. He stated he administered both narcotics and non-narcotic medications during each of these shifts. Interview with Licensed Practical Nurse (LPN) #1, on 04/21/16 at 1:10 PM, revealed she worked on 03/21/16 and was informed by SRNA #1 that he was going to pass medications on Hall two (2) and she was to pass medications on Hall one 1. She stated she was never told he was not a KMA and he administered the medications and narcotics on his hall. LPN #1 stated she passed medications to residents who required gastronomy medications and she conducted the glucose monitoring and insulin administration. However, she did not provide [MEDICAL CONDITION] or wound care treatments. She stated it was the responsibility of the nurse assigned to that resident to perform these duties. LPN #1 stated they were short staffed on 03/21/16 and that was why SRNA #1 informed her he could help administer medications on Hall two (2). Interview with Unit Manager #1, on 04/22/16 at 9:15 AM, revealed on 04/03/16, she was told by the Administrator to have SRNA #1 administer medications on the day shift. She stated she expected all resident care to be provided without neglect of the resident needs. Interview with the Director of Nursing, on 04/20/16 at 2:30 PM, revealed SRNA #1 administered medication on 03/21/16 from 7:00 PM to 7:00 AM on Hall two (2), on 04/03/16 from 7:00 AM to 3:00 PM; and, on 04/18/16 from 4:00 PM to 8:30 PM. She stated she asked him to administer medications on 04/18/16 due to short staffing and she assumed he could since he had passed medications on two (2) prior shifts. She expected that the licensed staff should perform the duties such [MEDICAL CONDITION] gastrostomy tube care. Interview with the Administrator, on 04/21/16 at 11:07 AM and on 04/23/16 at 1:54 PM, revealed SRNA #1 had worked three (3) shifts as a KMA but she had not validated if he had credentials as a KMA. The Administrator stated it was ultimately her responsibility to ensure all employees were qualified. She stated she had been told he was a KMA, by nursing staff she trusted and also by SRNA #1. She stated she did not feel any form of neglect had occurred because she assumed he had completed the KMA requirements. She stated the facility did not normally employ KMA's. Interview with the Regional Director of Operations (RDO), on 04/23/16 at 2:27 PM, revealed he expected the facility and the administrator to adhere to state and federal guidelines and regulations. He stated no resident within the facility should ever be neglected at any time. Interview with the Medical Director, on 04/23/16 at 1:56 PM, revealed he was aware of the situation of the non-certified staff passing medications. He stated he expected all staff hired to be qualified, credentials should be verified prior to them working in the resident care area, and all care and services ordered by the physician should be carried out. He revealed periodic checks should be completed to verify nursing licenses, and staff certifications remain active and not allowed to expire. He further stated competency evaluations should be conducted prior to any staff being allowed to work in the resident care area. The Medical Director stated in his professional opinion, SRNA #1 being allowed to pass medications on three (3) shifts was out of his scope of practice. He stated the Administrator allowing the SRNA to work out of his scope of practice was neglect and it could have potentially resulted in a medication error that could have caused serious harm. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. On 04/21/16 and 04/22/16, Nurse Unit Managers (UM) performed skin evaluations, pain evaluations, and vital signs as deemed necessary; no issues noted. 2. On 04/20/16, the Residents' MAR indicated [REDACTED]. The facility obtained a statement from LPN #1 and validated she administered all [DEVICE] medications but failed to document. 3. The Interim DON, Nurse Unit Managers and MDS Coordinator reviewed all Care Plans related to delivery of medications and updated them to validate they accurately reflected current care needs of residents on 04/25/16. Updates were related to risk potential related to the delivery of medication by the former employee. 4. An audit of the April 2016 MARs of current residents was completed by the Interim DON, and Unit Nurse Manager on 04/25/16 to determine if any medications were administered by unqualified personnel and if further care plan updates were needed with no concerns found. 5. On 04/24/16, the RQM completed education with the Regional Director of Operations (RDO), who began as the Interim Administrator on 04/25/16, and the Interim DON on 04/24/16, on the policy that included what constituted neglect, reporting neglect, and determination of investigation of neglect. This education included supervision, protection, and determination of qualified and determination of investigating of neglect. 6. Education was provided to Department Managers including Social Services, Marketing/Admissions, Dietary Manager, Activity Director, Housekeeping, Business Office Manager (BOM), Assistant BOM, Medical Records, and UMs by the RDO and RQM on 04/25/16. The inservice was on what constituted neglect, reporting neglect, and determination of investigation of neglect. This education included supervision, protection, and determination of qualifications and determination of investigating of neglect. 7. Education was presented to the facility staff by the RQM, Administrator, and Admissions Director by 04/25/16. The inservice was on what constituted neglect, reporting neglect, and determination of investigation of neglect. This education included supervision, protection, and determination of qualifications and determination of investigating of neglect. 8. Monitoring by the Regional Team will be taken to the Quality Assurance and Assessment (QAA) team meetings which will be held quarterly with at least one Regional Team member in attendance for four (4) weeks, then the facility will monitor monthly thereafter. The regional team consists of · ROD · RQM · Regional Marketing Manager · Regional Manager · Regional Liaison. Members of the facility QA team are all follows: · Interim Administrator · Interim DOM · Dietary manager · Business Office Manager · Social Services Manager · Medical Director participating at least quarterly and as needed. 9. Audits will be conducted by payroll personnel to validate current employees who need certifications or licenses to administer medications, to ensure they are up to date on 04/22/16. No KMA's were being utilized by the facility. The validations were checked through the KY Board of Nursing Website. 10. All nursing staff applications are forwarded to the Interim DON that are eligible to work. Then a list will be given to the scheduler of all staff that are valid to work. Anyone found not to be qualified will not be allowed to pass medication until licenses or certifications are updated and the interim Administrator has given approval for them to work and is signed by the interim Administrator. An RQM in-service was conducted to repeat the requirements to the ROD, Payroll Personnel, Unit Managers and MDS Coordinator. 11. Care plans were reviewed on 04/25/16 to validate if any resident care plans should be updated based on any of the QAA findings. 12. During the clinical meeting Monday through Friday, care plans are updated as needed for the potential adverse reactions from medication and to ensure there is no unqualified staff working. If any revisions of the care plan are needed then the Interim DON, Nurse Unit Manager, and DMA Coordinator will conduct them. The nursing supervisor will update care plans on weekends and holidays. 13. MAR indicated [REDACTED]. Audits will continue to be brought back to the regional teams for quarterly review. 14. Monitoring of the MARs for care related to medications will be conducted for twelve (12) weeks. This will begin 04/25/16 and end 07/18/16. Audits will continue to be brought back to the regional teams for quarterly review. 15. On 04/20/16, the Interim Administrator conducted an in-service with the facility's management staff to review the practice of how the verification will be conducted and how the audit will be conducted. 16. A minimum of ten (10) staff interviews per week was completed beginning on 04/28/16 to validate everyone's understanding of how the process will operate to ensure that no license staff are permitted to work without a current License. All audits conducted of the staff interviews will be reviewed at the QAA meetings for review. 17. The DON, SRNA #1 and the Administrator were terminated on 04/25/16. 18. The Interim Administrator and Interim DON were appointed on 04/25/16 by the Division Director of Operations, 19. A weekly Regional Tem meeting will be conducted for four (4) weeks to validate the effectiveness of the administrating qualified staff. This will begin on 04/26/16 **The State Survey Agency validated the corrective action taken by the facility as follows: 1. Review of the skin assessment, pain evaluation, and vital sign documentation provided by the facility revealed they were completed on 04/21-22/16. 2. Review of the facility QA's monitoring form, dated 04/20/16, revealed the residents' MARs, who SRNA #1 administered medications, were reviewed with no errors identified. A written statement was provided by the facility and signed by LPN #1 validating she gave all medications requiring gastrostomy tube administration on 03/21/16. 3. Interview with the Interim DON, on 05/06/16 at 3:00 PM, revealed all care plans were reviewed to ensure that care and services were being provided as appropriate for each resident. She stated the Nurse Unit Managers and MDS Coordinator assisted her. 4. Interview with the Interim DON, on 05/06/16 at 3:00 PM, revealed the MARs had been reviewed to ensure the orders matched the physician's orders [REDACTED]. She also stated that all the MARs had been reviewed for accuracy and to ensure monitoring of parameters as per the MD orders was on the MARs. 5. Review of inservice records, dated 04/25/16, revealed an in-service was conducted by the RDO to the Interim Administrator and Interim DON on the policy, which included what constituted neglect, reporting neglect, and determination of investigation of neglect. Interview with the Interim Administrator on 04/25/16 revealed they had attended this in-services training with an understanding of the facility's operations on neglegt. 6. Review of the sign-in sheet, dated 04/25/16, revealed there were eleven (11) in attendance at the Management Team in-service related to ensuring medications were given within their time frame, the appropriate medications were given by qualified staff, never sign a medication that staff member did not give and who to notify in the event of an error. Interviews on 05/06/16 with UM #1 at 1:30 PM and UM #2 at 1:40 PM, revealed they had attended an inservice on medications related to giving in the appropriate time frame, given by qualified staff, and never to sign a medication for another staff member. 7. Review of Inservice Records, dated 04/25/16, revealed all staff was educated on abuse, neglect, and pain assessments. Interview on 04/25/16 at 3:10 PM, with LPN #1, LPN #2 and LPN #3 revealed they had received education on abuse, neglect, and pain assessments within the past week. Interview on 05/05/16 at 10:00 AM with SRNA #2, on 05/06/16 at 1:55 PM with SRNA #3 and on 05/06/16 at 2:05 PM with SRNA #6, revealed they received inservice training on neglect on 04/25/16. 8. Interview with the Regional Quality Manager (RQM), on 04/26/16 at 5:00 PM revealed she verified that all staff had been in-serviced except those that could not be reached. She confirmed they would be in-serviced prior to being allowed to return to work. 9. Review of all facility's licensed staffs licenses revealed they were in good standing. 10. Interview with the BOA, 05/06/16 at 3:05 PM, revealed she runs a report weekly to verify the validity of all license staff and forwards this to the appropriate management staff. A review of the sign-in sheet of the RDO, Payroll Personnel, Unit Managers, and MDS Coordinator revealed they were inservice on validation of licensed staff. Interview with UM #1 and UM #2, on 05/05/16 at 10:00 AM, revealed they were inserviced on validation of staff licenses. 11. Review of an audit log, dated 04/25/16, revealed all residents' care plans were reviewed and updated as needed. This was monitored by the MDS Coordinator. 12. Interview with the Interim DON, on 05/06/16 at 3:00 PM, revealed during each morning meeting Monday through Friday, the care plans were updated as needed for the potential adverse reactions from medication. She provided the audit tool that was used by the weekend supervisor to conduct their audits. 13. Review of the MAR indicated [REDACTED]. 14. Interview with the Acting Administrator, on 05/05/16 at 10:10 AM, revealed the facility would continue to conduct audits for twelve (12) weeks for care related to medications administration and report back to the regional team. 15. Interview with the Interim Administrator, on 05/06/16 at 2:55 PM, and review of the inservice sign-in sheet, dated 04/20/16, revealed an in-service with Management Staff was conducted on 04/20/16 and will continue to review the practice of how the verification will be conducted and how the audit will be conducted. 16. Interview with the Interim Administrator, on 05/06/16 at 2:55 PM, revealed a minimum of ten (10) staff interviews per week were being completed related to the facility's process for verification of licenses. 17. Interview with the RDO, on 05/06/16 at 10:10 AM, revealed the DON, SRNA #1 and the Administrator were terminated on 04/25/16. 18. Interview with the RDO, on 05/06/16 at 10:10 AM, revealed the Interim Administrator and Interim DON were appointed on 04/25/16 by the Division Director of Operations, 19. Review of a sign in sheet revealed a Weekly Regional Team meeting was held on 05/05/16.

Based on interview, record review, Personnel record review, facility policy review, review of the facility's Employee Handbook, and review of the State Registered Nurse Aide (SRNA) #1's job description, and review of the Kentucky Medication Aide (KMA) Course Guidelines, it was determined the facility failed to have an effective system in place to ensure services provided by the facility met professional standards of quality for (12) of fifteen (15) sampled residents (Residents #3, #4, #9, #13, #1, #2, #5, #6, #7, #8, #11, and #12), and twenty-six (26) of thirty (30) unsampled residents (Residents M, N, R, O, S, I, A, C, D, F, G, J, H, L, P, T, V, U, W, X, Y, Z, AA, BB, CC, and DD). The facility utilized State Registered Nurse Aide (SRNA) #1 to perform the duties of a Kentucky Medication Aide (KMA). SRNA #1 administered medication to include administering medications that included narcotics (sedatives, antianxiety, anti-[MEDICAL CONDITION] and pain medication), antihypertensive, [MEDICATION NAME], antipsychotics, diuretics, muscle relaxer and potassium replacement therapy. In addition, SRNA #1 failed to obtain blood pressures prior to administering antihypertensive; failed to provide gastostomy and [MEDICAL CONDITION] care; and, obtain an oxygen saturation level. SRNA also failed to ensure resident pain pumps were check to ensure they were working appropriately. In addition, the facility failed to ensure Resident #9's [MEDICATION NAME] was administered on 04/16/16 at 4:00 AM, 10:00 AM, 4:00 PM and 10:00 PM and on 04/17/16 at 4:00 AM and 10:00 AM per physician order. The facility's failure to administer medication and treatments per physician's orders [REDACTED]. Immediate Jeopardy was identified, on 04/22/16 and determined to exist on 03/21/16. The facility was notified of the Immediate Jeopardy on 04/22/16. An acceptable Allegation of Compliance (AoC) was received on 05/04/16 alleging the removal of the Immediate Jeopardy on 05/06/16. The State Survey Agency validated, on 05/06/16, the Immediate Jeopardy was removed on 05/06/16. The scope and severity was lowered to an E while the facility develops and implements the Plan of Correction (PoC) and the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's Employee Handbook, dated December 2012, revealed all employees should have the proper credentials according to state regulations, which includes verification of credentials of certification. The employee is responsible for maintaining current credentials and providing them to the facility. Review of the facility's policy titled, Medication Administration General Guidelines, dated December 2012, revealed medications should be administered as prescribed in accordance with manufacturers' specifications, good nursing principles, and practices; and, only by a person legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medications. Medications should be prepared only by licensed nursing, medical, pharmacy or other personnel authorized by state regulations to prepare medications. Review of SRNA #1's job description, dated 06/14/14, revealed there was no documented evidence the SRNA's scope of practice included administering medications and/or treatments. Review of the Kentucky Medication Aide (KMA) Course Guidelines revealed the course includes the basic principles, techniques, and procedures of medication administration in accordance with established guidelines and requirements that direct the limited function of the KMA. A KMA does not convert drug dosages, administer injectable medications including subcutaneous, intramural, intramuscularly or intravenous route. They do not administer medications via tubes inserted into any body cavity. They do not administer Antineoplastic drugs. They cannot accept verbal/phone orders from those with prescriptive authority and may not dispense medication for resident temporarily out of the facility. In addition, a KMA may not perform Acc-Checks. Review of SRNA #1's Personnel Record revealed he was hired as an SRNA on 10/15/13 and had a current SRNA certification which would expire on 06/30/16. However, further personnel record review revealed there was no documented evidence he received education or passed the test to work as a Kentucky Medication Aide (KMA). Review of his employment history revealed he had not been employed as a Medication Aide (MA) with any previous employer. Review of the Nursing 2015 Drug Handbook revealed that blood pressures should be monitored when taking blood pressure medications. 1. Record review revealed the facility admitted Resident #4 on 03/09/16 with diagnoses, which included Amyotrophic Lateral [MEDICAL CONDITION] and Chronic Pain. Review of the physician's orders [REDACTED]. Further review revealed a physician's orders [REDACTED]. However, review of the March and April 2016 MAR and TAR revealed SRNA #1 failed to verify the pump was working effectively on 03/21/16 during the 7:00 PM to 7:00 AM shift and failed to [MEDICATION NAME] mg on 04/03/16 at 8:00 AM and 12:00 PM per the physician's orders [REDACTED].>2. Record review revealed the facility readmitted Resident #13 on 02/09/15 with diagnosis, which included Neoplasm of Epiglottis, [MEDICAL CONDITIONS], Pain, and Dysphagia. Review of the March and April 2016 physician's orders [REDACTED]. However, review of the March 2016 TAR revealed on 03/21/16, there was no documented evidence SRNA #1 ensured [DEVICE] (GT) care, [MEDICAL CONDITION] care, and an oxygen saturation level was completed on 03/21/16 on the 7:00 PM to 7:00 AM shift per physician order. 3. Record review revealed the facility admitted Unsampled Resident M on 03/07/16 with diagnoses, which included [MEDICAL CONDITION], Hypertension, and [MEDICAL CONDITION] Fibrillation. Review of the March 2016 physician's orders [REDACTED]. However, review of the March 2016 MAR revealed SRNA #1 (unqualified staff) administered [MEDICATION NAME] 25 mg, Potassium 20 meq, and [MEDICATION NAME] 20 mg to Unsampled Resident M on 03/21/16 at 8:00 PM. Further review revealed there was no documented evidence he obtained a blood pressure per nursing intervention on the MAR before administering the hypertensive medication. 4. Record review revealed the facility admitted Unsampled Resident N on 01/04/16 with diagnoses, which included Hypertension, Anxiety, and [MEDICAL CONDITION]. Review of the physician's orders [REDACTED]. However, review of the March 2016 MAR revealed SRNA #1 administered [MEDICATION NAME] 25 mg and [MEDICATION NAME] 3.125 mg on 03/21/16 at 8:00 PM and [MEDICATION NAME] 7.5 mg for [MEDICAL CONDITION] on 03/21/16 at 9:00 PM. In addition, there was no documented evidence he obtained a blood pressure prior to administering the hypertension medications per nursing intervention. Further review revealed there was no documented evidence [MEDICATION NAME] 5 mg was administered on 03/21/16 at 9:00 PM. 5. Record review revealed the facility admitted Unsampled Resident R on 12/10/15 with diagnoses, which included Severe Intellectual Disability, Developmental Disorder, [MEDICAL CONDITION], and Impulse Disorder. Review of the March 2016 Physician order [REDACTED]. However, review of the March 2016 MAR revealed SRNA #1 administered [MEDICATION NAME] ER 500 mg, Klonopin 1 mg, and [MEDICATION NAME] ER 25 mg on 03/21/16 at 8:00 PM to Unsampled Resident R. Further review revealed there was no documented evidence he obtained a blood pressure per nursing intervention on the MAR before administering the hypertensive medication. 6. Record review revealed the facility admitted Unsampled Resident O on 04/10/14 with [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED]. However, review of the March 2016 MAR revealed on 03/21/16 from 7 PM to 7 AM, SRNA #1 failed to verify the [MEDICATION NAME] Pump was functioning properly and failed to verify the Stat three (3) low air Mattress setting was set on 5 to 6. 7. Record review revealed the facility admitted Unsampled Resident S on 12/10/15 with [DIAGNOSES REDACTED]. Review of the March 2016 Physician order [REDACTED]. However, review of the March 2016 MAR for Unsampled Resident S revealed on 03/21/16, SRNA #1 administered Sodium [MEDICATION NAME] 650 mg at 9:00 PM, Tamsulosin 0.4 mg at 9:00 PM, [MEDICATION NAME] 5 mg at 9:00 PM, [MEDICATION NAME] 20 mg at 9:00 PM and [MEDICATION NAME] 0.5 mg give one-half at bedtime. 8. Record review revealed the facility admitted Unsampled Resident I on 11/21/06 with disgnoses which included [MEDICAL CONDITION] Infarction and [MEDICAL CONDITION]. Review of the March/April 2016 Physician order [REDACTED]. However, review of the March and April 2016 MAR's revealed on 03/09/16, 03/16/16, 03/25/16, 03/31/16 and from 04/01/16 through 04/23/16 revealed the [MEDICATION NAME] was administered daily but there was no documented evidence a blood pressure was obtained prior to the administration of the blood pressure medication per physician's orders [REDACTED].>9. Record review revealed the facility admitted Resident #3 on 12/10/15 with diagnoses, which included Hypertension. Review of the March/April 2016 physician's orders [REDACTED]. to be given daily and to obtain blood pressure and withhold medication if blood pressure less than ninety (90) over sixty (60). However, review of the March and April 2016 MAR revealed the Metoptolol was administered daily but there was no documented evidence the blood pressure was obtained on thirty-one (31) of thirty-one (31) days in March 2016 and twenty-two (22) of twenty-two (22) days from 04/01/15 through 04/22/16 prior to the administration of the hypertensive medication per the physician order. Interview with SRNA #1, on 04/21/16 at 8:12 AM, revealed he administered medications in the facility on three (3) occasions and had possession of the keys to the cart and narcotics during those times. He stated the Administrator called him at home to come in on 03/21/16 to work the medication cart from seven (7) PM to seven (7) AM and was told by Unit Manager #1 that the Administrator approved for him to work for eight (8) hours on 04/03/16 from seven (7) AM to three (3) PM. He further stated the DON asked him to cover the medication cart for four (4) hours on 04/18/18 from four (4) PM to eighty-thirty (8:30) PM. He stated he did not have proof he had a certification during the times he administered medications. Interview with the Director of Nursing (DON), on 04/20/16 at 2:30 PM, revealed SRNA #1 administered medication on 03/21/16 from 7:00 PM to 7:00 AM on Hall 2, on 04/03/16 from 7:00 AM to 3:00 PM, and on 4/18/16 from 4:00 PM to 8:30 PM. She stated she placed him on the medication cart because she assumed since he worked two (2) prior shifts administering medications his credentials had been verified. She stated she expected staff to administer medications, and obtain blood pressures per physician's orders [REDACTED]. Interview with the Administrator, on 04/21/16 at 11:07 AM, revealed SRNA #1 had worked on three (3) shifts as a KMA but she had never validated he had credentials as a KMA. She stated that on 03/22/16, the BOA made her aware that there was not a valid KMA credential on file for SRNA #1. The Administrator stated it was her ultimate responsibility to ensure all employees were qualified. She stated she expected staff to administer medication per the physician orders [REDACTED]. Interview with the Regional Director of Operations, on 04/22/16 at 2:14 PM, revealed he expected that no one should be in the work pool or on the floor unless their certification and/or licenses is verified prior to being allowed to work. He stated in his view, SRNA #1 should have never been allowed to pass medication. 10. Record review revealed the facility admitted Resident #9 on 06/20/14 with [DIAGNOSES REDACTED]. Review of a Physician Order, dated 01/12/16, revealed to administer [MEDICATION NAME] 4 mg QID at 4:00 AM, 10:00 AM, 4:00 PM, and 10:00 PM. However, review of the April 2016 Medication Administration Record (MAR), revealed there was no documented evidence the [MEDICATION NAME] was administered on 04/16/16 at 4:00 AM, 10:00 AM, 4:00 PM and 10:00 PM and on 04/17/16 at 4:00 AM and 10:00 AM which resulted in six (6) missed doses. Interview with Registered Nurse (RN) #2, on 04/21/16 at 8:39 AM, revealed she had attempted to notify the physician's office on 04/15/16 several times and the phone line was busy. She stated they thought another script for the [MEDICATION NAME] 4 mg was needed in order to get the medication. Interview with the Minimum Data Set (MDS) Nurse, on 04/21/16 at 11:06 AM, revealed she identified Resident #9 was out of [MEDICATION NAME] on 04/17/16 at 1:00 PM when she came on shift. She stated she called the pharmacy and mad them aware a refill was needed for Resident #9's [MEDICATION NAME]. She revealed the pharmacy stated it would be sent around 4:00 PM that day. She further stated an incident report was completed because it was considered a medication error. Interview with the Director of Nursing (DON) on 04/23/16 at 3:15 PM. revealed she expected staff to follow physician's orders [REDACTED]. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. On 04/21/16 and 04/22/16, Nurse Unit Managers (UM) performed skin evaluations, pain evaluations, and vital signs as deemed necessary; no issues noted. 2. On 04/20/16, the Residents' MAR was reviewed by the DON and Regional Quality Manager (RQM) to validate that no medications errors occurred and determined no errors were noted. The facility obtained a statement from LPN #1 and validated she administered all [DEVICE] medications but failed to document. 3. The Interim DON, Nurse Unit Managers and MDS Coordinator reviewed all Care Plans related to delivery of medications and updated them to validate they accurately reflected current care needs of residents on 04/25/16. Updates were related to risk potential related to the delivery of medication by the former employee. 4. An audit of the April 2016 MARs of current residents was completed by the Interim DON, and Unit Nurse Manager on 04/25/16 to determine if any medications were administered by unqualified personnel and if further care plan updates were needed with no concerns found. 5. On 04/24/16, the RQM completed education with the Regional Director of Operations (RDO), who began as the Interim Administrator on 04/25/16, and the Interim DON on 04/24/16, on the policy that included what constituted neglect, reporting neglect, and determination of investigation of neglect. This education included supervision, protection, and determination of qualified and determination of investigating of neglect. 6. Education was provided to Department Managers including Social Services, Marketing/Admissions, Dietary Manager, Activity Director, Housekeeping, Business Office Manager (BOM), Assistant BOM, Medical Records, and UMs by the RDO and RQM on 04/25/16. The inservice was on what constituted neglect, reporting neglect, and determination of investigation of neglect. This education included supervision, protection, and determination of qualifications and determination of investigating of neglect. 7. Education was presented to the facility staff by the RQM, Administrator, and Admissions Director by 04/25/16. The inservice was on what constituted neglect, reporting neglect, and determination of investigation of neglect. This education included supervision, protection, and determination of qualifications and determination of investigating of neglect. 8. Monitoring by the Regional Team will be taken to the Quality Assurance and Assessment (QAA) team meetings which will be held quarterly with at least one Regional Team member in attendance for four (4) weeks, then the facility will monitor monthly thereafter. The regional team consists of · ROD · RQM · Regional Marketing Manager · Regional Manager · Regional Liaison. Members of the facility QA team are all follows: · Interim Administrator · Interim DOM · Dietary manager · Business Office Manager · Social Services Manager · Medical Director participating at least quarterly and as needed. 9. Audits will be conducted by payroll personnel to validate current employees who need certifications or licenses to administer medications, to ensure they are up to date on 04/22/16. No KMA's were being utilized by the facility. The validations were checked through the KY Board of Nursing Website. 10. All nursing staff applications are forwarded to the Interim DON that are eligible to work. Then a list will be given to the scheduler of all staff that are valid to work. Anyone found not to be qualified will not be allowed to pass medication until licenses or certifications are updated and the interim Administrator has given approval for them to work and is signed by the interim Administrator. An RQM in-service was conducted to repeat the requirements to the ROD, Payroll Personnel, Unit Managers and MDS Coordinator. 11. Care plans were reviewed on 04/25/16 to validate if any resident care plans should be updated based on any of the QAA findings. 12. During the clinical meeting Monday through Friday, care plans are updated as needed for the potential adverse reactions from medication and to ensure there is no unqualified staff working. If any revisions of the care plan are needed then the Interim DON, Nurse Unit Manager, and DMA Coordinator will conduct them. The nursing supervisor will update care plans on weekends and holidays. 13. MAR audits will now be conducted three (3) times a week for twelve (12) weeks by the DON, ADON, Unit manager and MDS Coordinator beginning 04/25/16 through 07/18/16. Audits will continue to be brought back to the regional teams for quarterly review. 14. Monitoring of the MARs for care related to medications will be conducted for twelve (12) weeks. This will begin 04/25/16 and end 07/18/16. Audits will continue to be brought back to the regional teams for quarterly review. 15. On 04/20/16, the Interim Administrator conducted an in-service with the facility's management staff to review the practice of how the verification will be conducted and how the audit will be conducted. 16. A minimum of ten (10) staff interviews per week was completed beginning on 04/28/16 to validate everyone's understanding of how the process will operate to ensure that no license staff are permitted to work without a current License. All audits conducted of the staff interviews will be reviewed at the QAA meetings for review. 17. The DON, SRNA #1 and the Administrator were terminated on 04/25/16. 18. The Interim Administrator and Interim DON were appointed on 04/25/16 by the Division Director of Operations, 19. A weekly Regional Tem meeting will be conducted for four (4) weeks to validate the effectiveness of the administrating qualified staff. This will begin on 04/26/16 **The State Survey Agency validated the corrective action taken by the facility as follows: 1. Review of the skin assessment, pain evaluation, and vital sign documentation provided by the facility revealed they were completed on 04/21-22/16. 2. Review of the facility QA's monitoring form, dated 04/20/16, revealed the residents' MARs, who SRNA #1 administered medications, were reviewed with no errors identified. A written statement was provided by the facility and signed by LPN #1 validating she gave all medications requiring gastrostomy tube administration on 03/21/16. 3. Interview with the Interim DON, on 05/06/16 at 3:00 PM, revealed all care plans were reviewed to ensure that care and services were being provided as appropriate for each resident. She stated the Nurse Unit Managers and MDS Coordinator assisted her. 4. Interview with the Interim DON, on 05/06/16 at 3:00 PM, revealed the MARs had been reviewed to ensure the orders matched the physician's orders [REDACTED]. She also stated that all the MARs had been reviewed for accuracy and to ensure monitoring of parameters as per the MD orders was on the MARs. 5. Review of inservice records, dated 04/25/16, revealed an in-service was conducted by the RDO to the Interim Administrator and Interim DON on the policy, which included what constituted neglect, reporting neglect, and determination of investigation of neglect. Interview with the Interim Administrator on 04/25/16 revealed they had attended this in-services training with an understanding of the facility's operations on neglegt. 6. Review of the sign-in sheet, dated 04/25/16, revealed there were eleven (11) in attendance at the Management Team in-service related to ensuring medications were given within their time frame, the appropriate medications were given by qualified staff, never sign a medication that staff member did not give and who to notify in the event of an error. Interviews on 05/06/16 with UM #1 at 1:30 PM and UM #2 at 1:40 PM, revealed they had attended an inservice on medications related to giving in the appropriate time frame, given by qualified staff, and never to sign a medication for another staff member. 7. Review of Inservice Records, dated 04/25/16, revealed all staff was educated on abuse, neglect, and pain assessments. Interview on 04/25/16 at 3:10 PM, with LPN #1, LPN #2 and LPN #3 revealed they had received education on abuse, neglect, and pain assessments within the past week. Interview on 05/05/16 at 10:00 AM with SRNA #2, on 05/06/16 at 1:55 PM with SRNA #3 and on 05/06/16 at 2:05 PM with SRNA #6, revealed they received inservice training on neglect on 04/25/16. 8. Interview with the Regional Quality Manager (RQM), on 04/26/16 at 5:00 PM revealed she verified that all staff had been in-serviced except those that could not be reached. She confirmed they would be in-serviced prior to being allowed to return to work. 9. Review of all facility's licensed staffs licenses revealed they were in good standing. 10. Interview with the BOA, 05/06/16 at 3:05 PM, revealed she runs a report weekly to verify the validity of all license staff and forwards this to the appropriate management staff. A review of the sign-in sheet of the RDO, Payroll Personnel, Unit Managers, and MDS Coordinator revealed they were inservice on validation of licensed staff. Interview with UM #1 and UM #2, on 05/05/16 at 10:00 AM, revealed they were inserviced on validation of staff licenses. 11. Review of an audit log, dated 04/25/16, revealed all residents' care plans were reviewed and updated as needed. This was monitored by the MDS Coordinator. 12. Interview with the Interim DON, on 05/06/16 at 3:00 PM, revealed during each morning meeting Monday through Friday, the care plans were updated as needed for the potential adverse reactions from medication. She provided the audit tool that was used by the weekend supervisor to conduct their audits. 13. Review of the MAR review audit, dated 04/20/16, revealed the audits were completed and reviewed by the Regional Quality Manager. 14. Interview with the Acting Administrator, on 05/05/16 at 10:10 AM, revealed the facility would continue to conduct audits for twelve (12) weeks for care related to medications administration and report back to the regional team. 15. Interview with the Interim Administrator, on 05/06/16 at 2:55 PM, and review of the inservice sign-in sheet, dated 04/20/16, revealed an in-service with Management Staff was conducted on 04/20/16 and will continue to review the practice of how the verification will be conducted and how the audit will be conducted. 16. Interview with the Interim Administrator, on 05/06/16 at 2:55 PM, revealed a minimum of ten (10) staff interviews per week were being completed related to the facility's process for verification of licenses. 17. Interview with the RDO, on 05/06/16 at 10:10 AM, revealed the DON, SRNA #1 and the Administrator were terminated on 04/25/16. 18. Interview with the RDO, on 05/06/16 at 10:10 AM, revealed the Interim Administrator and Interim DON were appointed on 04/25/16 by the Division Director of Operations, 19. Review of a sign in sheet revealed a Weekly Regional Team meeting was held on 05/05/16.

Based on interview, record review, facility policy review, and the Centers for Medicare & Medicaid's Resident Assessment Instrument, Version 3.0 manual, dated 10/2011, it was determined the facility failed to ensure the care plan was implemented by qualified staff for twelve (12) of fifteen (15) sampled residents (Resident #3, #4, #13, #8, #9, #1, #2, #5, #6, #7, #11, and #12) and twenty-six (26) of thirty (30) unsampled residents (Residents M, N, O, S, I, R, U, A, C, D, F, G, J, H, L, P, T, V, W, X, Y, Z, AA, BB, CC, and DD). The facility failed to ensure qualified staff implemented the care plan when State Registered Nurse Aide (SRNA) #1 performed the duties of a Kentucky Medication Aide (KMA). SRNA #1 administered medication to include narcotics (sedatives, antianxiety, anti-[MEDICAL CONDITION] and pain medication), antihypertensive, [MEDICATION NAME], antipsychotics, diuretics, muscle relaxer and potassium replacement therapy. In addition, SRNA #1 failed to obtain blood pressures prior to administering antihypertensive; failed to provide gastostomy and [MEDICAL CONDITION] care; and, obtain an oxygen saturation level. SRNA also failed to ensure resident pain pumps were check to ensure they were working appropriately. In addition, the facility failed to obtain weekly weights and provide Restorative Dining for Resident #8 per the comprehensive care plan. The facility's failure to implement the care plan has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified, on 04/22/16 and determined to exist on 03/21/16. The facility was notified of the Immediate Jeopardy on 04/22/16. An acceptable Allegation of Compliance (AoC) was received on 05/04/16 alleging the removal of the Immediate Jeopardy on 05/06/16. The State Survey Agency validated, on 05/06/16, the Immediate Jeopardy was removed on 05/06/16. The scope and severity was lowered to a E while the facility develops and implements the Plan of Correction (PoC) and the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy, which was the Center for Medicare & Medicaid's Resident Assessment Instrument, Version 3.0 manual, dated 10/2011, revealed a comprehensive care plan is an interdisciplinary communication tool. It should include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the resident's highest practicable, physical, mental and psychosocial wellbeing. 1. Record review revealed the facility admitted Resident #4 on 03/09/16 with diagnoses, which included Amyotrophic Lateral [MEDICAL CONDITION] and Chronic Pain. Review of the admission Minimum Data Set (MDS) assessment, dated 03/16/16 revealed the facility assessed Resident #4's cognition as intact with a Brief Interview of Mental Status (BIMS) score of fifteen (15), indicating he/she was interviewable. Review of the Comprehensive Care Plan for Alteration in level of comfort, dated 03/09/16, and review of the March and April 2016 physician's orders [REDACTED].{narcotic pain medication} 2.5 milligrams/hour {mg/hr} for pain continuous and starting 04/03/16,[MEDICATION NAME] mg for muscle pain three (3) times a day). However, review of the March and April 2016 Medication Administration Record [REDACTED]. In addition, there was no documented evidence SRNA #1 [MEDICATION NAME] mg on 04/03/16 at 8:00 AM, 12:00 PM, and 4:00 PM per the physician's orders [REDACTED]. 2. Record review revealed the facility readmitted Resident #13 on 02/09/15 with diagnoses, which includes Neoplasm of Epiglottis, [MEDICAL CONDITIONS], Pain, and Dysphagia. Review of the Annual Minimum Data Set (MDS) assessment, dated 03/16/16, revealed the facility assessed Resident #13's cognition as intact with a Brief Interview for Mental Status (BIMS) score of fifteen (15) indicating he/she was interviewable. Review of the Comprehensive Care Plan related to [MEDICAL CONDITION] Care, dated 02/03/16, revealed the staff should perform [MEDICAL CONDITION] and gastrostomy care every shift and, as needed. Further review revealed oxygen saturations should be performed with change in cognition and/or anxiety. However, review of the March 2016 TAR revealed on 03/21/16, there was no documented evidence SRNA #1 (unqualified staff) ensured [DEVICE] (GT) care, [MEDICAL CONDITION] care, and an oxygen saturation level was completed on 03/21/16 on the 7:00 PM to 7:00 AM shift. The facility failed to ensure qualified staff provided these services. 3. Record review revealed the facility admitted Unsampled Resident M on 03/07/16 with diagnoses, which included [MEDICAL CONDITION], Hypertension, and [MEDICAL CONDITION] Fibrillation. Review of an initial MDS assessment, dated 03/16/16, revealed the facility assessed Unsampled Resident M's cognition as severely impaired with a BIMS score of four (4) indicating he/she was not interviewable. Review of the Comprehensive Care Plan for medication administration and adverse effects, dated 03/14/16, and the March 2016 physician's orders [REDACTED].{anti-hypertensive} 12.5 mg two {2} times a day, Potassium {potassium replacement therapy} 20 millequivalents {meq} two (2) times a day and [MEDICATION NAME] {diuretic} 20 mg three (3) times a day by mouth). However, review of the March 2016 MAR indicated [REDACTED]. The facility failed to ensure qualified staff provided these services. 4. Record review revealed the facility admitted Unsampled Resident N on 01/04/16 with diagnoses, which included Hypertension, Anxiety, and [MEDICAL CONDITION]. Review of the Quarterly MDS assessment, dated 03/16/16, revealed the facility assessed Unsampled Resident N's cognition as intact with a BIMS score of thirteen (13) indicating he/she was interviewable. Review of the Comprehensive Care Plan for Medication administration and adverse effects of medication, dated 02/01/16, and review of the March 2016 Physician order [REDACTED].{antihypertensive} 3.125 mg two (2) times a day, [MEDICATION NAME] {antihypertensive} 25 mg three (3) times a day and [MEDICATION NAME] {narcotic sedative} 7.5 mg at bedtime). However, review of the March 2016 MAR indicated [REDACTED]. Further review revealed there was no documented evidence [MEDICATION NAME] 5 mg was administered on 03/21/16 at 9:00 PM. The facility failed to ensure qualified staff provided these services. 5. Record review revealed the facility admitted Unsampled Resident R on 12/10/15 with diagnoses, which included Severe Intellectual Disability, Developmental Disorder, [MEDICAL CONDITION], and Impulse Disorder. Review of the Annual MDS assessment, dated 03/16/16, revealed the facility assessed Unsampled Resident R's cognition as severely impaired with a BIMS score of zero (0) indicating he/she was not interviewable. Review of the Comprehensive Care Plan for medication administration and adverse effects of medication, dated 03/11/16, and review of the March 2016 physician's orders [REDACTED].{narcotic used for Impulse Disorder} 1 mg three (3) times daily, and [MEDICATION NAME] {anti-[MEDICAL CONDITION]} 200 mg two (2) times daily). However, review of the March 2016 MAR indicated [REDACTED]. The facility failed to ensure qualified staff provided these services. 6. Record review revealed the facility admitted Unsampled Resident O on 04/10/14 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 03/10/16, revealed the facility assessed Unsampled Resident O's cognition as intact with a BIMS score of fifteen (15) indicating he/she was interviewable. The facility failed to ensure qualified staff provided these services. Review of the Comprehensive Care Plan for Medication Administration and Adverse Effects of Medications, dated 03/10/16, and review of the March 2016 Physician Orders, revealed the resident needed [MEDICATION NAME]/narcotics to be given per physician's orders [REDACTED]. However, review of the March 2016 TAR revealed on 03/21/16 from 7 PM to 7 AM, in which SRNA #1 was responsible for medications, there was no documented evidence SRNA #1 checked the [MEDICATION NAME] Pump alarms and no documented evidence he verified the Stat three (3) low air Mattress setting was set on 5 to 6. The facility failed to ensure qualified staff provided these services. 7. Record review revealed the facility admitted Unsampled Resident S on 12/10/15 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 04/20/16, revealed the facility assessed Unsampled Resident S's cognition was severely impired with a BIMS score of ninety-nine (99) indicating he/she was not interviewable. Review of the Comprehensive Care Plan for medications and adverse effects of medication, dated 03/07/16, and March 2016 physician's orders [REDACTED].{urine flow} 0.4 mg daily at bedtime, [MEDICATION NAME] {Alzheimer's} 5 mg daily at bedtime, [MEDICATION NAME] {antidepressant} 20 mg daily at bedtime and [MEDICATION NAME] {antipsychotic} 0.25 mg at 9:00 PM. However, review of the March 2016 MAR for Unsampled Resident S revealed on 03/21/16, SRNA #1 administered Sodium [MEDICATION NAME] 650 mg at 9:00 PM, Tamsulosin 0.4 mg at 9:00 PM, [MEDICATION NAME] 5 mg at 9:00 PM, [MEDICATION NAME] 20 mg at 9:00 PM and [MEDICATION NAME] 0.5 mg give one-half at bedtime. The facility failed to ensure qualified staff provided these services. 8. Record review revealed the facility admitted Unsampled Resident I on 11/21/06 with disgnoses which included [MEDICAL CONDITION] Infarction and [MEDICAL CONDITION]. Review of the Quarterly MDS assessment, dated 02/09/16, revealed the facility assessed Unsampled Resident I's cognition as moderately impaired with a BIMS score of nine (9) indicating he/she was interviewable. Review of Unsampled Resident I's Comprehensive Care Plan for Medications and adverse effects of medications, dated 02/09/16, and review of the March and April 2016 physician's orders [REDACTED].{2} times a day) and physician's specific parameters are to be followed when applicable (withhold if systolic blood pressure is less than one-hundred and ten {110} millimeter of Mercury {mmHg} or diastolic blood pressure is less than sixty {60} mmHg). However, review of the March and April 2016 MAR's revealed on 03/09/16, 03/16/16, 03/25/16, 03/31/16 and from 04/01/16 through 04/23/16 revealed the [MEDICATION NAME] was administered daily but there was no documented evidence a blood pressure was obtained prior to the administration of the blood pressure medication to determine if the medication needed to be withheld or not. The facility failed to ensure qualified staff provided these services. 9. Record review revealed the facility admitted Resident #3 on 12/10/15 with diagnoses, which included Hypertension. Review of the Quarterly MDS assessment, dated 01/24/16, revealed the facility assessed Resident #3's cognition as intact with a BIMS score of fifteen (15) indicating he/she was interviewable. Review of the Comprehensive Care Plan for Medication Administration and Adverse Effect of medications, dated 01/24/16, and review of the March and April 2016 Physician order [REDACTED]. to be given daily) and follow the physician specific parameters related to hypertension (obtain blood pressure and withhold medication if blood pressure less than ninety {90} over sixty {60}). However, review of the March and April 2016 MAR indicated [REDACTED]. The facility failed to ensure qualified staff provided these services. Interviews on 04/20/16 with Resident #DD (BIMS 15) at 8:55 AM, Resident #6 (BIMS 11) at 9:10 AM, Resident #5 (BIMS 15) at 9:15 AM, Unsampled Resident I (BIMS 09) at 9:53 AM, Unsampled Resident N (BIMS 13) at 9:58 AM, and Unsampled Resident Q (BIMS 09) at 10:02 AM, revealed SRNA #1 had administered medications to include narcotics to them on several shifts. Unsampled Resident #I stated he/she did not feel that SRNA #1 knew what he was doing and did not feel comfortable with SRNA #1 administering his/her medication. Interview with SRNA #1, on 04/21/16 at 8:12 AM, revealed he administered medications in the facility on three (3) occasions and had possession of the keys to the cart and narcotics during those times. He stated the Administrator called him at home to come in on 03/21/16 to work the medication cart from 7:00 PM to 7:00 AM and he was told by Unit Manager #1 that the Administrator approved for him to work for eight (8) hours on 04/03/16 from 7:00 AM to 3:00 PM. He further stated the DON asked him to cover the medication cart for four (4) hours on 04/18/18 from 4:00 PM to 8:30 PM. He stated he was not certified to administer medication in Kentucky. Interview with Licensed Practical Nurse (LPN) #1, on 04/21/16 at 1:10 PM, revealed she worked on 03/21/16 and was informed by SRNA #1 that he was going to pass medications on Hall 2 and she was to pass them on Hall 1. She stated she was never told he was not a KMA and he administered the medications and narcotics on his hall. She stated she did not perform any of the treatments on the Treatment Administration Record (TAR) for the residents that were under SRNA #1's care on this shift. Interview with the Director of Nursing (DON), on 04/20/16 at 2:30 PM, revealed SRNA #1 administered medication on 03/21/16 from 7:00 PM to 7:00 AM on Hall 2, on 04/03/16 from 7:00 AM to 3:00 PM, and on 4/18/16 from 4:00 PM to 8:30 PM. She stated she placed him on the medication cart because she assumed since he worked two (2) prior shifts administering medications his credentials had been verified. She further stated all staff should provide the care on the care plan per state and federal guidelines and per the facility's policy. Interview with the Administrator, on 04/21/16 at 11:07 AM, revealed SRNA #1 had worked on three (3) shifts as a KMA but she had never validated he had credentials as a KMA. She stated that on 03/22/16, the BOA made her aware that there was not a valid KMA credential on file for SRNA #1. The Administrator stated it was her ultimate responsibility to ensure all employees were qualified. She stated staff should follow the care plans and she expected staff to provide care as ordered and according to facility policy. Interview with the Regional Director of Operations, on 4/22/16 at 2:14 PM, revealed he expected no one to be in the work pool or on the floor unless their certification and/or licenses had been verified prior to being allowed to work. He further stated all treatments, medications, and care and services should be completed per the care plan and staff should follow facility policy. 10. Record review revealed the facility admitted Resident #8 on 05/16/14 with the [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) assessment, dated 02/29/16, revealed the facility assessed Resident #8's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of zero (0) indicating the resident was not interviewable. In addition, the resident required extensive assist of one (1) person with eating and was assessed as not having a five percent (5%) or more in the last month or ten percent (10%) or more in the last six (6) months. Review of Resident #8's Comprehensive Care Plan for at risk for Alteration in Nutrition, dated 02/29/16, and revealed interventions to assist with meals as needed (Restorative to provide verbal cues and tactile stimuli to ensure consumes meals for two meals daily) and obtain and monitor weight per protocol (weekly weights starting on 01/13/16). However, review of Resident #8's Weights revealed he/she was not weighed weekly from 02/16/16 through 03/02/16 at which time he/she had a nine (9) pound weight loss; and review of the Restorative Program Flow Sheets dated March and April 2016, revealed there was no documented evidence the Restorative Care Plan was followed for thirty-eight (38) of seventy (70) breakfast and lunch meals from 3/18/16 through 04/21/16. Observations on 04/20/16 at 12:06 PM and on 04/22/15 at 8:24 AM during the lunch and breakfast meal respectively, revealed the resident was no receiving Restorative assistance with meals. Interview with CNA #5 on 04/28/16 at 1:24 PM who is the Restorative Aide (RA) revealed Resident #8 was care planned to received restorative dining six (6) days a week twice a day for prompting, cueing, and assistance with utensils as needed. She stated the charting for Restorative was the responsibility of the Restorative Aide as those tasks are the responsibility of the Restorative Aides. She revealed the Restorative table is the first back table and she was not sure why Resident #8 was not receiving restorative for lunch or breakfast. She further stated the only reason for the blanks on the Restorative Program Flow Sheet would be if no one charted on the resident or the Restorative Aide was out of the facility with a resident on a doctor's appointment or pulled to the floor to work as a CNA. Interview with the DM, on 04/20/16 at 2:57 PM, on 04/21/16 at 2:25 PM, and on 04/22/16 at 8:26 AM, revealed she was concerned with Resident #8's weight loss and he/she should have been weekly weights due to his/her continued weight loss and in restorative dining. She further stated the resident was moved to Restorative Dining beginning 03/18/16 due to his/her weight loss. Interview with Director of Nursing (DON) on 04/20/16 at 4:16 PM, on 04/21/16 at 12:55 PM and on 04/22/16 at 8:17 AM, revealed she expected staff to follow the care plan. She stated the Restorative Aide performs the monthly weights and if a resident refused a weight, she would be made aware later. She stated the Dietary Manager (DM) is in charge of the weekly weights and she does not have anything to do with them. She revealed the CNAs perform the weights on Friday through Sunday and the DM reviews the weights the next week. She stated the resident should be in Restorative Dining per his/her care plan. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. On 04/21/16 and 04/22/16, Nurse Unit Managers (UM) performed skin evaluations, pain evaluations, and vital signs as deemed necessary; no issues noted. 2. On 04/20/16, the Residents' MAR indicated [REDACTED]. The facility obtained a statement from LPN #1 and validated she administered all [DEVICE] medications but failed to document. 3. The Interim DON, Nurse Unit Managers and MDS Coordinator reviewed all Care Plans related to delivery of medications and updated them to validate they accurately reflected current care needs of residents on 04/25/16. Updates were related to risk potential related to the delivery of medication by the former employee. 4. An audit of the April 2016 MARs of current residents was completed by the Interim DON, and Unit Nurse Manager on 04/25/16 to determine if any medications were administered by unqualified personnel and if further care plan updates were needed with no concerns found. 5. On 04/24/16, the RQM completed education with the Regional Director of Operations (RDO), who began as the Interim Administrator on 04/25/16, and the Interim DON on 04/24/16, on the policy that included what constituted neglect, reporting neglect, and determination of investigation of neglect. This education included supervision, protection, and determination of qualified and determination of investigating of neglect. 6. Education was provided to Department Managers including Social Services, Marketing/Admissions, Dietary Manager, Activity Director, Housekeeping, Business Office Manager (BOM), Assistant BOM, Medical Records, and UMs by the RDO and RQM on 04/25/16. The inservice was on what constituted neglect, reporting neglect, and determination of investigation of neglect. This education included supervision, protection, and determination of qualifications and determination of investigating of neglect. 7. Education was presented to the facility staff by the RQM, Administrator, and Admissions Director by 04/25/16. The inservice was on what constituted neglect, reporting neglect, and determination of investigation of neglect. This education included supervision, protection, and determination of qualifications and determination of investigating of neglect. 8. Monitoring by the Regional Team will be taken to the Quality Assurance and Assessment (QAA) team meetings which will be held quarterly with at least one Regional Team member in attendance for four (4) weeks, then the facility will monitor monthly thereafter. The regional team consists of · ROD · RQM · Regional Marketing Manager · Regional Manager · Regional Liaison. Members of the facility QA team are all follows: · Interim Administrator · Interim DOM · Dietary manager · Business Office Manager · Social Services Manager · Medical Director participating at least quarterly and as needed. 9. Audits will be conducted by payroll personnel to validate current employees who need certifications or licenses to administer medications, to ensure they are up to date on 04/22/16. No KMA's were being utilized by the facility. The validations were checked through the KY Board of Nursing Website. 10. All nursing staff applications are forwarded to the Interim DON that are eligible to work. Then a list will be given to the scheduler of all staff that are valid to work. Anyone found not to be qualified will not be allowed to pass medication until licenses or certifications are updated and the interim Administrator has given approval for them to work and is signed by the interim Administrator. An RQM in-service was conducted to repeat the requirements to the ROD, Payroll Personnel, Unit Managers and MDS Coordinator. 11. Care plans were reviewed on 04/25/16 to validate if any resident care plans should be updated based on any of the QAA findings. 12. During the clinical meeting Monday through Friday, care plans are updated as needed for the potential adverse reactions from medication and to ensure there is no unqualified staff working. If any revisions of the care plan are needed then the Interim DON, Nurse Unit Manager, and DMA Coordinator will conduct them. The nursing supervisor will update care plans on weekends and holidays. 13. MAR indicated [REDACTED]. Audits will continue to be brought back to the regional teams for quarterly review. 14. Monitoring of the MARs for care related to medications will be conducted for twelve (12) weeks. This will begin 04/25/16 and end 07/18/16. Audits will continue to be brought back to the regional teams for quarterly review. 15. On 04/20/16, the Interim Administrator conducted an in-service with the facility's management staff to review the practice of how the verification will be conducted and how the audit will be conducted. 16. A minimum of ten (10) staff interviews per week was completed beginning on 04/28/16 to validate everyone's understanding of how the process will operate to ensure that no license staff are permitted to work without a current License. All audits conducted of the staff interviews will be reviewed at the QAA meetings for review. 17. The DON, SRNA #1 and the Administrator were terminated on 04/25/16. 18. The Interim Administrator and Interim DON were appointed on 04/25/16 by the Division Director of Operations, 19. A weekly Regional Tem meeting will be conducted for four (4) weeks to validate the effectiveness of the administrating qualified staff. This will begin on 04/26/16 **The State Survey Agency validated the corrective action taken by the facility as follows: 1. Review of the skin assessment, pain evaluation, and vital sign documentation provided by the facility revealed they were completed on 04/21-22/16. 2. Review of the facility QA's monitoring form, dated 04/20/16, revealed the residents' MARs, who SRNA #1 administered medications, were reviewed with no errors identified. A written statement was provided by the facility and signed by LPN #1 validating she gave all medications requiring gastrostomy tube administration on 03/21/16. 3. Interview with the Interim DON, on 05/06/16 at 3:00 PM, revealed all care plans were reviewed to ensure that care and services were being provided as appropriate for each resident. She stated the Nurse Unit Managers and MDS Coordinator assisted her. 4. Interview with the Interim DON, on 05/06/16 at 3:00 PM, revealed the MARs had been reviewed to ensure the orders matched the physician's orders [REDACTED]. She also stated that all the MARs had been reviewed for accuracy and to ensure monitoring of parameters as per the MD orders was on the MARs. 5. Review of inservice records, dated 04/25/16, revealed an in-service was conducted by the RDO to the Interim Administrator and Interim DON on the policy, which included what constituted neglect, reporting neglect, and determination of investigation of neglect. Interview with the Interim Administrator on 04/25/16 revealed they had attended this in-services training with an understanding of the facility's operations on neglegt. 6. Review of the sign-in sheet, dated 04/25/16, revealed there were eleven (11) in attendance at the Management Team in-service related to ensuring medications were given within their time frame, the appropriate medications were given by qualified staff, never sign a medication that staff member did not give and who to notify in the event of an error. Interviews on 05/06/16 with UM #1 at 1:30 PM and UM #2 at 1:40 PM, revealed they had attended an inservice on medications related to giving in the appropriate time frame, given by qualified staff, and never to sign a medication for another staff member. 7. Review of Inservice Records, dated 04/25/16, revealed all staff was educated on abuse, neglect, and pain assessments. Interview on 04/25/16 at 3:10 PM, with LPN #1, LPN #2 and LPN #3 revealed they had received education on abuse, neglect, and pain assessments within the past week. Interview on 05/05/16 at 10:00 AM with SRNA #2, on 05/06/16 at 1:55 PM with SRNA #3 and on 05/06/16 at 2:05 PM with SRNA #6, revealed they received inservice training on neglect on 04/25/16. 8. Interview with the Regional Quality Manager (RQM), on 04/26/16 at 5:00 PM revealed she verified that all staff had been in-serviced except those that could not be reached. She confirmed they would be in-serviced prior to being allowed to return to work. 9. Review of all facility's licensed staffs licenses revealed they were in good standing. 10. Interview with the BOA, 05/06/16 at 3:05 PM, revealed she runs a report weekly to verify the validity of all license staff and forwards this to the appropriate management staff. A review of the sign-in sheet of the RDO, Payroll Personnel, Unit Managers, and MDS Coordinator revealed they were inservice on validation of licensed staff. Interview with UM #1 and UM #2, on 05/05/16 at 10:00 AM, revealed they were inserviced on validation of staff licenses. 11. Review of an audit log, dated 04/25/16, revealed all residents' care plans were reviewed and updated as needed. This was monitored by the MDS Coordinator. 12. Interview with the Interim DON, on 05/06/16 at 3:00 PM, revealed during each morning meeting Monday through Friday, the care plans were updated as needed for the potential adverse reactions from medication. She provided the audit tool that was used by the weekend supervisor to conduct their audits. 13. Review of the MAR indicated [REDACTED]. 14. Interview with the Acting Administrator, on 05/05/16 at 10:10 AM, revealed the facility would continue to conduct audits for twelve (12) weeks for care related to medications administration and report back to the regional team. 15. Interview with the Interim Administrator, on 05/06/16 at 2:55 PM, and review of the inservice sign-in sheet, dated 04/20/16, revealed an in-service with Management Staff was conducted on 04/20/16 and will continue to review the practice of how the verification will be conducted and how the audit will be conducted. 16. Interview with the Interim Administrator, on 05/06/16 at 2:55 PM, revealed a minimum of ten (10) staff interviews per week were being completed related to the facility's process for verification of licenses. 17. Interview with the RDO, on 05/06/16 at 10:10 AM, revealed the DON, SRNA #1 and the Administrator were terminated on 04/25/16. 18. Interview with the RDO, on 05/06/16 at 10:10 AM, revealed the Interim Administrator and Interim DON were appointed on 04/25/16 by the Division Director of Operations, 19. Review of a sign in sheet revealed a Weekly Regional Team meeting was held on 05/05/16.

Based on interview, record review, facility policy review, review of the facility Medication Administration General Guidelines and Employee Handbook it was determined the facility failed to provide the necessary care and services to attain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and care plan for twelve (12) of fifteen (15) sampled residents (Residents #4, #13, #3, #8, #9, #1, #2, #5, #6, #7, #11, and #12) and twenty-six (26) of thirty (30) unsampled residents (Residents M, N, R, O, S, I, U, A, C, D, F, G, J, H, L, P, T, V, W, X, Y, Z, AA, BB, CC, and DD). The facility utilized a State Registered Nurse Aide (SRNA) to perform the duties of a Kentucky Medication Aide (KMA) due to a shortage in staffing. SRNA #1 administered medication to include narcotics (sedatives, antianxiety, anti-[MEDICAL CONDITION] and pain medication), antihypertensive, [MEDICATION NAME], antipsychotics, diuretics, muscle relaxer and potassium replacement therapy to thirty-eight (38) residents over three (3) shifts; however, SRNA #1 did not have the proper credentials to do so. In addition, SRNA #1 failed to obtain blood pressures prior to administering antihypertensive; failed to provide gastostomy and [MEDICAL CONDITION] care; and, obtain an oxygen saturation level. SRNA also failed to ensure resident pain pumps were check to ensure they were working appropriately. The facility's failure to provide the necessary care and services to attain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and care plan has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified, on 04/22/16 and determined to exist on 03/21/16. The facility was notified of the Immediate Jeopardy on 04/22/16. An acceptable Allegation of Compliance (AoC) was received on 05/04/16, alleging the removal of the Immediate Jeopardy on 05/06/16. The State Survey Agency validated, on 05/06/16, the Immediate Jeopardy was removed on 05/06/16. The scope and severity was lowered to an E while the facility develops and implements the Plan of Correction (PoC) and the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy titled, Medication Administration General Guidelines, dated 12/2012, revealed medications are administered as prescribed in accordance with manufacturer ' s specifications, good nursing practices and only by persons legally authorized to do so. Medications are prepared only by licensed nursing, medical, pharmacy or other personnel authorized by state regulations. In addition, they should obtain and record vital signs as necessary prior to medication administration. Only individuals who administers the medication dose, records the administration on the resident's MAR immediately following the medication being given. Review of the facility's Employee Handbook, dated 12/2011, revealed all employees should have the proper credentials according to state regulations, which includes verification of credentials of certification. The employee is responsible for maintaining current credentials and providing them to the facility. Review of SRNA #1's Personnel Record revealed he was hired on 10/23/13 as an SRNA. Further review revealed his SRNA certification was active and would expire on 06/30/16; however, there was no documented evidence SRNA #1 had a Kentucky Medication Aide (KMA) credential on file. Review of SRNA #1's job description, dated 06/14/14, revealed his job description did not include being able to administer medications and complete treatments. However, review of the March and April 2016 Medication Administrator Records (MAR) and Treatment Administration Records (TAR) revealed SRNA #1 administered medications over three (3) days (on 03/21/16 from 7:00 PM to 7:00 AM; on 04/03/16 from 7:00 AM to 3:00 PM; and, on 04/18/16 from 4:00 PM to 8:30 PM), to thirty-eight (38) residents. Further review of the MARS and TARS, revealed SRNA #1 failed to ensure blood pressures were checked prior to the administration of antihypertensive medication, failed to obtain an oxygen saturation level, failed to complete treatments and care as order ([MEDICAL CONDITION], gastrostomy) and failed to ensure pain pumps were functioning. 1. Record review revealed the facility admitted Resident #4 on 03/09/16 with diagnoses, which included Amyotrophic Lateral [MEDICAL CONDITION] and Chronic Pain. Review of the Admission Minimum Data Set (MDS) assessment, dated 03/16/16 revealed the facility assessed Resident #4's cognition as intact with a Brief Interview of Mental Status (BIMS) score of fifteen (15), indicating he/she was interviewable. Review of the Comprehensive Care Plan for Alteration in level of comfort, dated 03/09/16, revealed intervention for pain medication to be administered as ordered, to report to physician any abnormal changes in resident condition, and to follow physician specific parameters when applicable. Further review revealed the resident had an Intravenous pain pump of [MEDICATION NAME] (narcotic pain medicine) continuous. Review of the physician's orders [REDACTED]. Further review revealed a physician's orders [REDACTED]. Review of the March and April 2016 MAR and TAR revealed SRNA #1 failed to ensure the concentration and continuous infusion of a [MEDICATION NAME] narcotic pump was verified on 03/21/16 during the 7:00 PM to 7:00 AM shift. Further review revealed this was to have been completed by two (2) nurses and not a SRNA. In addition, there was no documented evidence [MEDICATION NAME] mg was administered on 04/03/16 at 8:00 AM, 12:00 PM, and 4:00 PM per the physician's orders [REDACTED].>2. Record review revealed the facility readmitted Resident #13 on 02/09/15 with diagnoses, which included Neoplasm of Epiglottis, [MEDICAL CONDITIONS], Pain, and Dysphagia. Review of the Annual MDS assessment, dated 03/16/16, revealed the facility assessed Resident #13's cognition as intact with a BIMS score of fifteen (15) indicating he/she was interviewable. Review of the Comprehensive Care Plan related to [MEDICAL CONDITION] Care, dated 02/03/16, revealed the staff should perform [MEDICAL CONDITION] and gastrostomy care every shift and as needed. Further review revealed oxygen saturations should be performed with change in cognition and/or anxiety. Review of the March and April 2016 physician's orders [REDACTED]. In addition, medications were to be administered per Gastrostomy tube and [MEDICATION NAME] 7.5 mg was to be administered every four (4) hours via gastrostomy tube. Review of the March 2016 TAR revealed on 03/21/16, there was no documented evidence SRNA #1 ensured [DEVICE] (GT) care, [MEDICAL CONDITION] care, and an oxygen saturation level was completed on 03/21/16 on the 7:00 PM to 7:00 AM shift. In addition, review of the March 2016 MAR revealed SRNA #1 documented he had administered [MEDICATION NAME] (narcotic pain medication) 7.5 mg per [DEVICE] on 03/21/16 at 10:00 PM; however, interview with Licensed Practical Nurse (LPN) #1, on 04/21/16 at 1:10 PM, revealed she had administered Resident #13's medications per [DEVICE] on 03/21/16. 3. Record review revealed the facility admitted Unsampled Resident M on 03/07/16 with [DIAGNOSES REDACTED]. Review of an Initial MDS assessment, dated 03/16/16, revealed the facility assessed Unsampled Resident M's cognition as severely impaired with a BIMS score of four (4) indicating he/she was not interviewable. Review of the March 2016 physician's orders [REDACTED]. Review of the Comprehensive Care Plan for medication administration and adverse effects, dated 03/14/16, revealed cardiovascular medications should be given as ordered by the physician and physician specific parameters should be followed to monitor for adverse reactions. Review of the March 2016 MAR revealed SRNA #1 administered [MEDICATION NAME] 25 mg, Potassium 20 meq, and [MEDICATION NAME] 20 mg to Unsampled Resident M on 03/21/16 at 8:00 PM. Further review revealed there was no documented evidence he obtained a blood pressure per nursing intervention on the MAR before administering the hypertensive medication. 4. Record review revealed the facility admitted Unsampled Resident N on 01/04/16 with diagnoses, which included Hypertension, Anxiety, and [MEDICAL CONDITION]. Review of the Quarterly MDS assessment, dated 03/16/16, revealed the facility assessed Unsampled Resident N's cognition as intact with a BIMS score of thirteen (13) indicating he/she was interviewable. Review of the Comprehensive Care Plan for Medication administration and adverse effects of medication, dated 02/01/16, revealed staff should monitor for side effects of medications, report to physician any abnormal changes in resident condition, and follow physician specific parameters when applicable. Review of the physician's orders [REDACTED]. Review of the March 2016 MAR revealed SRNA #1 documented he administered [MEDICATION NAME] 25 mg and [MEDICATION NAME] 3.125 mg on 03/21/16 at 8:00 PM; however, there was no documented evidence he obtained a blood pressure prior to administering the hypertension medications per nursing intervention. Further review revealed SRNA #1 administered [MEDICATION NAME] 7.5 mg for [MEDICAL CONDITION] on 03/21/16 at 9:00 PM and there was no documented evidence he administered [MEDICATION NAME] 5 mg on 03/21/16 at 9:00 PM. 5. Record review revealed the facility admitted Unsampled Resident R on 12/10/15 with diagnoses, which included Severe Intellectual Disability, Developmental Disorder, [MEDICAL CONDITION], and Impulse Disorder. Review of the annual MDS assessment, dated 03/16/16, revealed the facility assessed Unsampled Resident R's cognition as severely impaired with a BIMS score of zero (0) indicating he/she was not interviewable. Review of the Comprehensive Care Plan for medication administration and adverse effects of medication, dated 03/11/16, revealed this resident is on cardiovascular and behavior medication with interventions to administer medications, monitor the effects of the medication, and to follow the parameters set forth by the physician. Review of the March 2016 Physician order [REDACTED]. Review of the March 2016 MAR revealed SRNA #1 administered [MEDICATION NAME] ER 500 mg, Klonopin 1 mg, and [MEDICATION NAME] ER 25 mg on 03/21/16 at 8:00 PM to Unsampled Resident R. Further review revealed there was no documented evidence he obtained a blood pressure per nursing intervention on the MAR before administering the hypertensive medication. 6. Record review revealed the facility admitted Unsampled Resident O on 04/10/14 with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment, dated 03/10/16, revealed the facility assessed Unsampled Resident O's cognition as intact with a BIMS score of fifteen (15) indicating he/she was interviewable. Review of the Comprehensive Care Plan for Medication Administration and Adverse Effects of Medications, dated 03/10/16, revealed the resident needed [MEDICATION NAME]/narcotics to be given per physician's orders [REDACTED]. Review of physician's orders [REDACTED]. In addition, there was an order for [REDACTED]. Review of the March 2016 MAR revealed on 03/21/16 from 7 PM to 7 AM, in which SRNA #1 was responsible for medications, there was no documented evidence SRNA #1 checked the [MEDICATION NAME] Pump alarms and no documented evidence he verified the Stat three (3) low air Mattress setting was set on 5 to 6. 7. Record review revealed the facility admitted Unsampled Resident S on 12/10/15 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 04/20/16, revealed the facility assessed Unsampled Resident S's cognition was severely impired with a BIMS score of ninety-nine (99) indicating he/she was not interviewable. Review of the Comprehensive Care Plan for medications and adverse effects of medication, dated 03/07/16, revealed this resident requires, antipsychotics, antidepressants, [MEDICATION NAME]/narcotics and antianxiety medications and an intervention to administer medication per physician's orders [REDACTED]. Review of the March 2016 Physician order [REDACTED]. Review of the March 2016 MAR for Unsampled Resident S revealed on 03/21/16, SRNA #1 (unqualified) administered Sodium [MEDICATION NAME] 650 mg at 9:00 PM, Tamsulosin 0.4 mg at 9:00 PM, [MEDICATION NAME] 5 mg at 9:00 PM, [MEDICATION NAME] 20 mg at 9:00 PM and [MEDICATION NAME] 0.5 mg give one-half at bedtime. 8. Record review revealed the facility admitted Unsampled Resident I on 11/21/06 with disgnoses which included [MEDICAL CONDITION] Infarction and [MEDICAL CONDITION]. Review of the Quarterly MDS assessment, dated 02/09/16, revealed the facility assessed Unsampled Resident I's cognition as moderately impaired with a BIMS score of nine (9) indicating he/she was interviewable. Review of Unsampled Resident I's Comprehensive Care Plan for Medications and adverse effects of medications, dated 02/0916, revealed interventions to administer medications per physician's orders [REDACTED]. Review of the March/April 2016 Physician order [REDACTED]. The Physician's parameters stated to withhold if systolic blood pressure is less than one-hundred and ten (110) millimeter of Mercury (mmHg) or diastolic blood pressure is less than sixty (60) mmHg. Review of the March and April 2016 MAR's revealed on 03/09/16, 03/16/16, 03/25/16, 03/31/16 and from 04/01/16 through 04/23/16 revealed the [MEDICATION NAME] was administered daily. Further review revealed there was no documented evidence a blood pressure was obtained prior to the administration of the blood pressure medication. 9. Record review revealed the facility admitted Resident #3 on 12/10/15 with diagnoses, which included Hypertension. Review of the Quarterly MDS assessment, dated 01/24/16, revealed the facility assessed Resident #3's cognition as intact with a BIMS score of fifteen (15) indicating he/she was interviewable. Review of the Comprehensive Care Plan for Medication Administration and Adverse Effect of medications, dated 01/24/16, revealed the resident needed hypertension medications with an intervention to administer the medications as ordered by the physician, and follow the physician specific parameters related to hypertension. Review of the March/April 2016 physician's orders [REDACTED]. to be given daily. Obtain blood pressure and withhold medication if blood pressure less than ninety (90) over sixty (60). Review of the March and April 2016 MAR revealed the Metoptolol was administered daily; however, there was no documented evidence the blood pressure was obtained on thirty-one (31) of thirty-one (31) days in March 2016 and twenty-two (22) of twenty-two (22) days from 04/01/15 through 04/22/16 prior to the administration of the hypertensive medication per physician order [REDACTED]. Interview with SRNA #1, on 04/21/16 at 8:12 AM, revealed he passed medications in the facility on three (3) occasions and had possession of the keys to the cart during those times. He stated the Administrator called him at home to come in on 03/21/16 to work the medication cart from seven (7) PM to seven (7) AM and was told by Unit Manager #1 that the Administrator approved for him to work for eight (8) hours on 04/03/16 from seven (7) AM to three (3) PM. He further stated the DON asked him to cover the medication cart for four (4) hours on 04/18/18 from four (4) PM to eighty-thirty (8:30) PM. He revealed he did not have proof he had a credentials as a KMA during the times he passed medications and he had told the Administrator on three (3) occasions. He stated he had not been oriented to the medication cart prior to passing medications on any of the three (3) shifts he performed KMA duties. In addition, he stated he was aware of the interventions on the care plans. Interview with LPN #1, on 04/21/16 at 1:10 PM, revealed she worked on 03/21/16 and was informed by SRNA #1 that he was going to pass medications on Hall 2 and she was to pass them on Hall 1. She stated she was never told he was not a KMA and he administered the medications and narcotics on his hall. She confirmed that she passed medications to residents that required gastrostomy medications, glucose monitoring and insulin administration however, she did not perform any of the treatment orders related [MEDICAL CONDITION] or wound care. In addition, she expected medication to be administered as ordered and if there was parameters set by the physician they should be monitored as ordered. Interview with the Director of Nursing (DON), on 04/20/16 at 2:30 PM, revealed SRNA #1 administered medication on 03/21/16 from 7:00 PM to 7:00 AM on Hall 2, on 04/03/16 from 7:00 AM to 3:00 PM, and on 4/18/16 from 4:00 PM to 8:30 PM. She stated she placed him on the medication cart because she assumed since he worked two (2) prior shifts administering medications his credentials had been verified. She stated she was not aware that SRNA #1 failed to perform the ordered treatments such [MEDICAL CONDITION] or wound care. In addition, she was not aware SRNA #1 failed to initial that the safety measures ordered were not documented as being completed. She expects that all care and services be performed in compliance with state and federal guidelines and per the facility's policy. Interview with the Administrator, on 04/21/16 at 11:07 AM, revealed SRNA #1 had worked on three (3) shifts as a Medication Aide (MA) but she had never validated he had credentials as a KMA. She stated that on 03/22/16, the BOA made her aware that there was not a valid certification on file. The Administrator stated she send an email to the BOA and DON denoting SRNA #1 was not to work as a KMA until the facility had a valid KMA credential in the facility. The Administrator stated it was ultimately her responsibility to ensure all employees were qualified and that the BOA verifies the licenses and certifications monthly. She stated she was not aware that SRNA #1 failed to perform treatments or safety awareness checks on the shift this was ordered to be completed. She stated she expected the staff to perform all duties ordered for each resident in accordance with state and federal guidelines, that care and services are provided as ordered, and to follow facility policies. Interview with the Regional Director of Operations, on 04/22/16 at 2:14 PM, revealed he expected no one to be in the work pool or on the floor unless their certification and/or licenses had been verified prior to being allowed to work. He stated the process was for the BOA, Administrator and DON to be informed prior to the employee being hired. He revealed in his personal view this should never been allowed to happen and the Administrator was responsible for overseeing this process. He stated he expected the staff to complete a competency check prior to being hired. He further stated all treatments, medications, and care and services should be performed as ordered, and staff should follow facility policies. Interview on 04/23/16 at 1:56 PM, with the Medical Director, revealed he was aware of the situation of the non-certified staff working passing medications. He stated he expected all staff hired to be qualified and that their credentials were verified prior to them working in the resident care area. He revealed all care and services should be carried out as ordered by the physician. He stated that periodic checks should be completed to verify the license remain active and has not been allowed to expire. The Medical Director stated in his professional opinion, SRNA #1 being allowed to pass medications on three (3) shifts was out of his scope of practice. He concluded that by SRNA #1 being allowed to work out of his scope of practice, a medication error could have occurred that would have caused serious harm or neglect to a resident. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. On 04/21/16 and 04/22/16, Nurse Unit Managers (UM) performed skin evaluations, pain evaluations, and vital signs as deemed necessary; no issues noted. 2. On 04/20/16, the Residents' MAR was reviewed by the DON and Regional Quality Manager (RQM) to validate that no medications errors occurred and determined no errors were noted. The facility obtained a statement from LPN #1 and validated she administered all [DEVICE] medications but failed to document. 3. The Interim DON, Nurse Unit Managers and MDS Coordinator reviewed all Care Plans related to delivery of medications and updated them to validate they accurately reflected current care needs of residents on 04/25/16. Updates were related to risk potential related to the delivery of medication by the former employee. 4. An audit of the April 2016 MARs of current residents was completed by the Interim DON, and Unit Nurse Manager on 04/25/16 to determine if any medications were administered by unqualified personnel and if further care plan updates were needed with no concerns found. 5. On 04/24/16, the RQM completed education with the Regional Director of Operations (RDO), who began as the Interim Administrator on 04/25/16, and the Interim DON on 04/24/16, on the policy that included what constituted neglect, reporting neglect, and determination of investigation of neglect. This education included supervision, protection, and determination of qualified and determination of investigating of neglect. 6. Education was provided to Department Managers including Social Services, Marketing/Admissions, Dietary Manager, Activity Director, Housekeeping, Business Office Manager (BOM), Assistant BOM, Medical Records, and UMs by the RDO and RQM on 04/25/16. The inservice was on what constituted neglect, reporting neglect, and determination of investigation of neglect. This education included supervision, protection, and determination of qualifications and determination of investigating of neglect. 7. Education was presented to the facility staff by the RQM, Administrator, and Admissions Director by 04/25/16. The inservice was on what constituted neglect, reporting neglect, and determination of investigation of neglect. This education included supervision, protection, and determination of qualifications and determination of investigating of neglect. 8. Monitoring by the Regional Team will be taken to the Quality Assurance and Assessment (QAA) team meetings which will be held quarterly with at least one Regional Team member in attendance for four (4) weeks, then the facility will monitor monthly thereafter. The regional team consists of · ROD · RQM · Regional Marketing Manager · Regional Manager · Regional Liaison. Members of the facility QA team are all follows: · Interim Administrator · Interim DOM · Dietary manager · Business Office Manager · Social Services Manager · Medical Director participating at least quarterly and as needed. 9. Audits will be conducted by payroll personnel to validate current employees who need certifications or licenses to administer medications, to ensure they are up to date on 04/22/16. No KMA's were being utilized by the facility. The validations were checked through the KY Board of Nursing Website. 10. All nursing staff applications are forwarded to the Interim DON that are eligible to work. Then a list will be given to the scheduler of all staff that are valid to work. Anyone found not to be qualified will not be allowed to pass medication until licenses or certifications are updated and the interim Administrator has given approval for them to work and is signed by the interim Administrator. An RQM in-service was conducted to repeat the requirements to the ROD, Payroll Personnel, Unit Managers and MDS Coordinator. 11. Care plans were reviewed on 04/25/16 to validate if any resident care plans should be updated based on any of the QAA findings. 12. During the clinical meeting Monday through Friday, care plans are updated as needed for the potential adverse reactions from medication and to ensure there is no unqualified staff working. If any revisions of the care plan are needed then the Interim DON, Nurse Unit Manager, and DMA Coordinator will conduct them. The nursing supervisor will update care plans on weekends and holidays. 13. MAR audits will now be conducted three (3) times a week for twelve (12) weeks by the DON, ADON, Unit manager and MDS Coordinator beginning 04/25/16 through 07/18/16. Audits will continue to be brought back to the regional teams for quarterly review. 14. Monitoring of the MARs for care related to medications will be conducted for twelve (12) weeks. This will begin 04/25/16 and end 07/18/16. Audits will continue to be brought back to the regional teams for quarterly review. 15. On 04/20/16, the Interim Administrator conducted an in-service with the facility's management staff to review the practice of how the verification will be conducted and how the audit will be conducted. 16. A minimum of ten (10) staff interviews per week was completed beginning on 04/28/16 to validate everyone's understanding of how the process will operate to ensure that no license staff are permitted to work without a current License. All audits conducted of the staff interviews will be reviewed at the QAA meetings for review. 17. The DON, SRNA #1 and the Administrator were terminated on 04/25/16. 18. The Interim Administrator and Interim DON were appointed on 04/25/16 by the Division Director of Operations, 19. A weekly Regional Tem meeting will be conducted for four (4) weeks to validate the effectiveness of the administrating qualified staff. This will begin on 04/26/16 **The State Survey Agency validated the corrective action taken by the facility as follows: 1. Review of the skin assessment, pain evaluation, and vital sign documentation provided by the facility revealed they were completed on 04/21-22/16. 2. Review of the facility QA's monitoring form, dated 04/20/16, revealed the residents' MARs, who SRNA #1 administered medications, were reviewed with no errors identified. A written statement was provided by the facility and signed by LPN #1 validating she gave all medications requiring gastrostomy tube administration on 03/21/16. 3. Interview with the Interim DON, on 05/06/16 at 3:00 PM, revealed all care plans were reviewed to ensure that care and services were being provided as appropriate for each resident. She stated the Nurse Unit Managers and MDS Coordinator assisted her. 4. Interview with the Interim DON, on 05/06/16 at 3:00 PM, revealed the MARs had been reviewed to ensure the orders matched the physician's orders [REDACTED]. She also stated that all the MARs had been reviewed for accuracy and to ensure monitoring of parameters as per the MD orders was on the MARs. 5. Review of inservice records, dated 04/25/16, revealed an in-service was conducted by the RDO to the Interim Administrator and Interim DON on the policy, which included what constituted neglect, reporting neglect, and determination of investigation of neglect. Interview with the Interim Administrator on 04/25/16 revealed they had attended this in-services training with an understanding of the facility's operations on neglegt. 6. Review of the sign-in sheet, dated 04/25/16, revealed there were eleven (11) in attendance at the Management Team in-service related to ensuring medications were given within their time frame, the appropriate medications were given by qualified staff, never sign a medication that staff member did not give and who to notify in the event of an error. Interviews on 05/06/16 with UM #1 at 1:30 PM and UM #2 at 1:40 PM, revealed they had attended an inservice on medications related to giving in the appropriate time frame, given by qualified staff, and never to sign a medication for another staff member. 7. Review of Inservice Records, dated 04/25/16, revealed all staff was educated on abuse, neglect, and pain assessments. Interview on 04/25/16 at 3:10 PM, with LPN #1, LPN #2 and LPN #3 revealed they had received education on abuse, neglect, and pain assessments within the past week. Interview on 05/05/16 at 10:00 AM with SRNA #2, on 05/06/16 at 1:55 PM with SRNA #3 and on 05/06/16 at 2:05 PM with SRNA #6, revealed they received inservice training on neglect on 04/25/16. 8. Interview with the Regional Quality Manager (RQM), on 04/26/16 at 5:00 PM revealed she verified that all staff had been in-serviced except those that could not be reached. She confirmed they would be in-serviced prior to being allowed to return to work. 9. Review of all facility's licensed staffs licenses revealed they were in good standing. 10. Interview with the BOA, 05/06/16 at 3:05 PM, revealed she runs a report weekly to verify the validity of all license staff and forwards this to the appropriate management staff. A review of the sign-in sheet of the RDO, Payroll Personnel, Unit Managers, and MDS Coordinator revealed they were inservice on validation of licensed staff. Interview with UM #1 and UM #2, on 05/05/16 at 10:00 AM, revealed they were inserviced on validation of staff licenses. 11. Review of an audit log, dated 04/25/16, revealed all residents' care plans were reviewed and updated as needed. This was monitored by the MDS Coordinator. 12. Interview with the Interim DON, on 05/06/16 at 3:00 PM, revealed during each morning meeting Monday through Friday, the care plans were updated as needed for the potential adverse reactions from medication. She provided the audit tool that was used by the weekend supervisor to conduct their audits. 13. Review of the MAR review audit, dated 04/20/16, revealed the audits were completed and reviewed by the Regional Quality Manager. 14. Interview with the Acting Administrator, on 05/05/16 at 10:10 AM, revealed the facility would continue to conduct audits for twelve (12) weeks for care related to medications administration and report back to the regional team. 15. Interview with the Interim Administrator, on 05/06/16 at 2:55 PM, and review of the inservice sign-in sheet, dated 04/20/16, revealed an in-service with Management Staff w

Based on interview, and review of the Administrator Job Duties, it was determined the facility failed to ensure it was administered in a manner that enables it to use its resource effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. On 03/21/16, the Administrator was called by a nurse who asked if State Registered Nurse Aide (SRNA) #1 could administer medications from 7:00 PM to 7:00 AM on the resident care unit. The Administrator was told SRNA #1 was a Kentucky Medication Aide (KMA). Without verifying SRNA #1's credentials with the proper agency, the Administrator allowed SRNA #1 to work as a Kentucky Medication Aide (KMA) administering medications, to include narcotics, on 03/21/16, 04/03/16, and again on 04/18/16, to a total of thirty-eight (38) residents on three (3) of four (4) units of the facility. The Administrator learned, on 03/22/16, SRNA #1 did not have credentials as a KMA; however, she allowed this practice to continue. The facility's failure to ensure it was administered in a manner to use its resources effectively and efficiently has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified, on 04/22/16 and determined to exist on 03/21/16. The facility was notified of the Immediate Jeopardy on 04/22/16. An acceptable Allegation of Compliance (AoC) was received on 05/04/16 alleging the removal of Immediate Jeopardy on 05/06/16. The State Survey Agency validated, on 05/06/16, Immediate Jeopardy was removed on 05/06/16. The scope and severity was lowered to an E at while the facility develops and implements the Plan of Correction (PoC) and the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's Administrator Position Description, dated 06/12/15, revealed he/she should direct the day-to-day functions of the facility in accordance with current federal, state and local standards, guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided at all times. The Administrator's Job responsibilities will encompass facility management, compliance management, facility staffing and retention, business management, marketing and revenue management and Community relations. Interview with the Administrator, on 04/22/16 at 1:05 PM, revealed SRNA #1 had worked on three (3) shifts as a KMA; however, she did not ensure that staff validated his credentials as a KMA. She stated nursing staff she trusted told her SRNA #1 was a KMA so she allowed him to work as a KMA without ensuring the BOM was able to validate his credientials. She stated the facillity's normal process was for the Business Office Manager to validate licensed staff's license's prior to hire and the facility does not use KMAs. Interview with the Regional Director of Operations, on 04/22/16 at 2:14 PM, revealed he expected the Business Office Assistant, the Administrator, and the Director of Nursing to be informed related to their qualifications prior to being hired. He stated SRNA #1 being allowed to work without proper credentials should not have been allowed, and the Administrator was responsible for this process. He stated an internal investigation was being conducted.

Based on interview, Personnel Record review, facility policy review, and Kentucky Medicaid Nurse Aide requirements, it was determined the facility failed to employ professional staff that was credentialed to perform administration of medications. State Registered Nurse Aide (SRNA) #1 was assigned to function as a Kentucky Medication Aide (KMA) without proper qualifications according to state law. SRNA #1 administered thirty-eight (38) residents' medications on three (3) different days, which included three (3) shifts. The facility's failure to verify SRNA #1 had valid credentials to administer medications has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified, on 04/22/16 and determined to exist on 03/21/16. The facility was notified of the Immediate Jeopardy on 04/22/16. An acceptable Allegation of Compliance (AoC) was received on 05/04/16, alleging the removal of the Immediate Jeopardy on 05/06/16. The State Survey Agency validated, on 05/06/16, the Immediate Jeopardy was removed on 05/06/16. The scope and severity was lowered to an E while the facility develops and implements the Plan of Correction (PoC) and the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the Kentucky Medicaid Nurse Aide requirements revealed a KMA was able to administer specific medications in a long-term care facility, as delegated and supervised by a licensed nurse. Additional duties the employer may delegate are not covered in this course (KRS 314.011 and 201 KAR 20:400 Section 2). The course shall include basic principles, techniques, and procedures of medication administration in accordance with established guidelines and requirements that direct the limited functions of the Kentucky Medication Aide. Kentucky Medication Aides DO NOT: 1 Convert drug dosages. 2 Administer injectable medications, including medications via subcutaneous, intradermal, intramuscular, or intravenous route. 3 Administer medications via tubes inserted into any body cavity. 4 Administer Antineoplastic drugs. 5 Accept verbal/phone orders from those with prescriptive authority. 6. Dispense medications for residents temporarily out of the facility. Review of SRNA #1's Personnel Record revealed he was hired as an SRNA on 10/15/13 and had a current SRNA certification which would expire on 06/30/16. Further personnel record review revealed there was no documented evidence he received education or passed the test to work as a Kentucky Medication Aide (KMA). Review of his employment history revealed he had not been employed as a Medication Aide (MA) with any previous employer. However, review of the March and April 2016 Medication Administration Records (MAR) revealed he administered medications to a total of thirty-eight (38) residents in the facility over three (3) days (03/21/16, 04/03/16 and 04/18/16). SRNA #1 administered narcotics, anti-[MEDICAL CONDITION] medication, anti-hypertensives, antipsychotics, antidepressants, and diuretics without being qualified to administer medications. In addition, SRNA #1 failed to obtain blood pressures prior to administering anti-hypertensives, failed to ensure narcotic pain pumps were functioning appropriately, and failed to ensure gastrostomy, [MEDICAL CONDITION] and an oxygen saturation level was obtained. Interview with SRNA #1, on 04/21/16 at 8:12 AM, revealed he administered medications to residents in the facility on three (3) occasions and had keys to the medication cart and narcotics. He stated the Administrator called him at home to come in on 03/21/16 to work the medication cart from seven (7) PM to seven (7) AM and was told by Unit Manager #1 that the Administrator approved for him to work for eight (8) hours on 04/03/16 from seven (7) AM to three (3) PM. He further stated the DON asked him to cover the medication cart for four (4) hours on 04/18/18 from 4:00 PM to 8:30 PM. He revealed he did not have documentation/credentials to work as a KMA during the times he administered medications and he had told the Administrator three (3) different times. SRNA #1 stated he had not been asked to sign a job description for a KMA or to complete proficiency verification prior to any of the dates, which he administered medications. He stated he had not been oriented to the medication cart prior to passing medications on any on the three (3) shift he performed KMA duties. Interview with the Business Office Assistant (BOA), on 04/20/16 at 4:10 PM, revealed she had attempted to verify SRNA #1 was credentialed as a KMA through the Kentucky Board of Nursing (KBN) on 03/22/16 when SRNA #1 came to her asking to be paid KMA pay. She stated she informed him that he would have to produce his KMA certification before the pay scale change could occur. She stated she was given the number to the Kentucky Community & Technical College System contact person; however, she was unable to verify his credentials through them either. She further stated she told the Administrator on 03/22/16 that SRNA #1 did not have a valid KMA credential on file and that she was unable to verify SRNA #1 held a KMA credential; however, SRNA #1 administered medications again on 04/03/6 and 04/18/16. Interview with the Director of Nursing (DON), on 04/20/16 at 2:30 PM, revealed SRNA #1 administered medication on 03/21/16 from 7:00 PM to 7:00 AM on Hall 2, on 04/03/16 from 7:00 AM to 3:00 PM, and on 04/18/16 from 4:00 PM to 8:30 PM. She stated she placed him on the medication cart because she assumed since he worked two (2) prior shifts administering medications his credentials had been verified. Interview with the Administrator, on 04/21/16 at 11:07 AM, revealed SRNA #1 had worked on three (3) shifts as a Medication Aide (MA) but she had never validated he had credentials as a KMA. She stated nursing staff she trusted told her SRNA #1 was a KMA so she allowed him to work as a KMA without ensuring the BOM was able to validate his credentials; however, she stated she did not remember who it was. She revealed the normal process was for the BOM to validate licensed staff had valid licenses prior to hire and they did not hire KMAs. She stated that on 03/22/16, the BOA made her aware that there was not a valid credential on file. The Administrator stated she sent an email to the BOA and DON denoting SRNA #1 was not to work as a KMA until the facility had a valid KMA credential in the facility. The Administrator stated it was her ultimate responsibility that all employees were qualified and that the BOA verified the credentials monthly. She stated she expected the facility to perform all duties for each resident in accordance with state and federal guidelines and that care and services were provided as ordered and should follow facility's policies. Interview with the Regional Director of Operations, on 04/22/16 at 2:14 PM, revealed he expected that no one should be in the work pool or on the floor unless their certification and/or licenses were verified prior to being allowed to work. He stated the Administrator was responsible for overseeing the verification process. He stated he expected all treatments, medications, care and services to be performed by a qualified staff member and in compliance with state and federal regulations as well as facility policies. Interview on 04/23/16 at 1:56 PM, with the Medical Director revealed all staff hired should be qualified and that their credentials should be verified prior to them working in the resident care area. He stated SRNA #1 being allowed to administer medications on three (3) shifts was out of his scope of practice. He stated that SRNA #1 working out of his scope of practice could have potentially led to a medication error that could have caused serious harm to a resident. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. On 04/21/16 and 04/22/16, Nurse Unit Managers (UM) performed skin evaluations, pain evaluations, and vital signs as deemed necessary; no issues noted. 2. On 04/20/16, the Residents' MAR indicated [REDACTED]. The facility obtained a statement from LPN #1 and validated she administered all [DEVICE] medications but failed to document. 3. The Interim DON, Nurse Unit Managers and MDS Coordinator reviewed all Care Plans related to delivery of medications and updated them to validate they accurately reflected current care needs of residents on 04/25/16. Updates were related to risk potential related to the delivery of medication by the former employee. 4. An audit of the April 2016 MARs of current residents was completed by the Interim DON, and Unit Nurse Manager on 04/25/16 to determine if any medications were administered by unqualified personnel and if further care plan updates were needed with no concerns found. 5. On 04/24/16, the RQM completed education with the Regional Director of Operations (RDO), who began as the Interim Administrator on 04/25/16, and the Interim DON on 04/24/16, on the policy that included what constituted neglect, reporting neglect, and determination of investigation of neglect. This education included supervision, protection, and determination of qualified and determination of investigating of neglect. 6. Education was provided to Department Managers including Social Services, Marketing/Admissions, Dietary Manager, Activity Director, Housekeeping, Business Office Manager (BOM), Assistant BOM, Medical Records, and UMs by the RDO and RQM on 04/25/16. The inservice was on what constituted neglect, reporting neglect, and determination of investigation of neglect. This education included supervision, protection, and determination of qualifications and determination of investigating of neglect. 7. Education was presented to the facility staff by the RQM, Administrator, and Admissions Director by 04/25/16. The inservice was on what constituted neglect, reporting neglect, and determination of investigation of neglect. This education included supervision, protection, and determination of qualifications and determination of investigating of neglect. 8. Monitoring by the Regional Team will be taken to the Quality Assurance and Assessment (QAA) team meetings which will be held quarterly with at least one Regional Team member in attendance for four (4) weeks, then the facility will monitor monthly thereafter. The regional team consists of · ROD · RQM · Regional Marketing Manager · Regional Manager · Regional Liaison. Members of the facility QA team are all follows: · Interim Administrator · Interim DOM · Dietary manager · Business Office Manager · Social Services Manager · Medical Director participating at least quarterly and as needed. 9. Audits will be conducted by payroll personnel to validate current employees who need certifications or licenses to administer medications, to ensure they are up to date on 04/22/16. No KMA's were being utilized by the facility. The validations were checked through the KY Board of Nursing Website. 10. All nursing staff applications are forwarded to the Interim DON that are eligible to work. Then a list will be given to the scheduler of all staff that are valid to work. Anyone found not to be qualified will not be allowed to pass medication until licenses or certifications are updated and the interim Administrator has given approval for them to work and is signed by the interim Administrator. An RQM in-service was conducted to repeat the requirements to the ROD, Payroll Personnel, Unit Managers and MDS Coordinator. 11. Care plans were reviewed on 04/25/16 to validate if any resident care plans should be updated based on any of the QAA findings. 12. During the clinical meeting Monday through Friday, care plans are updated as needed for the potential adverse reactions from medication and to ensure there is no unqualified staff working. If any revisions of the care plan are needed then the Interim DON, Nurse Unit Manager, and DMA Coordinator will conduct them. The nursing supervisor will update care plans on weekends and holidays. 13. MAR indicated [REDACTED]. Audits will continue to be brought back to the regional teams for quarterly review. 14. Monitoring of the MARs for care related to medications will be conducted for twelve (12) weeks. This will begin 04/25/16 and end 07/18/16. Audits will continue to be brought back to the regional teams for quarterly review. 15. On 04/20/16, the Interim Administrator conducted an in-service with the facility's management staff to review the practice of how the verification will be conducted and how the audit will be conducted. 16. A minimum of ten (10) staff interviews per week was completed beginning on 04/28/16 to validate everyone's understanding of how the process will operate to ensure that no license staff are permitted to work without a current License. All audits conducted of the staff interviews will be reviewed at the QAA meetings for review. 17. The DON, SRNA #1 and the Administrator were terminated on 04/25/16. 18. The Interim Administrator and Interim DON were appointed on 04/25/16 by the Division Director of Operations, 19. A weekly Regional Tem meeting will be conducted for four (4) weeks to validate the effectiveness of the administrating qualified staff. This will begin on 04/26/16 **The State Survey Agency validated the corrective action taken by the facility as follows: 1. Review of the skin assessment, pain evaluation, and vital sign documentation provided by the facility revealed they were completed on 04/21-22/16. 2. Review of the facility QA's monitoring form, dated 04/20/16, revealed the residents' MARs, who SRNA #1 administered medications, were reviewed with no errors identified. A written statement was provided by the facility and signed by LPN #1 validating she gave all medications requiring gastrostomy tube administration on 03/21/16. 3. Interview with the Interim DON, on 05/06/16 at 3:00 PM, revealed all care plans were reviewed to ensure that care and services were being provided as appropriate for each resident. She stated the Nurse Unit Managers and MDS Coordinator assisted her. 4. Interview with the Interim DON, on 05/06/16 at 3:00 PM, revealed the MARs had been reviewed to ensure the orders matched the physician's orders [REDACTED]. She also stated that all the MARs had been reviewed for accuracy and to ensure monitoring of parameters as per the MD orders was on the MARs. 5. Review of inservice records, dated 04/25/16, revealed an in-service was conducted by the RDO to the Interim Administrator and Interim DON on the policy, which included what constituted neglect, reporting neglect, and determination of investigation of neglect. Interview with the Interim Administrator on 04/25/16 revealed they had attended this in-services training with an understanding of the facility's operations on neglegt. 6. Review of the sign-in sheet, dated 04/25/16, revealed there were eleven (11) in attendance at the Management Team in-service related to ensuring medications were given within their time frame, the appropriate medications were given by qualified staff, never sign a medication that staff member did not give and who to notify in the event of an error. Interviews on 05/06/16 with UM #1 at 1:30 PM and UM #2 at 1:40 PM, revealed they had attended an inservice on medications related to giving in the appropriate time frame, given by qualified staff, and never to sign a medication for another staff member. 7. Review of Inservice Records, dated 04/25/16, revealed all staff was educated on abuse, neglect, and pain assessments. Interview on 04/25/16 at 3:10 PM, with LPN #1, LPN #2 and LPN #3 revealed they had received education on abuse, neglect, and pain assessments within the past week. Interview on 05/05/16 at 10:00 AM with SRNA #2, on 05/06/16 at 1:55 PM with SRNA #3 and on 05/06/16 at 2:05 PM with SRNA #6, revealed they received inservice training on neglect on 04/25/16. 8. Interview with the Regional Quality Manager (RQM), on 04/26/16 at 5:00 PM revealed she verified that all staff had been in-serviced except those that could not be reached. She confirmed they would be in-serviced prior to being allowed to return to work. 9. Review of all facility's licensed staffs licenses revealed they were in good standing. 10. Interview with the BOA, 05/06/16 at 3:05 PM, revealed she runs a report weekly to verify the validity of all license staff and forwards this to the appropriate management staff. A review of the sign-in sheet of the RDO, Payroll Personnel, Unit Managers, and MDS Coordinator revealed they were inservice on validation of licensed staff. Interview with UM #1 and UM #2, on 05/05/16 at 10:00 AM, revealed they were inserviced on validation of staff licenses. 11. Review of an audit log, dated 04/25/16, revealed all residents' care plans were reviewed and updated as needed. This was monitored by the MDS Coordinator. 12. Interview with the Interim DON, on 05/06/16 at 3:00 PM, revealed during each morning meeting Monday through Friday, the care plans were updated as needed for the potential adverse reactions from medication. She provided the audit tool that was used by the weekend supervisor to conduct their audits. 13. Review of the MAR indicated [REDACTED]. 14. Interview with the Acting Administrator, on 05/05/16 at 10:10 AM, revealed the facility would continue to conduct audits for twelve (12) weeks for care related to medications administration and report back to the regional team. 15. Interview with the Interim Administrator, on 05/06/16 at 2:55 PM, and review of the inservice sign-in sheet, dated 04/20/16, revealed an in-service with Management Staff was conducted on 04/20/16 and will continue to review the practice of how the verification will be conducted and how the audit will be conducted. 16. Interview with the Interim Administrator, on 05/06/16 at 2:55 PM, revealed a minimum of ten (10) staff interviews per week were being completed related to the facility's process for verification of licenses. 17. Interview with the RDO, on 05/06/16 at 10:10 AM, revealed the DON, SRNA #1 and the Administrator were terminated on 04/25/16. 18. Interview with the RDO, on 05/06/16 at 10:10 AM, revealed the Interim Administrator and Interim DON were appointed on 04/25/16 by the Division Director of Operations, 19. Review of a sign in sheet revealed a Weekly Regional Team meeting was held on 05/05/16.

Based on interview and facility policy review it was determined the facility failed to have an effective Quality Assurance Program in place to identify and correct resident care concerns to ensure the highest level of care was provided. The facility failed to ensure staff that required credentials actually had those credentials. The facility failed to ensure that a State Registered Nurse Aide (SRNA) had credentials to function in the capacity of a certified medication aide before the SRNA was allowed to pass medications on three (3) different occasions. The SRNA was responsible for passing medications to thirty-eight (38) residents. The Administration had State Registered Nurse Aide (SRNA) #1 performing duties of a Kentucky Medication Aide (KMA) without having the proper credentials to qualify him to perform these responsibilities. The facility failure to have an effective QA system in place to ensure SRNA #1 had the proper credentials to administer medication has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified, on 04/22/16 and determined to exist on 03/21/16. The facility was notified of the Immediate Jeopardy on 04/22/16. An acceptable Allegation of Compliance (AoC) was received on 05/04/16 alleging the removal of the Immediate Jeopardy on 04/26/16. The State Survey Agency validated, on 05/06/16, the Immediate Jeopardy was removed on 05/06/16. The scope and severity was lowered to a E while the facility develops and implements the Plan of Correction (PoC) and the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy titled, Quality Assurance (QA) Policy, last revised September 2015, revealed Nursing Administration will review the Twenty-four (24) Hour Report each day, and report all problems to the Director of Nursing (DON) or designee and the QA committee during the QA daily meeting. The QA Committee will follow up daily but no less than weekly, to review outcomes and ensure the highest level of care possible in all areas of the facility. The Interdisciplinary Team (IDT) will follow an incident process by investigating and reporting per the required regulatory guidelines. The investigation will be investigated in a systematic manner as follows: Identify hazards and risk, evaluating and analyzing hazards and risk, implementing interventions to reduce hazards and risk, monitoring for effectiveness, and modifying interventions when necessary. Interview with SRNA #1, on 04/21/16 at 8:12 AM, revealed he passed medications in the facility on three (3) occasions and had possession of the keys to the cart and narcotics during those times. He stated the Administrator called him at home to come in on 03/21/16 to administer medication from 7:00 PM to 7:00 AM. On another occasion, SRNA was told by Unit Manager #1 that the Administrator approved for him to administer medication on 04/03/16 from 7:00 AM to 3:00 PM. He further stated the Director of Nursing (DON) asked him to administer medications on 04/18/16 from 4:00 PM to 8:30 PM. SRNA #1 stated he did not have proof he had a credentials as a medication aide during the times he passed medications and he had told the Administrator on three (3) occasions. Interview with the DON, on 04/20/16 at 2:15 PM, revealed she had verified with SRNA #1 that he had taken a medication course that was a Kentucky Community and Technical College System approved program. She stated he currently did not hold Medication Aide credentials and had not taken the state examination prior to him passing medications on three (3) shifts over the past two (2) months. She stated she did not view this as a concern that should have been brought to the QA committee. However, according to the facility's policy, the Twenty-four (24) Hour Report would be reviewed each day, and all problems would be reported to the Director of Nursing (DON) or designee and the QA committee during the QA daily meeting. The QA Committee will follow up daily but no less than weekly, to review outcomes and ensure the highest level of care possible in all areas of the facility. Interview with the Administrator, on 04/21/16 at 11:07 AM, revealed SRNA #1 had worked on three (3) shifts as a KMA but had never been validated as a credentialed KMA and did not have any credentials on file. She stated that she never viewed this as a concern that needed to be brought to the QA team. Interview with the Regional Director of Operations, on 04/22/16 at 2:14 PM, revealed no one in the work pool should be allowed to work on the resident care area unless it was verified they had the appropriate credentials to perform those duties. He stated in his professional this should not have been allowed to occur and it was the responsibility of the Administrator to ensure this process occurred. He stated he expect a competency check to have been completed prior to being hired. He stated if there was a concern that could effect resident care this should have been taken to the QA team for review. Interview with the Medical Director, on 4/23/16 at 1:56 PM, revealed he was aware of the situation of the non-qualified staff administering medications. He stated he expected all staff hired to be qualified and that their credentials should be verified prior to them working in the resident care area. He revealed periodic checks should be completed to verify the credentials remain in active status. He stated competency evaluations should be conducted prior to any staff being allowed to work in the resident care area. He further stated in his professional opinion SRNA #1 being allowed to pass medications on three (3) shifts was out of his scope of practice and he could have made a medication error that could have caused serious harm or death to a resident. He stated that all unusual events affecting resident care should follow the QA process and be evaluated as well as follow up to ensure this does not occur again. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. On 04/21/16 and 04/22/16, Nurse Unit Managers (UM) performed skin evaluations, pain evaluations, and vital signs as deemed necessary; no issues noted. 2. On 04/20/16, the Residents' MAR indicated [REDACTED]. The facility obtained a statement from LPN #1 and validated she administered all [DEVICE] medications but failed to document. 3. The Interim DON, Nurse Unit Managers and MDS Coordinator reviewed all Care Plans related to delivery of medications and updated them to validate they accurately reflected current care needs of residents on 04/25/16. Updates were related to risk potential related to the delivery of medication by the former employee. 4. An audit of the April 2016 MARs of current residents was completed by the Interim DON, and Unit Nurse Manager on 04/25/16 to determine if any medications were administered by unqualified personnel and if further care plan updates were needed with no concerns found. 5. On 04/24/16, the RQM completed education with the Regional Director of Operations (RDO), who began as the Interim Administrator on 04/25/16, and the Interim DON on 04/24/16, on the policy that included what constituted neglect, reporting neglect, and determination of investigation of neglect. This education included supervision, protection, and determination of qualified and determination of investigating of neglect. 6. Education was provided to Department Managers including Social Services, Marketing/Admissions, Dietary Manager, Activity Director, Housekeeping, Business Office Manager (BOM), Assistant BOM, Medical Records, and UMs by the RDO and RQM on 04/25/16. The inservice was on what constituted neglect, reporting neglect, and determination of investigation of neglect. This education included supervision, protection, and determination of qualifications and determination of investigating of neglect. 7. Education was presented to the facility staff by the RQM, Administrator, and Admissions Director by 04/25/16. The inservice was on what constituted neglect, reporting neglect, and determination of investigation of neglect. This education included supervision, protection, and determination of qualifications and determination of investigating of neglect. 8. Monitoring by the Regional Team will be taken to the Quality Assurance and Assessment (QAA) team meetings which will be held quarterly with at least one Regional Team member in attendance for four (4) weeks, then the facility will monitor monthly thereafter. The regional team consists of · ROD · RQM · Regional Marketing Manager · Regional Manager · Regional Liaison. Members of the facility QA team are all follows: · Interim Administrator · Interim DOM · Dietary manager · Business Office Manager · Social Services Manager · Medical Director participating at least quarterly and as needed. 9. Audits will be conducted by payroll personnel to validate current employees who need certifications or licenses to administer medications, to ensure they are up to date on 04/22/16. No KMA's were being utilized by the facility. The validations were checked through the KY Board of Nursing Website. 10. All nursing staff applications are forwarded to the Interim DON that are eligible to work. Then a list will be given to the scheduler of all staff that are valid to work. Anyone found not to be qualified will not be allowed to pass medication until licenses or certifications are updated and the interim Administrator has given approval for them to work and is signed by the interim Administrator. An RQM in-service was conducted to repeat the requirements to the ROD, Payroll Personnel, Unit Managers and MDS Coordinator. 11. Care plans were reviewed on 04/25/16 to validate if any resident care plans should be updated based on any of the QAA findings. 12. During the clinical meeting Monday through Friday, care plans are updated as needed for the potential adverse reactions from medication and to ensure there is no unqualified staff working. If any revisions of the care plan are needed then the Interim DON, Nurse Unit Manager, and DMA Coordinator will conduct them. The nursing supervisor will update care plans on weekends and holidays. 13. MAR indicated [REDACTED]. Audits will continue to be brought back to the regional teams for quarterly review. 14. Monitoring of the MARs for care related to medications will be conducted for twelve (12) weeks. This will begin 04/25/16 and end 07/18/16. Audits will continue to be brought back to the regional teams for quarterly review. 15. On 04/20/16, the Interim Administrator conducted an in-service with the facility's management staff to review the practice of how the verification will be conducted and how the audit will be conducted. 16. A minimum of ten (10) staff interviews per week was completed beginning on 04/28/16 to validate everyone's understanding of how the process will operate to ensure that no license staff are permitted to work without a current License. All audits conducted of the staff interviews will be reviewed at the QAA meetings for review. 17. The DON, SRNA #1 and the Administrator were terminated on 04/25/16. 18. The Interim Administrator and Interim DON were appointed on 04/25/16 by the Division Director of Operations, 19. A weekly Regional Tem meeting will be conducted for four (4) weeks to validate the effectiveness of the administrating qualified staff. This will begin on 04/26/16 **The State Survey Agency validated the corrective action taken by the facility as follows: 1. Review of the skin assessment, pain evaluation, and vital sign documentation provided by the facility revealed they were completed on 04/21-22/16. 2. Review of the facility QA's monitoring form, dated 04/20/16, revealed the residents' MARs, who SRNA #1 administered medications, were reviewed with no errors identified. A written statement was provided by the facility and signed by LPN #1 validating she gave all medications requiring gastrostomy tube administration on 03/21/16. 3. Interview with the Interim DON, on 05/06/16 at 3:00 PM, revealed all care plans were reviewed to ensure that care and services were being provided as appropriate for each resident. She stated the Nurse Unit Managers and MDS Coordinator assisted her. 4. Interview with the Interim DON, on 05/06/16 at 3:00 PM, revealed the MARs had been reviewed to ensure the orders matched the physician's orders [REDACTED]. She also stated that all the MARs had been reviewed for accuracy and to ensure monitoring of parameters as per the MD orders was on the MARs. 5. Review of inservice records, dated 04/25/16, revealed an in-service was conducted by the RDO to the Interim Administrator and Interim DON on the policy, which included what constituted neglect, reporting neglect, and determination of investigation of neglect. Interview with the Interim Administrator on 04/25/16 revealed they had attended this in-services training with an understanding of the facility's operations on neglegt. 6. Review of the sign-in sheet, dated 04/25/16, revealed there were eleven (11) in attendance at the Management Team in-service related to ensuring medications were given within their time frame, the appropriate medications were given by qualified staff, never sign a medication that staff member did not give and who to notify in the event of an error. Interviews on 05/06/16 with UM #1 at 1:30 PM and UM #2 at 1:40 PM, revealed they had attended an inservice on medications related to giving in the appropriate time frame, given by qualified staff, and never to sign a medication for another staff member. 7. Review of Inservice Records, dated 04/25/16, revealed all staff was educated on abuse, neglect, and pain assessments. Interview on 04/25/16 at 3:10 PM, with LPN #1, LPN #2 and LPN #3 revealed they had received education on abuse, neglect, and pain assessments within the past week. Interview on 05/05/16 at 10:00 AM with SRNA #2, on 05/06/16 at 1:55 PM with SRNA #3 and on 05/06/16 at 2:05 PM with SRNA #6, revealed they received inservice training on neglect on 04/25/16. 8. Interview with the Regional Quality Manager (RQM), on 04/26/16 at 5:00 PM revealed she verified that all staff had been in-serviced except those that could not be reached. She confirmed they would be in-serviced prior to being allowed to return to work. 9. Review of all facility's licensed staffs licenses revealed they were in good standing. 10. Interview with the BOA, 05/06/16 at 3:05 PM, revealed she runs a report weekly to verify the validity of all license staff and forwards this to the appropriate management staff. A review of the sign-in sheet of the RDO, Payroll Personnel, Unit Managers, and MDS Coordinator revealed they were inservice on validation of licensed staff. Interview with UM #1 and UM #2, on 05/05/16 at 10:00 AM, revealed they were inserviced on validation of staff licenses. 11. Review of an audit log, dated 04/25/16, revealed all residents' care plans were reviewed and updated as needed. This was monitored by the MDS Coordinator. 12. Interview with the Interim DON, on 05/06/16 at 3:00 PM, revealed during each morning meeting Monday through Friday, the care plans were updated as needed for the potential adverse reactions from medication. She provided the audit tool that was used by the weekend supervisor to conduct their audits. 13. Review of the MAR indicated [REDACTED]. 14. Interview with the Acting Administrator, on 05/05/16 at 10:10 AM, revealed the facility would continue to conduct audits for twelve (12) weeks for care related to medications administration and report back to the regional team. 15. Interview with the Interim Administrator, on 05/06/16 at 2:55 PM, and review of the inservice sign-in sheet, dated 04/20/16, revealed an in-service with Management Staff was conducted on 04/20/16 and will continue to review the practice of how the verification will be conducted and how the audit will be conducted. 16. Interview with the Interim Administrator, on 05/06/16 at 2:55 PM, revealed a minimum of ten (10) staff interviews per week were being completed related to the facility's process for verification of licenses. 17. Interview with the RDO, on 05/06/16 at 10:10 AM, revealed the DON, SRNA #1 and the Administrator were terminated on 04/25/16. 18. Interview with the RDO, on 05/06/16 at 10:10 AM, revealed the Interim Administrator and Interim DON were appointed on 04/25/16 by the Division Director of Operations, 19. Review of a sign in sheet revealed a Weekly Regional Team meeting was held on 05/05/16.

Based on interview, record review, and facility policy review, it was determined the facility failed to have an effective system to ensure residents maintain acceptable parameters for body weight for one (1) of fifteen (15) sampled residents (Resident #8). Resident #8 was identified for risk of weight loss with a fifteen point one (15.1) pound weight loss over three (3) months. The facility failed to obtain weekly weights consistently and failed to ensure a Dietary recommendation for a supplement was implemented timely. The physician's orders [REDACTED]. In addition, staff failed to ensure Resident #8 participated in Restorative Dining, as care planned for verbal cues and tactile stimuli. The findings include: Review of the facility's policy titled, Weight Policy, dated 09/2015, revealed weights and nutritional status should be monitored by the Weight Committee and the Consultant Dietitian. The Director of Nursing (DON) or designee should see that weights are obtained regularly for all residents. Any weights reflecting possible medical condition changes should be brought to the attention of the supervisor immediately and Interact (Interventions to Reduce Acute Care Transfers) processes should be completed as needed. The facility Registered Dietitian's recommendations should be reviewed weekly during the Weight Variance Meeting and any deviation should be discussed and documented. Residents triggering a significant weight variance defined as five percent (5%) in one (1) month; seven point five percent (7.5 %) in three (3) months; and/or ten percent (10%) in six (6) months will be addressed by the Weight Variance Committee and placed on Weekly Weight monitoring. Any residents triggered for a variance will continue to be reviewed by the weekly Weight Variance Committee until variance issues have stabilized. The Dietary Manager and/or Nursing Supervisor will be responsible for ensuring recommendations are implemented and followed up accordingly. The resident's care plans shall be updated and documentation of the interventions maintained as part of the medical record. Record review revealed the facility admitted Resident #8 on 05/16/14 with the [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) assessment, dated 02/29/16, revealed the facility assessed Resident #8's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of zero (0) indicating the resident was not interviewable. In addition, the resident required the extensive assist of one (1) person with eating and was assessed as not having a five percent (5%) or more weight loss in the last month or ten percent (10%) or more in the last six (6) months. Review of Resident #8's Comprehensive Care Plan, for at risk for Alteration in Nutrition, dated 02/29/16, revealed the resident was at risk due to his/her diagnoses. Interventions included to provide diet per physician's orders [REDACTED]. Therapy as needed, and medications and labs as ordered. Review of the April 2016 physician's orders [REDACTED]. Review of Resident #8's weights revealed he/she weighed 152 pounds on 02/16/16 and 141 pounds on 03/02/16, which was an eleven pound (7%) weight loss in two (2) weeks. Review of the Nutritional Data Set and Progress Note, dated 03/09/16 prepared by the Dietician, revealed she recommended snacks twice a day, to continue weights weekly, and fortified foods. However, review of the Weight Change Comparison revealed Resident #8 was not weighed weekly from 02/16/16 through 03/02/16, during the time the weight loss occurred. Further review of Resident #8's weights revealed the resident weighed 138.7 pounds on 03/14/16 and 133.6 pounds on 03/21/16. The resident had an additional seven (7) pound weight loss since 03/02/16 (141 pounds). Review of the Restorative Care Plan, dated 03/18/16, revealed the resident was placed on Restorative Dining on 03/18/16 with an intervention to provide verbal cues and tactile stimuli for two (2) meals daily. However, review of the Restorative Program Flow Sheets dated March and April 2016, revealed there was no documented evidence the Restorative Care Plan was followed for thirty-eight (38) of seventy (70) breakfast and lunch meals from 03/18/16 through 04/21/16. Further review of the Weight Change Comparison revealed there were no weekly weights documented from 03/21/16 through 04/01/16. Review of the Nutritional Data Set and Progress Note, dated 04/06/16 prepared by the Dietician, revealed Resident #8 had a 15.1 pound weight loss in three (3) months and had eaten approximately forty-nine percent (49%) of his/her meals over the past seven (7) days. The Dietician recommended to start Medpass (nutritional supplement) 2.0 120 milliliters (ml) three (3) times a day for weight loss and to continue weekly weights until stable. However, review of the physician's orders [REDACTED]. Further review revealed the resident weighed 133 pounds on 04/19/16. Observation of Resident #8 during the lunch meal, on 04/20/16 at 12:06 PM, revealed the resident was eating in the dining room on the last row at the second table with two (2) other residents. There was no staff at the table assisting the resident. Observation of Resident #8 during the breakfast meal, on 04/22/16 at 8:24 AM, revealed the resident was eating in his/her room with no assistance. Certified Nurse Aide (CNA) #4 removed the tray from the room and verified the resident ate 100% of oats, 100% of sausage and eggs, and 100% of milkshake. Interview with Certified Nurse Aide (CNA) #3, on 04/22/16 at 8:36 AM, revealed the resident did not usually require assistance with eating and the resident did not go to the dining room this morning (04/22/16) because he/she did not want to go. Interview with CNA #5 on 04/28/16 at 1:24 PM, who is a Restorative Aide (RA) revealed Resident #8 received restorative dining six (6) days a week twice a day for prompting, cueing, and assistance with utensils as needed. She stated the charting for Restorative was the responsibility of the Restorative Aide. CNA #5 stated the Restorative Aides work 7:00 AM to 3:00 PM; therefore, the resident would have received restorative dining for breakfast and lunch. She stated the restorative table was the first back table and she was not sure why Resident #8 was not sitting at the restorative table for lunch on 04/20/16 at 12:06 PM. She further stated the staff should know the resident was on restorative dining. CNA #5 stated she was told the reason Resident #8 was on restorative dining was for more assistance with feeding himself/herself with no mention of weight loss. She stated there had only been one (1) restorative meeting in a year to review residents on restorative and their goals. CNA #5 stated the blanks on the Restorative Program Flow Sheet meant no one charted on the resident. During further interview she stated the reason would be either the Restorative Aide was out of the facility with a resident on a doctor's appointment or had been pulled to the floor to work as a CNA. CNA #5 stated Resident #8 should have been documented on twice a day in the Accunurse headset (a device worn during work hours to listen to the resident's care plan and to record care provided). Interview with Licensed Practical Nurse (LPN) #3 on 04/22/16 at 8:40 AM revealed Resident #8 eats well by himself/herself and other times he/she may need assistance. She stated sometimes he/she goes to the dining room for breakfast. LPN #3 stated she set up the resident's tray for breakfast this morning (04/22/16) and she was not sure why he/she did not go to the dining room for restorative dining. She stated night shift gets the residents up who go to the dining room for breakfast and if the resident refused a meal, he/she was able to tell staff if he/she was hungry. LPN #3 stated she was aware of the resident's weight loss. She stated Dietary takes care of the interventions, unless the resident was ordered a supplement and the nursing staff would give it. She stated Restorative staff obtained the weights and turned them into the Dietary Manager (DM) and the Director of Nursing (DON). Interview with the DM, on 04/20/16 at 2:57 PM; on 04/21/16 at 2:25 PM; and, on 04/22/16 at 8:26 AM, revealed she would discuss with the DON any resident's weight she was uncomfortable with to determine whether the resident should be a weekly or monthly weight. She stated she was concerned with Resident #8's weight loss and he/she should have been weekly weights due to his/her continued weight loss and because he/she was in restorative dining. The DM stated the resident was moved to Restorative Dining beginning 03/18/16, due to his/her weight loss. Further interview with the DM, on 04/28/16 at 9:00 AM, revealed Resident #8 was on weekly weights staring 01/13/16 and remained on weekly weights due to his/her instability. She stated she was not sure why the weights were not performed weekly between 02/16/16 though 03/02/16; 03/21/16 through 04/01/16; and 04/01/16 through 04/11/16. She stated that if a weight was missed the issue was either the resident refused or was out to the hospital or doctor but she could not provide information determining what might have occurred on these dates. She stated if either of these things had occurred she expected the weights to be obtained upon return that day or staff should try again later in the day. She verified that the QA meeting was performed weekly and was integrated with the Weight Committee. The DM stated the Committee reviewed weight loss for possible interventions and causes. She stated the committee members included the DON, ADON, Administrator, Unit Manager, DM, Social Services, and Activities. She stated she was responsible to ensure weekly and monthly weights were obtained. Interview with the Dietician, on 04/20/16 at 2:52 PM and, on 04/22/16 at 9:05 AM, revealed the Quality Assurance Committee (QA) should review the weekly and monthly weights when they meet weekly to determine whether to take the resident off weekly or add to weekly weights because she was only in the building twice a month. She stated she noticed on 04/20/16 that the Dietary Recommendation made on 04/06/16 for Medpass 2.0 120 ml three (3) times a day for Resident #8 had not been followed through with by staff. She stated she expected her recommendations to be followed per policy within a week with either an explanation for not implementing the recommendation or put in place timely due to the resident's weight loss. Further interview with the Dietician, on 04/28/16 at 11:25 AM revealed she expected policy to be followed for weekly weights. She stated the DM had a difficult time receiving weekly weights and ultimately it was nursing's responsibility to ensure weights were obtained. She stated since she was only in the facility twice a month she expected the QA committee to meet weekly and review the weekly weights in which the committee could and should pull the Weight Alert Report and not wait for her to put interventions in place for weight loss. She further stated that Resident #8's weight loss was likely due to not eating enough according to the Intake Report. Interview with Director of Nursing (DON) on 04/20/16 at 4:16 PM, on 04/21/16 at 12:55 PM and on 04/22/16 at 8:17 AM, revealed the Restorative Aide performed the monthly weights and if a resident refused a weight she would be made aware later. She stated the Dietary Manager (DM) was in charge of the weekly weights and she did not have anything to do with them. The DON stated the CNAs performed the weights on Friday through Sunday and the DM reviewed the weights the next week. She stated Resident #8's weights were unstable and she expected the resident to be kept on weekly weights. During further interview, the DON stated the Dietary Recommendation of Med Pass three (3) times a day should have been taken care of sooner than two (2) weeks due to Resident #8's weight loss. She stated the blanks on the restorative care flowsheet were due to either the CNAs not charting; or, documenting per their headset in a dead spot in the building and the information did not go through.

Based on observation, interview, record review, and review of the hospital emergency room Report; Hospice Registered Nurse documentation, the Resident Assessment Instrument (RAI) User Manual version 3.0; and, the Low Air Loss Mattress Manufacturers Guidelines, it was determined the facility failed to revise the care plan for one (1) of six (6) sampled residents (Resident #6). On [DATE], Resident #6's Comprehensive Care Plan was updated to include the use of a Low Air Loss Mattress with low pressure settings and bolsters. However, further review revealed the facility failed to revise the care plan to include what mattress setting was needed for Resident #6; and, failed to address the proper positioning of the resident on the mattress. On [DATE], Resident #6 slid off the specialty Low Air Loss Mattress sustaining an injury to the left side of his/her face and head which caused swelling and bruising. The resident also suffered a large skin tear to the left arm, and a [MEDICAL CONDITION]. The facility determined the resident was not positioned correctly in the bed. The findings include: Review of the facility's RAI version 3.0 Manual, dated ,[DATE], section 4.7, revealed the comprehensive care plan must be reviewed and revised periodically and services provided or arranged must be consistent with each written plan of care. The care plan should be revised on an ongoing basis to reflect changes in the resident and the care of the resident. Review of the Low Air Loss Mattress manufacturer's guidelines revealed settings were determined by the resident's weight and clinical assessment for need. Further review revealed the mattress did not have a firm perimeter that keeps the resident centered. The mattress has Anatomic Zones, integrated Bolsters and Alternating Pressure. Closed record review revealed the facility admitted Resident #6 on [DATE] with [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set (MDS) Assessment, dated [DATE], revealed the facility assessed Resident #6's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of ninety-nine (99) indicating the resident was not interviewable. The resident required extensive assistance with two (2) or more persons for Activities of Daily Living (ADL) and weighed one-hundred (100) pounds. Review of Resident #6's Comprehensive Care Plan for Terminal/End Stage [DIAGNOSES REDACTED]. Further review revealed on [DATE], the care plan was updated with an intervention for a low air loss mattress with bolsters with low pressure settings. However, there were no specific details for the settings of the mattress and no interventions related to the resident's positioning. Review of the [DATE] Treatment Administration Record (TAR) revealed to have a low air loss mattress with bolsters, monitor functioning and settings every shift; however, the TAR did not specify what the setting should be. Review of Nursing Note, dated [DATE] at 4:49 AM, and interview with Licensed Practical Nurse (LPN) #1 on [DATE] at 10:47 AM, revealed Resident #6 was heard yelling from his/her room and was found on the floor on [DATE] at approximately 10:45 PM, between the two (2) beds in the room, laying on his/her left side. Staff assessed the resident and identified a large skin tear on his/her left arm below his/her elbow and a knot and bruising to the left side of his/her head above the temple. Review of Nursing Notes, dated [DATE] at 6:40 AM and [DATE] at 1:45 PM; an emergency room (ER) Patient Record, dated [DATE] at 1:55 PM, and the Hospitalist Discharge Summary, dated [DATE], revealed the resident was complaining of pain anytime staff moved his/her left arm. The Physician was called and an order was received for an x-ray. Resident #6 was identified with a [MEDICAL CONDITION] upper arm. Resident #6 told the Hospitalist he/she just wanted his/her pain controlled and if the pain could not be controlled they should just let (him/her) die. The resident was admitted to the Inpatient Hospice for comfort measures on [DATE], and expired on [DATE]. Interview with Certified Nurse Aide (CNA) #3, on [DATE] at 2:45 PM, revealed she had provided incontinent care for Resident #6 and turned him/her to the left side. She stated she completed her care and left the room to go across the hall to another resident when not five (5) minutes later she heard Resident #6 calling out for help. CNA #3 said she re-entered the room to find Resident #6 on the floor in the position she had left him/her. She stated, I don't know how it happened, the way I had positioned him/her way over towards the left side of the bed, it's like he/she slid off backwards. She stated the resident was on a specialty constant air flow mattress, but she was not aware of any settings for the mattress. Further interview revealed CNA #3 stated she had no inservice prior to [DATE], on the air mattresses that she could recall to ensure she was aware to make sure the resident was centered in the bed. Interview, on [DATE] at 10:05 AM with Hospice Nurse Aide State Registered (NASR), revealed she visited Resident #6 three (3) days a week for his/her bath. She stated when she asked the resident about his/her fall the resident stated, I must have fell out of bed, I told them I was too close to the edge, they think I'm stupid or something, the bed was slick and oops the next thing I know they were picking me up off the floor. Interview with Licensed Practical Nurse (LPN) #4, on [DATE] at 3:00 PM, revealed she wrote the intervention on the Impaired Skin Integrity Care Plan for the Low Air Loss Mattress with Bolsters and low pressure settings on [DATE] after an inservice conducted by the Director of Nursing (DON). She stated she was not aware of what specific setting the mattress needed to be set LPN #4 stated Resident #5 was about the same size and weight as another resident (Resident #5) so she would think their mattresses would have been at the same setting. She stated all staff should try to position any resident centered on the bed for safety. Observation of Resident #5, on [DATE] at 11:00 AM, revealed Resident #5's mattress was set on eighty-five (85) pounds. Interview with the Director of Nursing (DON), on [DATE] at 12:45 PM, revealed she expected the licensed staff to update and revise a resident's care plan per the facility's policy; on admission, re-admission, when there were any changes in treatment and, at least quarterly. The DON further revealed she expected the licensed nurses to be specific when care planning for any piece of equipment. She stated the Low Air Loss Mattresses may be different with a different pressure controller so the settings should be included on the care plan. She stated Physician Orders, Medication Administration Records and TARs should reflect that specificity, and for residents' safety, they should be positioned centered in the bed no matter what type mattress was being used.

Based on observation, interview, record review, facility policy review, and review of the Low Air Loss Mattress Manufacturer Instructions; a hospital emergency room Report; and, review of the Hospice Registered Nurse documentation, it was determined the facility failed to ensure the resident's environment remained free of accident hazards as possible; and adequate supervision and assistive devices were provided to prevent accidents for (1) of six (6) sampled residents (Resident #6). On [DATE], Resident #6's Comprehensive Care Plan was updated to include the use of a Low Air Loss Mattress (alternating pressure) with low pressure settings and bolsters, and the need to position the resident in the center of the bed. However, the facility failed to revise the care plan to include what mattress setting was needed for Resident #6 and to position the resident on the center of the mattress. On [DATE], Resident #6 slid off a specialty Low Air Loss Mattress sustaining an injury to the left side of the face and head which caused swelling and bruising, a large skin tear to the left arm, and a fracture of the humerus. The facility determined the resident was not positioned correctly in the bed. In addition, the facility had care planned Resident #6 for a bed alarm after a fall on [DATE]; however, there was no bed alarm in place at the time of the [DATE] fall to notify staff if the resident needed assistance. The findings include: Review of the facility's policy titled, Fall Assessment/Intervention Process not dated, revealed all residents on any admission and re-admission and at least quarterly will be assessed for fall risk and appropriate interventions initiated immediately to reduce the risk of injuries with falls. Further review revealed at the time of a fall after assessing and caring for the resident the Resident Incident Report and Incident Investigation should be initiated to determine appropriate intervention. Review of the Low Air Loss Mattress manufacturer's guideline revealed this was the type mattress used by Resident #6. The mattress had Anatomic Zones, integrated Bolsters and Alternating Pressure; however it did not have a firm perimeter which was a standard feature on other mattresses to keep residents centered. Closed record review revealed the facility admitted Resident #6 on [DATE] with [DIAGNOSES REDACTED]. Review of an Quarterly Minimum Data Set (MDS) Assessment, dated [DATE], revealed the facility assessed Resident #6's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of ninety-nine (99) indicating the resident was not interviewable. The resident required extensive assistance with two (2) or more persons for Activities of Daily Living; was at risk for falls; and, weighed one-hundred (100) pounds. Review of the Comprehensive Care Plan, dated [DATE] revealed an intervention for a low air loss mattress with bolsters for pressure relief; and, an intervention dated [DATE], for staff to apply a chair alarm and bed alarm. Further review revealed on [DATE], an intervention was added for a low air loss mattress with bolsters with low pressure settings. However, the care plan did not address the specific mattress setting for Resident #6 and did not state to ensure the resident was positioned in the center of the bed. Review of Resident #6's July Treatment Administration Record (TAR) revealed there was a treatment to have low air loss mattress with bolsters, monitor functioning and settings every shift. However, it did not specify the mattress setting and there were no initials in the boxes dated [DATE]-[DATE] to indicate the mattress and mattress settings were checked every shift. Interview with LPN #4, on [DATE] at 3:00 PM, revealed she wrote the intervention on the Impaired Skin Integrity Care Plan for the Low Air Loss Mattress with Bolsters and low pressure settings on [DATE] after an inservice conducted by the Director of Nursing (DON). She stated she was not aware of what specific setting the mattress needed to be set, but Resident #5 was about the same size and weight of Resident #6 so she would think their mattresses would have been at the same setting. She stated, We should always try to position any resident centered on the bed for safety. Observation of Resident #5, on [DATE] at 11:00 AM, revealed Resident #5's mattress was set on eighty-five (85) pounds. Review of Nursing Note, dated [DATE] at 4:49 AM, revealed Resident #6 was heard yelling from his/her room and was found on the floor between the two (2) beds in the room, laying on his/her left side. Resident #6 was assessed and placed back into bed, and he/she was noted to have bruising and a knot on the left side of the head just above the temple and a large skin tear on his/her left arm below the elbow. Review of the Fall Investigation Work Sheet, dated [DATE], revealed there was no alarm in place at the time of the fall. Further review revealed the facility determined the Certified Nurse Aide (CNA) had failed to ensure the resident was positioned in the center of the bed. Review of a Nursing Note, dated [DATE] at 6:40 AM, revealed the resident was complaining of pain anytime the resident's left arm was moved. The Physician was notified and an order was received to obtain an x-ray. Review of a Nursing Note, dated [DATE] at 1:45 PM, revealed the the resident had a fracture to the upper left arm, and the resident's family wanted him/her sent to the hospital. Review of the emergency room (ER) Patient Record of Resident #6, revealed he/she arrived on [DATE] at 1:55 PM and was assessed as having ecchymosis (bruising) and tenderness to the left arm and a skin tear and tenderness and ecchymosis to the left forehead. Review of the ER Physician's Note revealed he ordered an x-ray of the left arm which revealed a fracture of the proximal humerus (upper arm). Review of the Hospitalist Discharge Summary, dated [DATE], revealed Resident #6 just wanted his/her pain controlled and if the pain could not be controlled they should just let him/her die. The resident was then admitted to Inpatient Hospice for comfort measures on [DATE] and, expired on [DATE]. Interview with CNA #3, on [DATE] at 2:45 PM, revealed she had provided incontinent care for Resident #6 and turned him/her to the left side, noting the resident was on a specialty constant air flow mattress, but she was not aware of any settings for the mattress. She stated she completed her care and left the room to go across the hall to another resident when not five (5) minutes later, she heard Resident #6 calling for help. CNA #3 re-entered the room to find Resident #6 on the floor, in the position she had left him/her. She stated I don't know how it happened, the way I had positioned him/her way over towards the left side of the bed, it's like he/she slid off backwards. CNA #3 stated RN #2 had CNA #7 pick up the resident off the floor and put him/her back in the bed and LPN #1 assessed the resident. CNA #3 stated the resident was not complaining of any pain, but he/she did have a goose egg on his/her left side of head. CNA #3 stated she had not been inserviced on the use of the mattress. Interview with Licensed Practical Nurse (LPN) #1, on [DATE] at 11:25 AM, revealed she was Resident #6's nurse on [DATE] when he/she was found on the floor beside his/her bed. She stated she didn't know what happened, we just found him/her on the floor. LPN #1 noted the resident had a goose egg to the left side of his/her head and a skin tear on his/her left elbow. Interview, on [DATE] at 10:05 AM with the Hospice Nurse Aide State Registered (NASR), revealed she visited Resident #6 three (3) days a week for his/her bath. She stated she talked with him/her at length about how he/her injured his/her head and arm. She stated Resident #6's exact words to her were, I fell out of bed, I told them I was too close to the edge, they think I'm stupid or something, the bed was slick and oops the next thing I know they were picking me up off the floor. Interview with LPN #2/MDS Assistant, on [DATE] at 3:00 PM, revealed she recalled talking about Resident #6's fall on [DATE] in morning meeting and they care planned the resident to have alarms to the bed and chair to alert staff for need of assistance. She stated the Unit Manager was in the morning meeting and should have contacted the physician for the order and placed the notation for the alarms on the Treatment Administration Record and initiated the alarms. Interview with Registered Nurse (RN) #1 (Unit Manager), on [DATE] at 1:09 PM, revealed she was not the Unit Manager on [DATE]. However, she was responsible for checking the residents' care plans. She stated she was not Resident #6 had been care planned by LPN #2 for alarms to alert staff that resident needed assistance. Interview on [DATE] at 12:45 PM with the Director of Nursing (DON) revealed she would expect the licensed staff to update a resident's care plan per the facility's policy; on admission, re-admission, with any changes in treatment and at least quarterly. The DON stated she expected the licensed nurses to be specific when care planning for any piece of equipment. She stated the Low Air Loss Mattresses may be different with a different pressure controller so the settings should be included on the care plan. The DON stated Physician Orders, MARs and TARs should reflect that specifically, and for residents' safety they should be positioned centered in the bed no matter what type mattress was being used. She further stated she was not aware of Resident #6 ever having an alarm on his/her bed or chair. The DON stated she expected staff to follow the care plans to ensure residents received adequate supervision and assistive devices to prevent accidents.

Based on interview, record review, and review of the facility's policy and procedure it was determined the facility failed to ensure the plan of care was followed for one (1) of five (5) sampled residents (Resident #1) related to transfers. Resident #1 was care planned for the assistance of two (2) staff with a mechanical lift with transfers. However, on 05/08/14, Certified Nursing Assistant (CNA) #1 failed to follow the care plan and attempted to transfer the resident with a mechanical lift unassisted, which resulted in the resident being lowered to the floor causing injury. Resident #1 was sent to the hospital due to complaints of pain to the ribs, head, chest and legs and it was determined the resident sustained [REDACTED]. [MEDICATION NAME] (anti-[MEDICAL CONDITION]) 550 milligrams (mg) was ordered twice a day for seven (7) days after the fall for increased pain management and soft tissue swelling to the posterior skull area. In addition, prior to the fall, Resident #1 was receiving Hospice Care and had an order for [REDACTED].#1 did not require the pain medication until after the fall. Resident #1 complained of pain to the ribs, head, legs and chest. Resident #1 received eighteen (18) doses of the [MEDICATION NAME] between 05/09/14 and 05/17/14. The findings include: Review of the facility's policy and procedure titled "Resident Comprehensive Care Plan" dated 09/2008, revealed "The residents comprehensive care plan should be viewed as an Interdisciplinary approach to managing the acute and chronic needs of the resident living in the facility. Record review revealed the facility admitted Resident #1 on 10/17/12 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 04/02/14, revealed the facility assessed Resident #1's cognition as moderately impaired with a Brief Interview of Mental Status (BIMS) score of eight (8). The facility assessed the resident to require two (2) person assist for transfers. Review of the Comprehensive Care Plan titled "Risk for Injury related to Falls", dated 02/11/14, revealed an intervention to transfer with the assistance of two (2) staff with a mechanical lift. Review of the CNA Care Plan titled "Activities of Daily Living (ADL) Plan of Care" dated 04/18/14, revealed Resident #1 required two (2) or more person physical assist and total dependence with a sling lift and wheelchair for transfers. Review of the facility's investigation, dated 05/09/14, revealed on 05/08/14 at approximately 7:55 PM, CNA #1 attempted to transfer Resident #1 from a wheel chair to the bed unassisted with a mechanical lift when the sling began to shift which resulted in Resident #1 being caught and lowered to the floor. Resident #1 sustained injuries to the head and ribs. Review of the emergency room Patient Record and Radiology Reports for x-rays of the ribs and review of the CT Scan (Computed Tomogaphy Scan) of the head, dated 05/09/14, revealed the resident sustained [REDACTED]. Review of the May 2014 Medication Administration Record [REDACTED]. Further review of the MAR indicated [REDACTED]" [MEDICATION NAME] between 05/09/14 through 05/17/14 for complaints of pain in the ribs, chest, head and leg. He/She had not received any as needed [MEDICATION NAME] prior to the fall. In addition, the resident was ordered [MEDICATION NAME] (anti-[MEDICAL CONDITION]) 550 milligrams (mg) twice a day for seven (7) days after the fall for increased pain management and soft tissue swelling to the posterior skull area. Interview with CNA #1, on 06/04/14 at 11:05 AM and on 06/05/14 at 8:09 AM, revealed she was caring for Resident #1 on 05/08/14 when the incident occurred. She stated she was aware of the need to follow the Accu-Nurse Care Plan (the CNA ADL Care Plan is the care plan in Accu-Nurse {computer system} in which the CNAs listen to a headset to know what care needs to be provided). She stated CNA #2 was in the room to assist her with the mechanical lift but did not provide any assistance; however, interview with Licensed Practical Nurse (LPN)/Charge Nurse #1, on 06/05/14 at 7:45 AM, revealed CNA #1 had to have been in the resident's room alone because CNA #2 was up the hallway caring for other residents when CNA #1 came to get her to assess the resident. Interview with CNA #2, on 06/04/14 at 10:49 AM, revealed she was not in the room when Resident #1 fell on [DATE]. She stated there was three (3) CNAs on duty on Hall 1 that night and she had rooms nine (9) through fifteen (15). She stated CNA #1 never asked her for assistance with the lift. CNA #2 stated CNA #1 told her that she had attempted to transfer Resident #1 to the bed and the lift gave and the resident began to fall but never hit the floor because she had grabbed the resident. Interview with Registered Nurse (RN) #1, on 06/06/14 at 1:30 PM, revealed she monitored the CNAs on the hall to ensure they were following the care plan. She further stated when she was not present, the Charge Nurses were responsible to oversee the CNAs and ensure the resident's care plan was being followed. Interview with the Assistant Director of Nursing (ADON), on 06/05/14 at 12:22 PM, revealed she would have expected CNA #1 to have followed Resident #1's care plan and to ask for assistance prior to using a mechanical lift. Additional interview, on 06/06/14 at 1:07 PM, revealed every staff member had been inservice related to following the resident's plan of care. There was no competency testing completed with the inservice and the CNAs were instructed to report to licensed staff if they were unable to follow the plan of care for any reason. Interview with the Director of Nursing (DON), on 06/06/14 at 2:41 PM, revealed when she interviewed CNA #1 regarding the use of the mechanical lift unassisted, CNA #1 admitted she was trying to save time and therefore did not follow the care plan to have two (2) staff for the transfer.

Based on interview, record review, and review of the facility's policy and procedure it was determined the facility failed to provide adequate supervision to prevent accidents for one (1) of five (5) sampled residents (Resident #1) during a transfer with a mechanical lift which resulted in a fall with injury to the resident's ribs and head. On 05/08/14, Certified Nurse Aide #1 attempted to transfer Resident #1 with a mechanical lift by herself, when the sling gave and she had to lower the resident to the floor. The CNA failed to obtain assistance from another staff member to ensure adequate supervision was provided during the mechanical lift transfer. Resident #1 had complaints of pain in the ribs, head, chest, and legs after the fall and was sent to the hospital and diagnosed with [REDACTED]. The resident returned to the facility with an order for [REDACTED]. In addition, Resident #1 was receiving Hospice Care and had an order for [REDACTED]. Resident #1 complained of pain to the head, chest, ribs and legs and received eighteen (18) doses between 05/09/14 and 05/17/14 after the fall. The findings include: Review of the facility's policy titled "Fall Assessment/Intervention Process" revised 09/2013, revealed "Accu-Nurse care plan updated frequently for point of care needs of the resident to ensure safety and accurate care was being delivered." Review of the facility's "Skills Check Off/Return Demonstration" for the Invacare 450/600 Total Lift, dated 06/23/11 revealed "Use number of staff required for the procedure." Record review revealed the facility admitted Resident #1 on 10/17/12 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 04/02/14, revealed the facility assessed Resident #1's cognition as moderately impaired with a Brief Interview of Mental Status (BIMS) score of eight (8). The facility assessed the resident to require two (2) person assist for transfers. Review of a facility investigation, dated 05/09/14, revealed CNA #1 was working on second shift and was assigned care for Resident #1. The facility assessed Resident #1 to require a mechanical lift with two (2) person assist for transfers from the bed to the chair and the chair to the bed. However, on 05/08/14 at approximately 7:55 PM, CNA #1 attempted to transfer Resident #1 from a wheel chair to the bed unassisted with a mechanical lift when the sling began to shift which resulted in Resident #1 being caught by CNA #1 and lowered to the floor which resulted in injuries to the resident's head and ribs. Review of the emergency room Patient Record and Radiology Reports for x-rays of the ribs and CT Scan (Computed Tomography) of the head, dated 05/09/14, revealed the resident sustained [REDACTED]. Review of the May 2014 Medication Administration Record (MAR) revealed Resident #1 had an order for [REDACTED]. Further review of the MAR revealed Resident #1 received eighteen (18) doses of the "as needed" Roxanol between 05/09/14 and 05/17/14 for complaints of pain to the head, ribs, chest and leg, which was after the fall on 05/08/14. He/She had not received any "as needed" Roxanol prior to the fall. In addition, the resident had an order to receive Naproxen (anti-inflammatory) 550 mg twice a day for seven (7) days for increased pain management and soft tissue swelling to the posterior skull area Review of the Comprehensive Care Plan titled "Risk for Injury related to Falls", dated 02/11/14, revealed an intervention for Resident #1 to require two (2) staff with a mechanical lift for transfers. Interview with Resident #1's roommate, on 06/04/14 at 9:55 AM, revealed he/she recalled Resident #1 lying on the floor after the lift was used to get him/her up. Interview with CNA #1, on 06/04/14 at 11:05 AM and on 06/05/14 at 8:09 AM, revealed she was caring for Resident #1 on 05/08/14 when the incident occurred. She stated CNA #2 was in the room to assist her with the mechanical lift but did not provide any assistance. She stated the lift she used had a sling that fit between the resident's legs and when she started to move the lift back something gave with the sling and the resident began to fall. She stated she caught him/her and lowered the resident to the floor but the resident hit his/her head on the dresser on the way down. CNA #1 revealed after the resident was on the floor, she and CNA #2 assessed the lift to see if they could see anything wrong with it and found nothing to be in non-working order. CNA #1 stated she then proceeded to place Resident #1 back on the lift and transferred him/her to the bed prior to getting the Charge Nurse, (Licensed Practical Nurse (LPN) #1), to assess the resident. CNA #1 revealed after the resident was back in the bed, CNA #1 went to get LPN #1 and told her the resident was complaining of head and chest/rib pain but did not tell the Charge Nurse the resident had fallen. CNA #1 stated LPN #1 assessed the resident and gave the resident some pain medication but did not send the resident to the emergency room for evaluation because she was unaware of the fall and the resident had chronic pain related to malignant [DIAGNOSES REDACTED]. Interview with CNA #2, on 06/04/14 at 10:49 AM, revealed she was not in the room when Resident #1 fell on [DATE]. She stated CNA #1 never asked her for assistance and CNA #1 told her that she had attempted to transfer Resident #1 to the bed when the lift gave and the resident began to fall. CNA #2 revealed CNA #1 said the resident never hit the floor because she had grabbed him/her when he/she began to fall. CNA #2 stated staff was taught to never use a mechanical lift unassisted and to always follow the resident's plan of care. Interview with LPN #1, on 06/04/14 at 2:08 PM, revealed she was unaware of Resident #1 experiencing a fall on 05/08/14 and she did not find out about the fall until 05/09/14. LPN #1 stated CNA #1 had come to her and asked her to come and assess the resident because he/she was complaining of pain in the ribs and in the head. She stated CNA #1 began to question her about the rib and head pain and was wondering if the pain could have been the result of a fall but she never told her the resident had fallen. Additionally, she revealed the resident was in the bed when she went in to assess him/her, so there was no reason for her to suspect the resident had fallen. Further interview, on 06/05/14 at 7:45 AM, revealed CNA #1 had to have been in the resident's room alone because CNA #2 was up the hallway caring for other residents when CNA #1 came to get her to assess the resident. Interview with the Staff Development Coordinator (SDC), on 06/05/14 at 8:23 AM, revealed she had inserviced staff related to the use of a mechanical lift with two (2) staff members and she did not know why CNA #1 would use the lift unassisted to transfer a resident. She stated she had educated staff related to waiting for assistance or asking the resident to wait to be transferred until staff was available to assist with the transfer. Interview with Assistant Director of Nursing, on 06/06/14 at 1:07 PM, revealed every staff member was inserviced related to following the resident's plan of care and the proper use of the mechanical lift. She was unable to explain why CNA #1 attempted to transfer Resident #1 with a mechanical lift unassisted. Interview with the Director of Nursing (DON), on 06/06/14 at 2:41 PM, revealed CNA #1 told her she was trying to save time when she used the mechanical lift unassisted for Resident #1 and the CNA did not provide adequate supervision for the transfer.

Based on interview and review of the resident's record, nursing notes, Interdisciplinary Team Note, physician's orders, hospital's Emergency Department Physician Chart, and facility's policy/procedure, it was determined the facility failed to immediately consult with the physician when there was a significant change in condition; and the Registered Nurse's (RN) inability to start treatment for one (1) of five (5) sampled residents (Resident #1). On 11/30/13 at approximately 5:00 AM, a Certified Nurse Aide (CNA) reported to RN #1 that Resident #1 was having diarrhea, did not want to drink and was not easily aroused. RN #1 called the physician and left a message between 5:30-6:00 AM. However, RN #1 discussed the physician not calling them back with RN #2 and they decided not to attempt to notify the physician again. At 6:00 AM, RN #1 received orders for a Complete Blood Count (CBC), Comprehensive Metabolic Profile (CMP), Urinalysis (UA), chest x-ray, Intravenous Fluids (IV) Normal Saline at 90 cubic centimeters (cc) per hour (hr), and IV [MEDICATION NAME] (an antibiotic) 500 milligrams (mg) three times a day (TID). RN #1 failed to notify the physician that she did not attempt to start the IV because she felt she couldn't start it because the resident was so dehydrated. When Licensed Practical Nurse (LPN) #1 (day shift nurse) went to the resident's room between 7:00 AM-7:30 AM to carry out the physician's orders, she noted Resident #1 was having difficulty breathing. The resident's feet, knees and hands were mottled and the resident was not responding. LPN #1 initiated oxygen (02) at two (2) liters and performed an in and out catheterization for urine for the UA. The nurse obtained approximately five to seven (5-7) cc's of dark tea colored urine. The resident's blood pressure (B/P) was 55/24 (normal range:120/70), O2 saturation was 81% (normal range: 98-100%) before the oxygen was started. Resident #1 was mouth breathing, pulse was 47 (normal range: 70), respirations were 24 (normal range 20), and his/her temperature was 97.1 (normal 98.6). LPN #2 initiated the IV in the resident's right arm and started Normal Saline at 90 cc's per hour. LPN #1 attempted to contact the physician at 7:30 AM to send the resident out to the hospital with no success. The LPN did not call the physician back until 8:00 AM-8:15 AM and at that time, she received orders to send the resident to the emergency room for evaluation. The resident was admitted to the hospital with [REDACTED]. Resident #1 was admitted to the Intensive Care Unit, Coded and passed away at 4:42 PM. The facility's failure to immediately notify the resident's physician of a significant change in condition and the inability to start treatment has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 12/13/13, and was determined to exist on 11/30/13. The facility was notified of the Immediate Jeopardy on 12/13/13. An acceptable Allegation of Compliance (AoC) was received on 12/19/13 and the State Survey Agency validated the Immediate Jeopardy had been removed on 12/20/13, as alleged. A partial extended survey was conducted on 12/20/13. The scope and severity was lowered to a "D" while the facility develops and implements the Plan of Correction (POC) and the facility's Quality Assurance monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy and procedure "Change in Condition", dated 01/11, revealed a change of condition in a resident should target many areas of the Interdisciplinary Team (IDT) function. To ensure the optimal outcome for the resident, the nursing process of Assessment, Plan, Intervention, and Evaluation will be used. Physician involvement is always required, as is follow-up assessment per Federal Guidelines. Process: Interact 11 system is to be used with this protocol. Change in condition Assessment Guidelines will be followed by the licensed nurse for the initial, and when necessary the follow-up assessment to detect change in condition by symptoms and categories. Interact tool "Immediate Notification" revealed any symptom, sign or apparent discomfort that is acute or sudden in onset, and a marked change (more severe) in relation to usual symptoms and signs, or unrelieved by measures already prescribed. All information triggers in this reference will be used when notifying the physician. A Situation-Background-Assessment/Appearance Request (SBAR) form is to be used for documentation prior to notifying the physician. This form will contain information gathered when doing an assessment and is to be utilized as a Nursing Note in the medical record. Notification of Resident Change in Condition: Clinicians will immediately consult with the resident's physician when there is a significant change in condition. Document in the Nurses' Notes the times notification was made and the names of the person(s) to whom you spoke. Record review revealed the facility admitted Resident #1 on 12/31/08 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment, dated 10/07/13, revealed the facility assessed Resident #1's cognition as severely impaired. Review of the physician orders, dated 11/01/13 through 11/30/13, revealed Resident #1 was a full code. Interview with CNA #1, on 12/13/13 at 7:05 AM, revealed she reported to RN #1, on 11/30/13 at approximately 5:00 AM, that Resident #1 was having diarrhea, did not want to drink anything, and was not easily aroused. Review of the nursing notes for 11/30/13 revealed there was no evidence the physician was notified of the resident's change in condition. Interview with RN #1, on 12/10/13 at 12:42 PM, and on 12/13/13 at 7:36 AM, revealed CNA #1 had reported to her that Resident #1 was having diarrhea and was not wanting to take fluids. RN #1 stated around 5:00 AM, she assessed and checked Resident #1's vital signs. RN #1 stated Resident #1's blood pressure was eighty something over fifty something; however, she could not remember the specifics and she did not document this assessment. RN #1 stated she contacted the on-call physician and left a message between 5:30 AM and 6:00 AM. RN #1 stated she then started administering the morning medications and did not call the physician back when he did not return her call. Further interview revealed she discussed the physician not calling her back with RN #2 and they decided not to call the physician again. The RN stated she received a return call from the physician at 6:00 AM with orders for labs, an x-ray, IV fluids, and medications. RN #1 stated she did not start the IV because Resident #1 was dehydrated and wasn't drinking and she did not have a lot of experience with starting an IV on someone that was dehydrated. Another reason she did not start the IV was due to not having "good feeling" in her fingertips. She stated in the past when she started an IV in the facility she always had another nurse with her. The RN revealed she did not notify the physician she was unable to start the IV. She stated she knew the day shift nurse would assist when she arrived. RN #1 stated she asked RN #2 for assistance a few different times during her shift; however, RN #2 could not help due to having issues going on with her residents and she was in the middle of a medication pass. She stated she asked RN #2 what to do since when was unable to contact the physician and they decided to wait for the physician to call back. The RN stated everything was happening around 5:00 AM-5:30 AM, and she felt overwhelmed. RN #1 stated she was not familiar with the Interact process related to the gathering of information to notify the physician. Interview with RN #2, on 12/12/13 at 6:03 PM, revealed she worked the night Resident #1 was sick and had to be sent to the hospital. She stated RN #1 had came over and told her Resident #1 was confused and had a change in condition. RN #2 stated she told RN #1 to obtain the resident's vital signs and call the physician. The RN stated this was before 6:00 AM and RN #1 never came back after that. Review of a physician's telephone order, dated 11/30/13 at 6:00 AM, revealed orders for a CBC, CMP, a UA now, chest x-ray, IV Normal Saline at 90 cc's hr, and IV [MEDICATION NAME] 500 TID. Review of the Interdisciplinary Team Notes, dated 11/30/13 at 1:13 PM, revealed at 7:30 AM, LPN #1 called mobile x-ray for a stat chest x-ray. Further review revealed when LPN #1 entered Resident #1's room to obtain the urine for the UA she observed Resident #1 was having difficulty breathing. The resident's feet, knees and hands were mottled and the resident was not responding. LPN #1 initiated oxygen (02) at two (2) liters and conducted an in and out catheterization for urine for the UA. The nurse obtained approximately five to seven cc's of dark tea colored urine. The resident's blood pressure (B/P) was 55/24 (normal 120/70), O2 saturation was 81% (normal 98-100%) before O2 started, and Resident #1 was mouth breathing. Another nurse initiated the IV in the resident's right arm, Normal Saline was started at 90 cc's an hour. LPN #1 continued to take the resident's B/P and it was down to 55/24, pulse was 47 (normal 70), respirations 24 (normal 20), temp 97.1 (normal 98.7). The physician was called at 8:15 AM and advised of Resident #1's condition and code status. The Physician stated to send Resident #1 to the emergency room for evaluation. Interview with LPN #1, on 12/10/13 at 10:30 AM and on 12/12/13 at 4:10 PM, revealed she arrived at work at shift change and was told by RN #1 an IV needed to be started. LPN #1 stated RN #1 stated Resident #1 wasn't doing well. The LPN stated she could see that RN #1 was really overwhelmed and behind so she started helping. She stated when she entered Resident #1's room, the resident was pale, would not respond to staff, but would moan when touched. The LPN stated she checked the resident's vital signs after she did the in and out catheter to obtain the urine for the UA. The LPN stated the vital signs were abnormal. She stated the resident's B/P was "like 55 over something" and she noted Resident #1 had mottling. The physician was called to get an order to send Resident #1 to the hospital at approximately 7:30 AM with no response from the physician. LPN #1 stated she did not call the physician back until 8:00 AM or 8:15 AM and at that time, she received orders to send Resident #1 to the hospital for evaluation. Review of the hospital's Emergency Department Physician Chart revealed Resident #1 was admitted to the hospital on [DATE], with [DIAGNOSES REDACTED]. Interview with the Hospital Social Worker, on 12/10/13 at 9:03 AM, revealed the resident was admitted to the Intensive Care Unit, Coded and passed away at 4:42 PM. Interview with the Director of Nursing (DON), on 12/11/13 at 2:15 PM, revealed if the nurse was unable to reach a physician, the nurse should have tried again to notify the physician. She stated she expected a return call from the physician within thirty (30) minutes. The DON stated the facility did not have a policy with a specific time, nursing was to use their judgement. She stated there was no documentation as to the time the physician was notified. Interview with the on-call physician, on 12/10/13 at 3:04 PM, revealed he was contacted regarding Resident #1 and orders were given to the nurse. He stated the RN told him Resident #1 was having diarrhea and loose watery stools. **The facility implemented the following actions to remove the Immediate Jeopardy: On 12/14/13, the Regional Director of Operations re-educated the Administrator related to the responsibility of the Administrator to oversee the facility in accordance with Federal regulations to include monitoring of the Director of Nursing related to the supervision of nursing staff. On 12/14/13, the Administrator re-educated the Director of Nursing on the requirements to supervise nursing staff to include guidance and direction for new nurses as well as follow up questions in communications with the nursing staff. On 12/14/13, the Regional Nurse Consultant re-educated the Director of Nursing, Assistant Director of Nursing and Unit Managers for hall one and two on the Interact Process, timely notification of the physician and using the Medical Director if unable to reach the attending physician timely including calling 911 in an emergency situation. The Interact Process is an evidence based practice program developed at the request of the Centers for Medicaid and Medicare Services to reduce unnecessary return hospitalization s. The Regional Nurse Consultant also re-educated the Director of Nursing, Assistant Director of Nursing and Unit Managers for units one and two on notification of the physician if the nurse was unable to follow MD orders in a timely manner. It includes suggestions for nurses on when to notify the physician and what recommendations for treatments to make, but does not override the judgement of the nurse at bedside. Resident #1 was discharged from the facility on 11/30/13. All Current residents of the facility have been reviewed by the Interdisciplinary Team (IDT) to include the Director of Nursing, Unit Managers for halls one and two, Assistant Director of Nursing, MDS Coordinator and Social Services Director, to assure that any current resident who is experiencing a significant change in condition had physician notification. Any resident who was deemed to have had a significant change in condition in the past thirty (30) days without physician notification had immediate physician notification. This review included a set of vital signs and visual examination of the resident for apparent acute distress by the Director of Nursing, Assistant Director of Nursing or Unit Managers; and, a review of the medical record for the past thirty (30) days by the IDT. This was completed on 12/14/13. The IDT, which included the Director of Nursing, Unit Managers, MDS Coordinator and Social Services Director, reviewed all current residents' care plans on 12/14/13 to assure that the care plan was up to date and met the needs of the resident, and that the care plan interventions were in place. Any resident whose care plan was not up to date to meet the needs of the resident had the care plan updated. Any interventions not in place were implemented. Beginning 12/14/13, all licensed staff was re-educated on immediate notification of the physician with a significant change in condition using the Interact Process as a guideline, but not to supercede the judgement of the nurse in attendance. In addition, the education included notification of the Medical Director if they were unable to reach the attending physician timely. This re-education was completed by the Director of Nursing, Assistant Director of Nursing or Unit Manager for hall number one. No licensed staff will work after 12/14/13 without having received this education. Beginning on 12/14/13, all licensed staff was re-educated on the completion of appropriate nursing assessments with follow up based upon the resident's condition with examples of abnormal vital signs, respiratory and gastro-intestinal using the Interact guidelines and pathways as a guide, not to supercede the judgement of the nurses in attendance. This re-education was completed by the Director of Nursing, Assistant Director of Nursing or Unit Manager for hall number one. No licensed staff will work after 12/14/13 without having received this re-education. On 12/14/13, the Regional Nurse Consultant will provide education to the Director of Nursing and the Unit Manager for hall one related to skill procedures for IV insertion, emergency oxygen administration, and airway obstruction with competency testing. The Director of Nursing or Unit Manager for hall one will provide training to all licensed nurses on IV insertion, emergency oxygen administration and airway obstruction with competency testing. No staff will work after 12/19/13, without having received this education and validation competency. An Ad Hoc Quality Assurance Committee meeting (QPI) was held on 12/14/13 to review the alleged deficient practice as well as the plan for removal to include audits for care plans and care plan interventions to assure care plans meet the needs of the residents and interventions are followed, and all training material presented to licensed staff. The discussion also included training completed for the Administrator and the Director of Nursing and how the facility will monitor corrective actions. In attendance was the Administrator, the Director of Nursing, the Assistant Director of Nursing, Unit Manager, MDS Nurse and the Social Service Director. The Medical Director attended via conference call. No further recommendations were made by the committee. The Quality Assurance Committee will meet weekly to review the removal plan as well as monitoring of actions weekly until substantial compliance is achieved. Monitoring of the allegation of compliance will be conducted by doing the following: The Director of Nursing or Unit Manager for hall one will review the Twenty Four Hour Report and all physician orders daily for two weeks, followed by five times a week for at least ten weeks to assure all changes in condition had appropriate physician notification, assessment and follow up. In addition, the Director of Nursing, Assistant Director of Nursing or Unit Manager for hall one will contact the facility once each shift to review with each nurse any significant changes in resident condition to assure licensed staff are assessing and notifying the physician timely. This will occur daily for two weeks, followed by five times per week for at least ten weeks on each shift. The Administrator will speak with all new nurses within the first thirty (30) days of employment and at least five nurses per month for three months to assure training needs are met as well as to assure communication with the Director of Nursing is open and appropriate. The Director of Nursing will audit five resident records per week for twelve weeks to ensure that the care plans meet the needs of the resident and care plan interventions are followed. All monitoring will be received weekly by the Quality Assurance Committee for further recommendations if needed until substantial compliance is achieved. If at any time concerns are identified, a Quality Assurance Committee meeting will be convened to make further recommendations. The Quality Assurance Committee will consist of the Administrator, Director of Nursing, Social Services Director, Unit Managers for hall one and two, the Dietary Services Manager and the Medical Director attending at least quarterly. Failure to comply with any of the above will result in individual re-training and as appropriate disciplinary action. The Center alleges by the above actions that the immediate Jeopardy was abated for all residents on 12/20/13. **The State Survey Agency validated the corrective action taken by the facility as follows: Review of an in-service provided to the Administrator on 12/14/13 revealed the Administrator was inserviced on the Administration, Supervision and monitoring of system implementation to understand administrative duties and Federal regulations. The supervision of the DON and other direct reports and the method and frequency of system monitoring. Review of an in-service provided to nursing staff on 12/14/13 revealed it included physician notification regarding a resident change in condition, completion of appropriate nursing assessments and follow up, Interact Process review, notification of the physician, call the Medical Director if unable to reach the attending physician timely and to call 911 in an emergency, with no need to call the physician first. Review of the Regional Director Officer's education of the Administrator revealed the Administrator was educated on 12/14/13 related to monitoring the DON's supervision of the nursing staff to include guidance and direction for new nurses and follow up communication. Review of the Regional Nurse Consultant's re-education of the DON, ADON and Unit Managers for halls one and two on 12/14/13 revealed it included: the Interact Process, timely notification, using the Medical Director, and calling 911 if unable to follow physician orders. Review of all residents' assessments performed on 12/14/13 revealed an assessment was conducted which included vital signs and visual examinations. Physician notification was completed if needed for a change in condition by the DON, ADON and Unit Managers. The results were reviewed by the IDT. Review of inservices conducted on 12/14/13 revealed all staff received the inservices, except for two staff who were off for long extended times. The staff was inserviced by the DON on using the Interact Process and what to do if they were unable to reach the physician. Staff who had not completed the in-service will not work until the in-service has been completed. The Unit Manager on hall one, who is present at the start of each shift, will ensure no one works until they have been in-serviced. The Unit Manager on hall one begins each shift by providing education on the completion of appropriate nursing assessments. Review of the in-service that was provided to the DON on 12/19/13 by the Regional Nurse Consultant revealed it included IV insertion, emergency oxygen, and airway obstruction. The Unit Manager on hall one will ensure staff who have not completed the in-service will not work until in-serviced. Further review revealed all staff had been inserviced. Skills checks were also completed with staff related to IV insertion, emergency oxygen and airway obstruction. All staff scheduled to work after 7:00 PM Sunday had completed the skills check off. Interviews with LPN #1, LPN #2, LPN #3, LPN #4, LPN #5, RN #3 and RN #4 on 12/20/13 at 1:50 PM, 3:35 PM, 3:45 PM, and 4:10 PM, revealed they had been in-serviced related to residents' change in conditions, timely notification of the physician and/or the Medical Director, or to call 911 in an emergency. In addition, the staff revealed they were in-serviced on the Interact Process, accurate chart documentation, IV techniques and oxygen administration in an emergency. Interview with the DON, on 12/20/13 at 3:30 PM, revealed she was re-educated on 12/14/13 by the Regional Nurse Consultant which included educating the nurses to ensure they were comfortable with doing their job and completing their skills. In-services included education on documentation, emergency procedures, oxygen administration, physician notification, the Interact Process, and SBAR. The nurses were also strongly encouraged to not let these guidelines override their nursing judgement. The DON stated she will be more involved with nurses so she can identify their skill needs, and what education they may need. She stated the staff was instructed on timely notification, the Interact System, how to treat emergencies as emergencies and to err on the side of caution. The facility's expectation is for physician orders to be implemented and residents be sent out of the facility, if needed. Orders should be done timely and staff should be proactive and prevent emergencies instead of trying to hustle to get a resident out to the hospital. The assessment process should prevent those emergencies from happening. She stated she assisted the Assistant Director of Nursing and the Unit Manager and assessed all residents to ensure all needs were being met. Vital signs and visual assessments were completed, the information was documented, the charts were reviewed and compared with the care plans. All care plans were updated to ensure the residents' needs were being met. The Process now is to have a daily clinical meeting which includes (DON, ADON, and UM) to review new orders, care plans, and resident conditions. If needed, they will have an afternoon meeting to review anything that needed to be followed up on from the morning meeting. Any resident who had a significant change in the past thirty (30) days without physician notification had immediate physician notification. Further interview revealed medical records were reviewed on all residents for the last thirty (30) days beginning 12/14/13. All licensed staff was re-educated on the immediate notification of the physician with a sudden change in condition using the Interact Process, as a guide. If staff was unable to reach the physician, they may call the Medical Director. If the Medical Director doesn't answer within ten to fifteen minutes to send the resident out to the hospital. The Regional Nurse Consultant provided education to her and the acting ADON/UM for hall one. Education included the procedure for picking an IV site and insertion of the IV, follow up assessments every shift, signs and symptoms of infection, notification of the physician and documentation. Oxygen administration which included when to assess and apply, what to start the oxygen at, stay with the resident and to notify the physician to get a order. Competency validation with no staff working after 12/19/13 without having the education and the validated competency. A Quality Assurance meeting was held on 12/14/13, they discussed the concerns and issues with the Medical Director and began making plans of correction that included in-services and education, assessments of residents, updated care plans and significant changes that the physician would need to be notified about. She stated they were monitoring for corrective actions and it was her responsibility to monitor the Twenty Four Hour Reports daily and to call the facility three (3) times a day on each shift to speak with the nurses and get a report on their residents. She stated she reviewed orders and care plans daily in the clinical meeting and she was auditing all admissions. Further interview revealed she would audit five records daily right now to ensure everything was in place then will audit weekly. Monitoring was reviewed by the Quality Assurance team. Interview with the Administrator, on 12/20/13 at 4:10 PM, revealed he was re-educated by the Regional Director Officer on 12/14/13. His education included understanding administrative duties, federal regulations, supervision of the Director of Nursing and other direct reports. They also reviewed their method and frequency of system monitoring. He stated he educated the Director of Nursing which included supervision of nursing staff on guidance and direction for all nurses. The education also included information to follow up with and communicate with nursing staff. He reviewed the DON's administrative duties, supervision of direct reports and method and frequency of system monitoring. He stated he was involved in the Quality Assurance meeting on 12/14/13 with the IDT members and the Medical Director via a conference call. Further interview revealed he reviewed all findings of the Immediate Jeopardy survey and the abatement. He stated he was overseeing audits, twenty four hour reports, physician orders review and daily shift reviews for significant changes in conditions. He stated he is also speaking with all new nurses within thirty (30) days of hire; and, a total of five nurses per month for three months to ensure their training needs were being met and communication with the DON was open and appropriate.

Based on interview and review of the Minimum Data Set (MDS) assessment, nursing and Interdisciplinary Team Notes, physician's orders, Comprehensive Care Plan, hospital's Emergency Department Physician Chart, and Death Certificate it was determined the facility failed to provide care in accordance with the plan of care of one (1) of five (5) sampled residents (Resident #5). Registered Nurse (RN) #1 failed to monitor vital signs, monitor for signs and symptoms of dehydration, monitor for change in level of consciousness, monitor for shortness of breath, monitor for cyanosis, administer oxygen (O2) as needed, provide Meds/treatments as ordered, report adventitious breath sounds, and update the physician as needed per Resident #1's plan of care. On 11/29/13 when RN #1 came on duty at 7:00 PM she was made aware Resident #1 was a little lethargic and she needed to obtain urine for an Urinalysis because the physician thought the resident might have a Urinary Tract Infection [MEDICAL CONDITION]. ON 11/30/13 at 5:00 AM, the Certified Nurse Aide (CNA) reported to RN #1 that Resident #1 was not drinking, having diarrhea and hard to arouse. RN #1 looked in on the resident and obtained the resident's vital signs then called and left a message for the physician sometime between 5:30 AM-6:00 AM. At 6:00 AM, the physician called the facility and RN #1 received orders for a Complete Blood Count (CBC), Comprehensive Metabolic Profile (RCMP), Urinalysis (UA), chest x-ray, intravenous fluids (IV), Normal Saline at 90 cubic centimeters (cc) per hour (hr), and IV [MEDICATION NAME] (an antibiotic) 500 milligrams (mg) three times a day (TID); however, RN #1 failed to follow the care plan for meds/treatments as ordered as she did not initiate the IV per the physician's order. Further record review and interview revealed there was no documented evidence RN #1 monitored Resident #1's vital signs, monitored for signs and symptoms of dehydration, monitored for any further change in level of consciousness, monitored for shortness of breath, and obtained lung sounds per the resident's care plan from the time she came on duty on 11/29/13 at 7:00 PM until 11/30/13 at at 7:30 AM. Licensed Practical Nurse (LPN) #1 (the day shift nurse) arrived at the facility and when she entered Resident #1's room at 7:30 AM she noted Resident #1 was having difficulty breathing, the resident's feet, knees and hands were mottled and Resident #1 was not responding. LPN #1 initiated oxygen (02) at two (2) liters. The resident's blood pressure (B/P) was 55/24 (normal range is 120/70), O2 saturation was 81% (normal range 98-100%) before O2 started, Resident #1 was mouth breathing, pulse was 47 (normal range 70), respirations were 24 (normal 20), and temperature was 97.1 (normal 98.6). The physician was called and the resident was sent to the emergency room for evaluation. The resident was diagnosed with [REDACTED]. Resident #1 was admitted to the Intensive Care Unit, Coded and passed away at 4:42 PM. Review of the Resident #1's Death Certificate received 01/13/14, dated 12/16/13, revealed the immediate cause of death was Pneumonia, secondary to General Debility with the underlying cause of [MEDICAL CONDITION]. The facility's failure to provide care according to the plan of care has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 12/13/13, and was determined to exist on 11/30/13. The facility was notified of the Immediate Jeopardy on 12/13/13. An acceptable Allegation of Compliance (AoC) was received on 12/19/13 and the State Survey Agency validated the Immediate Jeopardy was removed on 12/20/13, as alleged. A partial extended survey was conducted on 12/20/13. The scope and severity was lowered to a "D" while the facility develops and implements the Plan of Correction (POC) and the facility's Quality Assurance monitors the effectiveness of the systemic changes. The findings include: Interview with the Director of Nursing (DON), on 01/21/14 at 4:10 PM revealed the facility did not have a policy/procedure that addressed the implementation of the care plan by staff. Record review revealed the facility admitted Resident #1 on 12/31/08 with [DIAGNOSES REDACTED]. Review of the MDS assessment, dated 10/07/13, revealed the facility assessed Resident #1's cognition as severely impaired. Review of Resident #1's Comprehensive Care Plan for Potential for Alteration in Oxygen Exchange and Infection related to history of pneumonia and [MEDICAL CONDITION], dated 04/16/13, revealed interventions to obtain vital signs as ordered/needed, monitor for signs of dehydration, monitor for change in level of consciousness, monitor for shortness of breath, monitor for cyanosis, lung sounds as ordered/needed, medications/treatments as ordered, report adventitious breath sounds, and update physician as needed. Interview with RN #1, on 12/10/13 at 12:42 PM, on 12/13/13 at 7:36 AM, and on 01/20/14 at 6:00 PM, revealed when she came on duty on 11/29/13 she was told in report that she needed to obtain a UA because Resident #1 was a little lethargic and might have a urinary tract infection. RN #1 stated she had not reviewed Resident #1's care plan but she told CNA #1 to push fluids throughout the night. RN #1 stated CNA #1 reported to her on 11/30/13 at approximately 5:00 AM that Resident #1 was not wanting to take fluids, was having diarrhea, and was not easily aroused. RN #1 stated she assessed Resident #1's vital signs and the resident's blood pressure was "eighty something over fifty something". However, there was no documented evidence RN #1 obtained the resident's vital signs per the plan of care. Per interview, RN #1 called the on-call physician and left a message between 5:30 AM and 6:00 AM. The physician called at 6:00 AM with orders for labs, an x-ray, IV fluids, and medications. However, there was no documented evidence RN #1 provided Resident #1 the medications and treatments ordered by the physician per the resident's plan of care. RN #1 stated she did not start the IV because "Resident #1 was dehydrated, wasn't drinking" and she did not have a lot of experience with starting an IV on someone that was dehydrated. However, per interview and record review, RN #1 failed to update the physician, per the plan of care, that she was unable to start the IV fluids. The RN stated she looked in on the resident around 6:30 AM and he/she was asleep. She stated the resident opened his/her eyes but RN #1 did not take his/her vital signs or assess the resident. Further record review which included the Nurses Notes and Interdisciplinary Team Notes, dated 11/29/13 and 11/30/13, revealed there was no documented evidence Resident #1's interventions related to the resident's history of pneumonia and [MEDICAL CONDITION] were implemented from 11/29/13 at 7:00 PM through 11/30/13 at 7:30 AM when LPN #1 (day shift nurse) went to Resident #1's room. Interview with LPN #1, on 12/10/13 at 10:30 AM and 12/12/13 at 4:10 PM, revealed when she entered Resident #1's room the resident was pale, was not responding to staff, and would moan when touched. The resident's vital signs were abnormal and the resident's extremities were mottling. She stated the resident's O2 sat was 81%, so she obtained an oxygen (O2) concentrator and placed the resident on O2 at two (2) liters per minute per nasal cannula. LPN #1 stated she called the physician at approximately 7:30 AM to send the resident to the hospital with no response and she called the physician again at 8:00 AM-8:15 AM and received an order to send the resident to the hospital for evaluation. Review of a Interdisciplinary Team Note, dated 11/30/13 at 1:13 PM, revealed at 7:30 AM, LPN #1 (day shift nurse) entered Resident #1's room and noted Resident #1 was having difficulty breathing, the resident's feet, knees and hands were mottled, and the resident was not responding. The resident's blood pressure (B/P) was 55/24, O2 saturation was 81% before O2 was started and the resident was mouth breathing. LPN #2 placed the resident on oxygen per nasal cannula and LPN #2 (day shift nurse) initiated the IV in the resident's right arm and administered Normal Saline at 90 cc's an hour. The resident's pulse was 47, respirations 24, and temperature was 97.1 degrees Fahrenheit. The physician was called and advised of Resident #1's condition and code status. The Physician stated to send Resident #1 to the emergency room for evaluation. Review of the Hospital Emergency Department Physician Chart, dated 11/30/13, revealed Resident #1 was diagnosed with [REDACTED]. Review of the Resident #1's Death Certificate, dated 12/16/13, revealed the immediate cause of death was Pneumonia, secondary to General Debility with the underlying cause of [MEDICAL CONDITION]. Interview with the DON, on 01/21/14 at 10:28 AM, revealed she expected the nurse to follow the care plan. **The facility implemented the following actions to remove the Immediate Jeopardy: On 12/14/13, the Regional Director of Operations re-educated the Administrator related to the responsibility of the Administrator to oversee the facility in accordance with Federal regulations to include monitoring of the Director of Nursing related to the supervision of nursing staff. On 12/14/13, the Administrator re-educated the Director of Nursing on the requirements to supervise nursing staff to include guidance and direction for new nurses as well as follow up questions in communications with the nursing staff. On 12/14/13, the Regional Nurse Consultant re-educated the Director of Nursing, Assistant Director of Nursing and Unit Managers for hall one and two on the Interact Process, timely notification of the physician and using the Medical Director if unable to reach the attending physician timely including calling 911 in an emergency situation. The Interact Process is an evidence based practice program developed at the request of the Centers for Medicaid and Medicare Services to reduce unnecessary return hospitalization s. The Regional Nurse Consultant also re-educated the Director of Nursing, Assistant Director of Nursing and Unit Managers for units one and two on notification of the physician if the nurse was unable to follow MD orders in a timely manner. It includes suggestions for nurses on when to notify the physician and what recommendations for treatments to make, but does not override the judgement of the nurse at bedside. Resident #1 was discharged from the facility on 11/30/13. All Current residents of the facility have been reviewed by the Interdisciplinary Team (IDT) to include the Director of Nursing, Unit Managers for halls one and two, Assistant Director of Nursing, MDS Coordinator and Social Services Director, to assure that any current resident who is experiencing a significant change in condition had physician notification. Any resident who was deemed to have had a significant change in condition in the past thirty (30) days without physician notification had immediate physician notification. This review included a set of vital signs and visual examination of the resident for apparent acute distress by the Director of Nursing, Assistant Director of Nursing or Unit Managers; and, a review of the medical record for the past thirty (30) days by the IDT. This was completed on 12/14/13. The IDT, which included the Director of Nursing, Unit Managers, MDS Coordinator and Social Services Director, reviewed all current residents' care plans on 12/14/13 to assure that the care plan was up to date and met the needs of the resident, and that the care plan interventions were in place. Any resident whose care plan was not up to date to meet the needs of the resident had the care plan updated. Any interventions not in place were implemented. Beginning 12/14/13, all licensed staff was re-educated on immediate notification of the physician with a significant change in condition using the Interact Process as a guideline, but not to supercede the judgement of the nurse in attendance. In addition, the education included notification of the Medical Director if they were unable to reach the attending physician timely. This re-education was completed by the Director of Nursing, Assistant Director of Nursing or Unit Manager for hall number one. No licensed staff will work after 12/14/13 without having received this education. Beginning on 12/14/13, all licensed staff was re-educated on the completion of appropriate nursing assessments with follow up based upon the resident's condition with examples of abnormal vital signs, respiratory and gastro-intestinal using the Interact guidelines and pathways as a guide, not to supercede the judgement of the nurses in attendance. This re-education was completed by the Director of Nursing, Assistant Director of Nursing or Unit Manager for hall number one. No licensed staff will work after 12/14/13 without having received this re-education. On 12/14/13, the Regional Nurse Consultant will provide education to the Director of Nursing and the Unit Manager for hall one related to skill procedures for IV insertion, emergency oxygen administration, and airway obstruction with competency testing. The Director of Nursing or Unit Manager for hall one will provide training to all licensed nurses on IV insertion, emergency oxygen administration and airway obstruction with competency testing. No staff will work after 12/19/13, without having received this education and validation competency. An Ad Hoc Quality Assurance Committee meeting (QPI) was held on 12/14/13 to review the alleged deficient practice as well as the plan for removal to include audits for care plans and care plan interventions to assure care plans meet the needs of the residents and interventions are followed, and all training material presented to licensed staff. The discussion also included training completed for the Administrator and the Director of Nursing and how the facility will monitor corrective actions. In attendance was the Administrator, the Director of Nursing, the Assistant Director of Nursing, Unit Manager, MDS Nurse and the Social Service Director. The Medical Director attended via conference call. No further recommendations were made by the committee. The Quality Assurance Committee will meet weekly to review the removal plan as well as monitoring of actions weekly until substantial compliance is achieved. Monitoring of the allegation of compliance will be conducted by doing the following: The Director of Nursing or Unit Manager for hall one will review the Twenty Four Hour Report and all physician orders daily for two weeks, followed by five times a week for at least ten weeks to assure all changes in condition had appropriate physician notification, assessment and follow up. In addition, the Director of Nursing, Assistant Director of Nursing or Unit Manager for hall one will contact the facility once each shift to review with each nurse any significant changes in resident condition to assure licensed staff are assessing and notifying the physician timely. This will occur daily for two weeks, followed by five times per week for at least ten weeks on each shift. The Administrator will speak with all new nurses within the first thirty (30) days of employment and at least five nurses per month for three months to assure training needs are met as well as to assure communication with the Director of Nursing is open and appropriate. The Director of Nursing will audit five resident records per week for twelve weeks to ensure that the care plans meet the needs of the resident and care plan interventions are followed. All monitoring will be received weekly by the Quality Assurance Committee for further recommendations if needed until substantial compliance is achieved. If at any time concerns are identified, a Quality Assurance Committee meeting will be convened to make further recommendations. The Quality Assurance Committee will consist of the Administrator, Director of Nursing, Social Services Director, Unit Managers for hall one and two, the Dietary Services Manager and the Medical Director attending at least quarterly. Failure to comply with any of the above will result in individual re-training and as appropriate disciplinary action. The Center alleges by the above actions that the immediate Jeopardy was abated for all residents on 12/20/13. **The State Survey Agency validated the corrective action taken by the facility as follows: Review of an in-service provided to the Administrator on 12/14/13 revealed the Administrator was inserviced on the Administration, Supervision and monitoring of system implementation to understand administrative duties and Federal regulations. The supervision of the DON and other direct reports and the method and frequency of system monitoring. Review of an in-service provided to nursing staff on 12/14/13 revealed it included physician notification regarding a resident change in condition, completion of appropriate nursing assessments and follow up, Interact Process review, notification of the physician, call the Medical Director if unable to reach the attending physician timely and to call 911 in an emergency, with no need to call the physician first. Review of the Regional Director Officer's education of the Administrator revealed the Administrator was educated on 12/14/13 related to monitoring the DON's supervision of the nursing staff to include guidance and direction for new nurses and follow up communication. Review of the Regional Nurse Consultant's re-education of the DON, ADON and Unit Managers for halls one and two on 12/14/13 revealed it included: the Interact Process, timely notification, using the Medical Director, and calling 911 if unable to follow physician orders. Review of all residents' assessments performed on 12/14/13 revealed an assessment was conducted which included vital signs and visual examinations. Physician notification was completed if needed for a change in condition by the DON, ADON and Unit Managers. The results were reviewed by the IDT. Review of inservices conducted on 12/14/13 revealed all staff received the inservices, except for two staff who were off for long extended times. The staff was inserviced by the DON on using the Interact Process and what to do if they were unable to reach the physician. Staff who had not completed the in-service will not work until the in-service has been completed. The Unit Manager on hall one, who is present at the start of each shift, will ensure no one works until they have been in-serviced. The Unit Manager on hall one begins each shift by providing education on the completion of appropriate nursing assessments. Review of the in-service that was provided to the DON on 12/19/13 by the Regional Nurse Consultant revealed it included IV insertion, emergency oxygen, and airway obstruction. The Unit Manager on hall one will ensure staff who have not completed the in-service will not work until in-serviced. Further review revealed all staff had been inserviced. Skills checks were also completed with staff related to IV insertion, emergency oxygen and airway obstruction. All staff scheduled to work after 7:00 PM Sunday had completed the skills check off. Interviews with LPN #1, LPN #2, LPN #3, LPN #4, LPN #5, RN #3 and RN #4 on 12/20/13 at 1:50 PM, 3:35 PM, 3:45 PM, and 4:10 PM, revealed they had been in-serviced related to residents' change in conditions, timely notification of the physician and/or the Medical Director, or to call 911 in an emergency. In addition, the staff revealed they were in-serviced on the Interact Process, accurate chart documentation, IV techniques and oxygen administration in an emergency. Interview with the DON on 12/20/13 at 3:30 PM, revealed she was re-educated on 12/14/13 by the Regional Nurse Consultant which included educating the nurses to ensure they were comfortable with doing their job and completing their skills. In-services included education on documentation, emergency procedures, oxygen administration, physician notification, the Interact Process, and SBAR. The nurses were also strongly encouraged to not let these guidelines override their nursing judgement. The DON stated she will be more involved with nurses so she can identify their skill needs, and what education they may need. She stated the staff was instructed on timely notification, the Interact System, how to treat emergencies as emergencies and to err on the side of caution. The facility's expectation is for physician orders to be implemented and residents be sent out of the facility, if needed. Orders should be done timely and staff should be proactive and prevent emergencies instead of trying to hustle to get a resident out to the hospital. The assessment process should prevent those emergencies from happening. She stated she assisted the Assistant Director of Nursing and the Unit Manager and assessed all residents to ensure all needs were being met. Vital signs and visual assessments were completed, the information was documented, the charts were reviewed and compared with the care plans. All care plans were updated to ensure the residents' needs were being met. The Process now is to have a daily clinical meeting which includes (DON, ADON, and UM) to review new orders, care plans, and resident conditions. If needed, they will have an afternoon meeting to review anything that needed to be followed up on from the morning meeting. Any resident who had a significant change in the past thirty (30) days without physician notification had immediate physician notification. Further interview revealed medical records were reviewed on all residents for the last thirty (30) days beginning 12/14/13. All licensed staff was re-educated on the immediate notification of the physician with a sudden change in condition using the Interact Process, as a guide. If staff was unable to reach the physician, they may call the Medical Director. If the Medical Director doesn't answer within ten to fifteen minutes to send the resident out to the hospital. The Regional Nurse Consultant provided education to her and the acting ADON/UM for hall one. Education included the procedure for picking an IV site and insertion of the IV, follow up assessments every shift, signs and symptoms of infection, notification of the physician and documentation. Oxygen administration which included when to assess and apply, what to start the oxygen at, stay with the resident and to notify the physician to get a order. Competency validation with no staff working after 12/19/13 without having the education and the validated competency. A Quality Assurance meeting was held on 12/14/13, they discussed the concerns and issues with the Medical Director and began making plans of correction that included in-services and education, assessments of residents, updated care plans and significant changes that the physician would need to be notified about. She stated they were monitoring for corrective actions and it was her responsibility to monitor the Twenty Four Hour Reports daily and to call the facility three (3) times a day on each shift to speak with the nurses and get a report on their residents. She stated she reviewed orders and care plans daily in the clinical meeting and she was auditing all admissions. Further interview revealed she would audit five records daily right now to ensure everything was in place then will audit weekly. Monitoring was reviewed by the Quality Assurance team. Interview with the Administrator on 12/20/13 at 4:10 PM, revealed he was re-educated by the Regional Director Officer on 12/14/13. His education included understanding administrative duties, federal regulations, supervision of the Director of Nursing and other direct reports. They also reviewed their method and frequency of system monitoring. He stated he educated the Director of Nursing which included supervision of nursing staff on guidance and direction for all nurses. The education also included information to follow up with and communicate with nursing staff. He reviewed the DON's administrative duties, supervision of direct reports and method and frequency of system monitoring. He stated he was involved in the Quality Assurance meeting on 12/14/13 with the IDT members and the Medical Director via a conference call. Further interview revealed he reviewed all findings of the Immediate Jeopardy survey and the abatement. He stated he was overseeing audits, twenty four hour reports, physician orders review and daily shift reviews for significant changes in conditions. He stated he is also speaking with all new nurses within thirty (30) days of hire; and, a total of five nurses per month for three months to ensure their training needs were being met and communication with the DON was open and appropriate.

Based on interview and review of the Minimum Data Set (MDS) assessment, physician's orders, Comprehensive Care Plan, nursing and Interdisciplinary Team Notes, resident transfer form, Ambulance Service Run Report, hospital physical, laboratory reports, hospital Emergency Department Physician Chart, Death Certificate and facility policy/procedure it was determined the facility failed to provide the necessary care and services to attain or maintain the highest practical physical, mental, and psychosocial well being, in accordance with the comprehensive assessment and plan of care for one (1) of five (5) sampled residents (Resident #1). On 11/29/13, when Registered Nurse (RN) #1 came on duty at 7:00 PM, she was made aware Resident #1 was a little lethargic and she needed to obtain a Urinalysis because the physician thought he/she might have a Urinary Tract Infection [MEDICAL CONDITION]. On 11/30/13 at approximately 5:00 AM, a Certified Nurse Aide (CNA) reported to RN #1 that Resident #1 was having diarrhea, did not want to drink and would not arouse easily. RN #1 assessed the resident and called the physician and left a message at approximately 5:30-6:00 AM. RN #1 proceeded to administer other residents' medication while she waited for the return call from the physician. The physician called at 6:00 AM with orders for a Complete Blood Count (CBC), Comprehensive Metabolic Profile (CMP), Urinalysis (UA), chest x-ray, Intravenous Fluids (IV) Normal Saline at 90 cubic centimeters (cc) per hour (hr), and IV [MEDICATION NAME] (antibiotic) 500 milligrams (mg) three times a day (TID). RN #1 failed to provide care according to the care plan related to the physician's orders for the IV which was in the scope of practice of an RN and failed to notify the physician she was unable to initiate the IV. In addition, there was no evidence the RN provided the care and services related to conducting ongoing assessments and monitoring of the resident from 11/29/13 at 7:00 PM when she was made aware of the resident's condition until 11/30/13 at 7:30 AM when the day shift nurse arrived. When Licensed Practical Nurse (LPN) #1 (day shift nurse) went to the resident's room at 7:30 AM to carry out the physician's orders, she noted Resident #1 was having difficulty breathing, the resident's feet, knees and hands were mottled and Resident #1 was not responding. The nurse initiated oxygen (02) at two (2) liters and conducted an in and out catheterization for urine for the UA. The nurse obtained approximately five to seven cc's of dark tea colored urine. The resident's blood pressure (B/P) was 55/24 (normal range: 120/70), O2 saturation was 81% (normal range: 98-100%) before O2 started, Resident #1 was mouth breathing, pulse was 47 (normal range: 70), respirations were 24 (normal range: 20), and temperature was 97.1 (normal range: 98.7). LPN #2 initiated the IV per the physician's order. The physician was called at 7:30 AM for orders to send the resident to the hospital with no response from the physician. LPN #1 did not call the physician back until 8:00-8:15 AM with orders received to send the resident to the emergency room for evaluation at that time. Resident #1 was diagnosed with [REDACTED]. Resident #1 was admitted to the Intensive Care Unit, coded and passed away at 4:42 PM. Refer to F157, F281 and F282. The facility's failure to provide the necessary care and services to attain or maintain the highest practical physical, mental and psychosocial well being in accordance with the comprehensive assessment and care plan has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 12/13/13, and was determined to exist on 11/30/13. The facility was notified of the Immediate Jeopardy on 12/13/13. An acceptable Allegation of Compliance (AoC) was received on 12/19/13 and the State Survey Agency validated the Immediate Jeopardy was removed on 12/20/13, as alleged. A partial extended survey was conducted on 12/20/13. The scope and severity was lowered to a "D" while the facility develops and implements the Plan of Correction (POC) and the facility's Quality Assurance monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy and procedure "Change in Condition", dated 01/11, revealed a change of condition in a resident should target many areas of the Interdisciplinary Team (IDT) function. To ensure the optimal outcome for the resident, the nursing process of Assessment, Plan, Intervention, and Evaluation will be used. Physician involvement is always required, as is follow-up assessment per Federal Guidelines. Process: Interact 11 system is to be used with this protocol. Change in condition Assessment Guidelines will be followed by the licensed nurse for the initial, and when necessary the follow-up assessment to detect change in condition by symptoms and categories. Interact tool "Immediate Notification" revealed any symptom, sign or apparent discomfort that is acute or sudden in onset, and a marked change (more severe) in relation to usual symptoms and signs, or unrelieved by measures already prescribed. All information triggers in this reference will be used when notifying the physician. A Situation-Background-Assessment/Appearance Request (SBAR) form is to be used for documentation prior to notifying the physician. This form will contain information gathered when doing an assessment and is to be utilized as a Nursing Note in the medical record. Notification of Resident Change in Condition: Clinicians will immediately consult with the resident's physician when there is a significant change in condition. Document in the Nurses' Notes the times notification was made and the names of the person(s) to whom you spoke. Record review revealed the facility admitted Resident #1 on 12/31/08 with [DIAGNOSES REDACTED]. Review of the MDS assessment, dated 10/07/13, revealed the facility assessed Resident #1's cognition as severely impaired. Review of the physician orders, dated 11/01/13 through 11/30/13, revealed Resident #1 was a full code. Review of Resident #1's Comprehensive Care Plan for Potential for Oxygen Exchange, Infection related to incontinence and Nutritional Risk, dated 10/10/13, revealed interventions to obtain vital signs as ordered/needed, O2 as ordered/needed, encourage fluid intake, monitor for signs of dehydration, monitor for change in level of consciousness, monitor for shortness of breath, monitor for cyanosis, lung sound as ordered/needed, Meds/treatments as ordered, report adventitious breath sounds, and update physician as needed. Interview with CNA #1, on 12/13/13 at 7:05 AM, revealed she reported to RN #1, on 11/30/13 at approximately 5:00 AM, Resident #1 was having diarrhea, did not want to drink anything, and was not easily aroused. Record review revealed no documented evidence a Situation-Background-Assessment/Appearance Request was completed by RN #1 related to any assessments of Resident #1 by the nurse when a change in condition was identified. Review of a telephone physician order, dated 11/30/13 at 6:00 AM, revealed an order for [REDACTED]. Interview with RN #1, on 12/10/13 at 12:42 PM, on 12/13/13 at 7:36 AM, and on 01/20/14 at 6:00 PM revealed when she reported to work on 11/29/13 at 7:00 PM, the off going nurse told her that Resident #1 was a little lethargic and she needed to obtain a Urinalysis because the physician thought he/she might have a Urinary Tract Infection [MEDICAL CONDITION]. She stated she instructed the CNA to push fluids. At 5:00 AM, CNA #1 reported that Resident #1 was having diarrhea and not wanting to take fluids. RN #1 stated around 5:00 AM she assessed Resident #1's vital signs and the resident's blood pressure was "eighty something over fifty something". RN #1 stated she documented the assessment and vital signs on a note pad and threw the note away without documenting the information in the resident's records. She stated she was not aware of the Interact process and did not complete a SBAR per the facility's policy. RN #1 called the on-call physician and left a message between 5:30 AM and 6:00 AM. RN #1 revealed she then administered the morning medications to other residents until the physician called at 6:00 AM with orders for labs, an x-ray, IV fluids and medications. The RN stated she did not start the IV because "Resident #1 was dehydrated, wasn't drinking" and she did not have a lot of experience with starting an IV on someone that was dehydrated. Another reason she did not start the IV was due to not having "good feeling" in her fingertips. She stated she had started IV's in the facility in the past but she always had another nurse with her. She stated she asked for assistance a few different times during her shift from RN #2; however, RN #2 could not help due to having issues going on with her residents and she was in the middle of a medication pass. She stated she did not notify the physician she was unable to start the IV fluids. The RN stated everything was happening around 5:00 - 5:30 AM, and she felt overwhelmed. She stated after she received the physician's order at 6:00 AM, she called the Director of Nursing (DON), who was on call after 6:00 AM, to let her know Resident #1 had a change in condition and what the physician ordered. She stated she knew the day shift nurse would be coming in and she told the DON she would ask for help with the IV when the nurse got there. She stated she continued to work on passing her medications. She stated when the day shift LPN (LPN #2) arrived, she flagged her down and told her she needed help to start an IV. LPN #2 then clocked in and started the IV. Interview with LPN #2, on 12/10/13 at 11:47 AM and on 12/12/13 at 4:50 PM revealed she was asked by RN #1 to start Resident #1's IV because RN #1 didn't think she could start it since the resident was dehydrated. She stated she gathered the supplies and started Resident #1's IV around 7:00 AM. Resident #1 did not look good, his/her eyes were sunken and looked dehydrated. She stated she filled out the transfer form around 8:00 AM and the vitals signs and an assessment were conducted before the resident was transferred to the hospital. She stated LPN #1 called the physician and Resident #1 was sent out. Review of an Interdisciplinary Team Note, dated 11/30/13 at 1:13 PM, revealed at 7:30 AM, LPN #1 (day shift nurse) called the mobile x-ray agency for a stat chest x-ray. When LPN #1 entered the resident's room to catheterize Resident #1 to obtain the UA, she observed Resident #1 was having difficulty breathing, the resident's feet, knees and hands were mottled, and the resident was not responding. LPN #1 initiated O2 at two (2) liters, and obtained urine with an in and out catheter. She was able to obtain approximately five (5) to seven (7) cc's of dark tea colored urine. The resident's blood pressure (B/P) was 55/24, O2 saturation was 81% before O2 was started and the resident was mouth breathing. LPN #2 initiated the IV in the resident's right arm and administered Normal Saline at 90 cc's an hour. The resident's pulse was 47, respirations 24, and temperature was 97.1 degrees Fahrenheit. The physician was called and advised of Resident #1's condition and code status. The Physician stated to send Resident #1 to the emergency room for evaluation. Interview with LPN #1, on 12/10/13 at 10:30 AM and 12/12/13 at 4:10 PM, revealed she walked in at shift change and was told an IV needed to be started. She stated RN #1 told her Resident #1 wasn't doing well. She stated she could see RN #1 was really overwhelmed, behind and she started helping. She stated when she entered Resident #1's room she noted Resident #1 was pale, was not responding to staff, and would moan when touched. She stated the resident's vital signs were abnormal and the resident's extremities were mottling. She stated the resident's O2 sat was 81%, so she obtained an oxygen (O2) concentrator and placed the resident on O2 at two (2) liters per minute per nasal cannula. LPN #1 stated she called the physician at approximately 7:30 AM to send the resident to the hospital with no response and she called the physician again at 8:00 AM-8:15 AM and received an order to send the resident to the hospital for evaluation. Review of the physician telephone order, dated 11/30/13 at 8:15 AM, revealed an order to send Resident #1 to the emergency room (ER) for evaluation. Review of a transfer form, dated 11/30/13 (no time) filled out by LPN #1, revealed the reason for transfer was decreased oxygen saturation, B/P 63/25, pulse 0-43, O2 sat 72%, mottling of hands, feet and knees, and dehydration. An IV of normal saline was started at 7:00 AM at 90 ccs per hour. The Physician was notified of Resident #1's change in condition and oxygen saturation continued dropping. Review of the Ambulance Service Run Report and narrative, dated 11/30/13, revealed a call was received from the facility at 8:22 AM with the chief complaint that Resident #1 was unresponsive. The ambulance arrived at the facility at 8:28 AM and the attendants were at Resident #1's side at 8:30 AM. Initial assessment revealed Resident #1 was unresponsive, cold and pale, the left and right pupil were 2-mm non-reactive, lung sounds of the left and right upper and lower lungs were decreased, and the resident was incontinent with diarrhea. The resident's brachial pulse, femoral pulse, pedal pulse and radial pulse were absent. The facility staff had started O2 and an IV 24 gauge with normal saline was in place but was not running. The resident was unresponsive and nursing staff was at bedside. Vital signs were checked, they were unable to obtain B/P, the carotid pulse was present but very weak. They were unable to obtain SPO2 (oxygen saturation) due to cold extremities. They increased O2 to non rebreather mask at 15 liters per minute. They established IV 20 ga to left forearm with Normal saline 0.9% initiated at open rate. They established a second IV to the left anticubal with Normal saline 0.9% at open rate. The resident's skin was pale, cool and dry with poor skin turgor. Respirations were shallow and rapid, lung sounds were diminished in both upper and lower lobes. They were unable to palpate distal pulses. Review of the hospital physical, dated 11/20/13 at 8:30 AM, revealed Resident #1 had dry mucus membranes, was hypoxic (lack of oxygen), pale and unresponsive. Review of the Hospital Laboratory Report, dated 11/30/13 at 9:00 AM, revealed Resident #1's BUN (Blood, Urea, Nitrogen) was 149 (reference range 7-18) and Creatinine 7.6 (reference range 0.8-1.4). Review of the Hospital Emergency Department Physician charting, dated 11/30/13, revealed Resident #1 was diagnosed with [REDACTED]. Interview with the Hospital Social Worker, on 12/10/13 at 9:03 AM, revealed the resident was admitted to the Intensive Care Unit, Coded and passed away at 4:42 PM. Review of Resident #1's Death Certificate received 01/13/14, dated 12/16/13, revealed the immediate cause of death was Pneumonia, secondary to General Debility with the underlying cause of [MEDICAL CONDITION]. Interview with Resident #1's physician, on 12/10/13 at 3:56 PM, revealed Resident #1 had diarrhea with a blood pressure that had dropped. Resident #1 was intubated due to respiratory distress and he/she had pneumonia. Interview with the Director of Nursing (DON), on 12/11/13 at 2:15 PM, on 12/12/13 at 5:15 PM; and, on 12/13/13 at 3:05 PM, revealed if the nurse was unable to reach a provider, the nurse should re-call the physician and should try again within thirty (30) minutes. She stated there was no policy with a specific time, nursing was to use their judgement. She stated there was no documentation as to the time the physician was called. The DON revealed she would have expected the nurse to initiate the IV immediately. The DON stated she was on call and the nurses call whoever is on call related to any incidents, changes in condition and keep them updated on what is going on in the home. She stated when RN #1 called her the second time she was preparing to come in to the facility and she got to the facility at 9:00 AM. She stated the nurses can call administrative staff anytime they have issues and we will come in. The DON stated she did not feel like she needed to hurry up and go in. She stated RN #1 could have asked RN #2 to assist, called the IV Team or sent Resident #1 to the hospital. She stated she was not sure if RN #1 asked for assistance to start the IV. She stated she received a call from RN #1 at 6:30 AM with an update about transfers and the RN had told her Resident #1 wasn't doing well. RN #1 stated she had received orders from the physician for an IV, stat labs and chest x-ray, UA and antibiotics. The DON stated RN #1 never said she was overwhelmed and needed help. The DON stated she did not ask RN #1 if she needed help. She stated she then received a call around 8:00 AM to 8:45 AM about Resident #1 being sent out per 911 emergency from LPN #1. The DON revealed RN #1 was a fairly new nurse and had worked at the facility six to seven months. She stated RN #1 had completed orientation; however; there was no competency for IV's. She stated the RN was trained on the Interact system and how to use the SBAR to document resident assessment findings so when the physician was called the information could be relayed to the physician. **The facility implemented the following actions to remove the Immediate Jeopardy: On 12/14/13, the Regional Director of Operations re-educated the Administrator related to the responsibility of the Administrator to oversee the facility in accordance with Federal regulations to include monitoring of the Director of Nursing related to the supervision of nursing staff. On 12/14/13, the Administrator re-educated the Director of Nursing on the requirements to supervise nursing staff to include guidance and direction for new nurses as well as follow up questions in communications with the nursing staff. On 12/14/13, the Regional Nurse Consultant re-educated the Director of Nursing, Assistant Director of Nursing and Unit Managers for hall one and two on the Interact Process, timely notification of the physician and using the Medical Director if unable to reach the attending physician timely including calling 911 in an emergency situation. The Interact Process is an evidence based practice program developed at the request of the Centers for Medicaid and Medicare Services to reduce unnecessary return hospitalization s. The Regional Nurse Consultant also re-educated the Director of Nursing, Assistant Director of Nursing and Unit Managers for units one and two on notification of the physician if the nurse was unable to follow MD orders in a timely manner. It includes suggestions for nurses on when to notify the physician and what recommendations for treatments to make, but does not override the judgement of the nurse at bedside. Resident #1 was discharged from the facility on 11/30/13. All Current residents of the facility have been reviewed by the Interdisciplinary Team (IDT) to include the Director of Nursing, Unit Managers for halls one and two, Assistant Director of Nursing, MDS Coordinator and Social Services Director, to assure that any current resident who is experiencing a significant change in condition had physician notification. Any resident who was deemed to have had a significant change in condition in the past thirty (30) days without physician notification had immediate physician notification. This review included a set of vital signs and visual examination of the resident for apparent acute distress by the Director of Nursing, Assistant Director of Nursing or Unit Managers; and, a review of the medical record for the past thirty (30) days by the IDT. This was completed on 12/14/13. The IDT, which included the Director of Nursing, Unit Managers, MDS Coordinator and Social Services Director, reviewed all current residents' care plans on 12/14/13 to assure that the care plan was up to date and met the needs of the resident, and that the care plan interventions were in place. Any resident whose care plan was not up to date to meet the needs of the resident had the care plan updated. Any interventions not in place were implemented. Beginning 12/14/13, all licensed staff was re-educated on immediate notification of the physician with a significant change in condition using the Interact Process as a guideline, but not to supercede the judgement of the nurse in attendance. In addition, the education included notification of the Medical Director if they were unable to reach the attending physician timely. This re-education was completed by the Director of Nursing, Assistant Director of Nursing or Unit Manager for hall number one. No licensed staff will work after 12/14/13 without having received this education. Beginning on 12/14/13, all licensed staff was re-educated on the completion of appropriate nursing assessments with follow up based upon the resident's condition with examples of abnormal vital signs, respiratory and gastro-intestinal using the Interact guidelines and pathways as a guide, not to supercede the judgement of the nurses in attendance. This re-education was completed by the Director of Nursing, Assistant Director of Nursing or Unit Manager for hall number one. No licensed staff will work after 12/14/13 without having received this re-education. On 12/14/13, the Regional Nurse Consultant will provide education to the Director of Nursing and the Unit Manager for hall one related to skill procedures for IV insertion, emergency oxygen administration, and airway obstruction with competency testing. The Director of Nursing or Unit Manager for hall one will provide training to all licensed nurses on IV insertion, emergency oxygen administration and airway obstruction with competency testing. No staff will work after 12/19/13, without having received this education and validation competency. An Ad Hoc Quality Assurance Committee meeting (QPI) was held on 12/14/13 to review the alleged deficient practice as well as the plan for removal to include audits for care plans and care plan interventions to assure care plans meet the needs of the residents and interventions are followed, and all training material presented to licensed staff. The discussion also included training completed for the Administrator and the Director of Nursing and how the facility will monitor corrective actions. In attendance was the Administrator, the Director of Nursing, the Assistant Director of Nursing, Unit Manager, MDS Nurse and the Social Service Director. The Medical Director attended via conference call. No further recommendations were made by the committee. The Quality Assurance Committee will meet weekly to review the removal plan as well as monitoring of actions weekly until substantial compliance is achieved. Monitoring of the allegation of compliance will be conducted by doing the following: The Director of Nursing or Unit Manager for hall one will review the Twenty Four Hour Report and all physician orders daily for two weeks, followed by five times a week for at least ten weeks to assure all changes in condition had appropriate physician notification, assessment and follow up. In addition, the Director of Nursing, Assistant Director of Nursing or Unit Manager for hall one will contact the facility once each shift to review with each nurse any significant changes in resident condition to assure licensed staff are assessing and notifying the physician timely. This will occur daily for two weeks, followed by five times per week for at least ten weeks on each shift. The Administrator will speak with all new nurses within the first thirty (30) days of employment and at least five nurses per month for three months to assure training needs are met as well as to assure communication with the Director of Nursing is open and appropriate. The Director of Nursing will audit five resident records per week for twelve weeks to ensure that the care plans meet the needs of the resident and care plan interventions are followed. All monitoring will be received weekly by the Quality Assurance Committee for further recommendations if needed until substantial compliance is achieved. If at any time concerns are identified, a Quality Assurance Committee meeting will be convened to make further recommendations. The Quality Assurance Committee will consist of the Administrator, Director of Nursing, Social Services Director, Unit Managers for hall one and two, the Dietary Services Manager and the Medical Director attending at least quarterly. Failure to comply with any of the above will result in individual re-training and as appropriate disciplinary action. The Center alleges by the above actions that the immediate Jeopardy was abated for all residents on 12/20/13. **The State Survey Agency validated the corrective action taken by the facility as follows: Review of an in-service provided to the Administrator on 12/14/13 revealed the Administrator was inserviced on the Administration, Supervision and monitoring of system implementation to understand administrative duties and Federal regulations. The supervision of the DON and other direct reports and the method and frequency of system monitoring. Review of an in-service provided to nursing staff on 12/14/13 revealed it included physician notification regarding a resident change in condition, completion of appropriate nursing assessments and follow up, Interact Process review, notification of the physician, call the Medical Director if unable to reach the attending physician timely and to call 911 in an emergency, with no need to call the physician first. Review of the Regional Director Officer's education of the Administrator revealed the Administrator was educated on 12/14/13 related to monitoring the DON's supervision of the nursing staff to include guidance and direction for new nurses and follow up communication. Review of the Regional Nurse Consultant's re-education of the DON, ADON and Unit Managers for halls one and two on 12/14/13 revealed it included: the Interact Process, timely notification, using the Medical Director, and calling 911 if unable to follow physician orders. Review of all residents' assessments performed on 12/14/13 revealed an assessment was conducted which included vital signs and visual examinations. Physician notification was completed if needed for a change in condition by the DON, ADON and Unit Managers. The results were reviewed by the IDT. Review of inservices conducted on 12/14/13 revealed all staff received the inservices, except for two staff who were off for long extended times. The staff was inserviced by the DON on using the Interact Process and what to do if they were unable to reach the physician. Staff who had not completed the in-service will not work until the in-service has been completed. The Unit Manager on hall one, who is present at the start of each shift, will ensure no one works until they have been in-serviced. The Unit Manager on hall one begins each shift by providing education on the completion of appropriate nursing assessments. Review of the in-service that was provided to the DON on 12/19/13 by the Regional Nurse Consultant revealed it included IV insertion, emergency oxygen, and airway obstruction. The Unit Manager on hall one will ensure staff who have not completed the in-service will not work until in-serviced. Further review revealed all staff had been inserviced. Skills checks were also completed with staff related to IV insertion, emergency oxygen and airway obstruction. All staff scheduled to work after 7:00 PM Sunday had completed the skills check off. Interviews with LPN #1, LPN #2, LPN #3, LPN #4, LPN #5, RN #3 and RN #4 on 12/20/13 at 1:50 PM, 3:35 PM, 3:45 PM, and 4:10 PM, revealed they had been in-serviced related to residents' change in conditions, timely notification of the physician and/or the Medical Director, or to call 911 in an emergency. In addition, the staff revealed they were in-serviced on the Interact Process, accurate chart documentation, IV techniques and oxygen administration in an emergency. Interview with the DON on 12/20/13 at 3:30 PM, revealed she was re-educated on 12/14/13 by the Regional Nurse Consultant which included educating the nurses to ensure they were comfortable with doing their job and completing their skills. In-services included education on documentation, emergency procedures, oxygen administration, physician notification, the Interact Process, and SBAR. The nurses were also strongly encouraged to not let these guidelines override their nursing judgement. The DON stated she will be more involved with nurses so she can identify their skill needs, and what education they may need. She stated the staff was instructed on timely notification, the Interact System, how to treat emergencies as emergencies and to err on the side of caution. The facility's expectation is for physician orders to be implemented and residents be sent out of the facility, if needed. Orders should be done timely and staff should be proactive and prevent emergencies instead of trying to hustle to get a resident out to the hospital. The assessment process should prevent those emergencies from happening. She stated she assisted the Assistant Director of Nursing and the Unit Manager and assessed all residents to ensure all needs were being met. Vital signs and visual assessments were completed, the information was documented, the charts were reviewed and compared with the care plans. All care plans were updated to ensure the residents' needs were being met. The Process now is to have a daily clinical meeting which includes (DON, ADON, and UM) to review new orders, care plans, and resident conditions. If needed, they will have an afternoon meeting to review anything that needed to be followed up on from the morning meeting. Any resident who had a significant change in the past thirty (30) days without physician notification had immediate physician notification. Further interview revealed medical records were reviewed on all residents for the last thirty (30) days beginning 12/14/13. All licensed staff was re-educated on the immediate notification of the physician with a sudden change in condition using the Interact Process, as a guide. If staff was unable to reach the physician, they may call the Medical Director. If the Medical Director doesn't answer within ten to fifteen minutes to send the resident out to the hospital. The Regional Nurse Consultant provided education to her and the acting ADON/UM for hall one. Education included the procedure for picking an IV site and insertion of the IV, follow up assessments every shift, signs and symptoms of infection, notification of the physician and documentation. Oxygen administration which included when to assess and apply, what to start the oxygen at, stay with the resident and to notify the physician to get a order. Competency validation with no staff working after 12/19/13 without having the education and the validated competency. A Quality Assurance meeting was held on 12/14/13, they discussed the concerns and issues with the Medical Director and began making plans of correction that included in-services and education, assessments of residents, updated care plans and significant changes that the physician would need to be notified about. She stated they were monitoring for corrective actions and it was her responsibility to monitor the Twenty Four Hour Reports daily and to call the facility three (3) times a day on each shift to speak with the nurses and get a report on their residents. She stated she reviewed orders and care plans daily in the clinical meeting and she was auditing all admissions. Further interview revealed she would audit five records daily right now to ensure everything was in place then will audit weekly. Monitoring was reviewed by the Quality Assurance team. Interview with the

Based on interview, record review, and review of the facility's policy/procedure, it was determined the facility failed to ensure each resident received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one (1) of three (3) sampled residents (Resident #1). The facility admitted Resident #1, on 10/29/13 at approximately 7:00 PM; however, the facility did not complete an assessment of the resident upon admission. The resident had a [DIAGNOSES REDACTED]. He/she asked for pain medication at approximately 10:00 PM and 4:00 AM the next day; however, he/she did not receive the medication. The resident left the facility with a family member, on 10/30/13 at 6:45 AM, (approximately twelve {12} hours later), as a result of the facility's failure to provide pain management. The findings include: Review of the facility's "Admission To Do List", undated, revealed the following: 1. Review discharge orders 2. Call pharmacy and fax over orders and face sheet with room number 3. Complete Pain Assessment 4. Complete Nursing Note Review of the facility's Pain Management Process Policy/Procedure, last revised 06/17/13, revealed the facility recognized that each resident had the right to treatment and services to maintain their quality of life. Upon admission and re-admission, the facility would complete a pain assessment/evaluation. Physician and family would be notified when pain levels were outside normal levels for each individual resident. Record review revealed the facility admitted Resident #1 on 10/29/13, with [DIAGNOSES REDACTED]. Review of the Admission Data Set, dated 10/29/13, revealed all areas of the admission assessment for Resident #1 were incomplete, including the resident's pain status. Interview with Licensed Practical Nurse (LPN) #1, on 11/05/13 at 1:30 PM, revealed she did not complete the resident's admission assessment as it should have been completed by the previous nurse. However, interview with the Director of Nursing (DON), on 11/06/13 at 9:45 AM, revealed she expected LPN #1 to complete the admission paperwork and assessment of the resident. She revealed the admission process should be completed as quickly as possible. Review of Resident #1's Physician Discharge Orders for Nursing Homes, dated 10/29/13 at 4:00 PM, revealed the following orders: 1. [MEDICATION NAME] (pain) Patch 50 micrograms (mcg) every seventy-two (72) hours 2. [MEDICATION NAME] 2 milligrams (mg) as needed for pain, every two (2) hours Review of Resident #1's facility physician's orders [REDACTED]. Review of the updated Physician Discharge Orders, dated 10/29/13, revealed to change the [MEDICATION NAME] to [MEDICATION NAME] Sublingual (SL) 20 mg per milliliter (ml); give 0.5 ml every four (4) hours, as needed. Interview with the Director of Nursing (DON), on 11/06/13 at 9:45 AM, revealed the updated orders were brought in with the resident upon admission, at approximately 7:00 PM. However, she could not provide documented evidence that the orders were faxed to the pharmacy. Interview with the spouse of Resident #1, on 11/06/13 at 8:20 AM, revealed he/she brought the resident to the facility, on 10/29/13 at approximately 7:00 PM, with orders from the hospital. The Spouse indicated at approximately 10:30 PM, the resident complained of pain due to the swelling of hi/her esophagus. The Spouse stated the staff indicated the medication had not arrived from pharmacy at that time. Further interview with the Spouse revealed he/she went home shortly afterwards; however, the resident called him/her at approximately 4:30 AM, indicating he/she was "sick" and "hurting so bad." The Spouse stated when he/she arrived at the facility, the orders brought with the resident were still sealed at the nurse's desk. Interview with Resident #1, on 11/06/13 at 8:45 AM, revealed it was reported at approximately 10:00 PM that he/she was "hurting really bad," with a hand on his/her chest. The resident reported he/she "cat napped" throughout the night. Between 3:30 AM-4:00 AM, an aide came in and brought some ice into his/her room. The resident informed the aide of the need for pain medication, as he/she was hurting about an "8 or 9" on a pain scale of 0-10. The aide indicated she would check on it; however, the aide never came back into the resident's room. The resident stated at approximately 4:30 AM, he/she contacted a family member indicating he/she was in pain and "could not stand it any longer". The resident was discharged from the facility later that morning. Further interview with the resident verified the paperwork brought in from the hospital was still unopened at the nurse's desk. Interview with Certified Nurse Aide (CNA) #5, on 11/05/13 at 8:30 AM, revealed she was the aide taking care of Resident #1, on 10/29/13 from 11:00 PM to 7:00 AM on 10/30/13. She stated the resident put on his/her call light sometime between 3:00 AM and 5:00 AM, asking for pain medication. CNA #5 revealed LPN #1 was made aware of the resident's request for pain medication. However, she was informed the resident's medications had not been received from the pharmacy. Interview with LPN #1, on 11/04/13 at 3:50 PM; on 11/05/13 at 1:30 PM; and, on 11/06/13 at 4:00 PM, revealed she did not receive any paperwork upon the resident's admission to the facility. LPN #1 stated she was not aware of the updated orders from the hospital, and verified she did not fax any orders to the pharmacy. Further interview with LPN#1 revealed she was the resident's nurse from 7:00 PM to 7:00 AM; however, the resident never indicated he/she was in pain. She stated she did not have any reports of the resident's pain made during the shift. Interview with the DON, on 11/06/13 at 9:45 AM, revealed LPN #1 should have faxed the updated pain medication orders to the pharmacy, to ensure arrival at the facility that night.

Based on interview and record review, and review of the facility's policy guidelines, it was determined the facility failed to have an effective system to ensure care plan interventions were implemented for one resident (#1), in the selected sample of nine. Resident #1 was a forty-two year old Quadriplegic who utilized a motorized wheelchair and had functional limitation in range of motion in bilateral upper and lower extremities. Resident #1 was assessed and care planned for supervision with smoking. The facility assessed Resident #1 as a dependent smoker and developed a plan of care for supervised smoking. However, record review and interview revealed staff would assist the resident out of the facility and the resident was allowed to leave facility property to smoke unsupervised. On 12/21/12, Resident #1 exited the facility with the assistance of staff at an undetermined time, was left outside unsupervised, and was found off the facility property by a staff member who was leaving the facility for lunch at approximately 12:00 PM. The resident was found unresponsive in his/her motorized wheelchair, on a two lane residential side street, in front of a parked Semi truck. The resident was assessed by facility staff to have a body temperature of 85.4 degrees Fahrenheit (F), an oxygen saturation of 60% on 5 liters of oxygen, and a heart rate of 58. The Emergency Medical Services was notified at 12:40 PM and the resident was transported to the emergency room and assessed to have a core temperature of 91.5 degrees F at 1:40 PM; a warming blanket was utilized; and, the resident was admitted to the Intensive Care Unit with a [DIAGNOSES REDACTED]. The facility's failure to implement care plan interventions for residents who required supervised smoking has caused or is like to cause serious injury, harm, impairment or death to a resident. The facility was notified of the Immediate Jeopardy on 01/03/13. An acceptable Allegation of Compliance (AoC) was received on 01/04/13 and the State Survey Agency validated that the Immediate Jeopardy was removed on 01/04/13, as alleged. The scope and severity was lowered to a "D" while the facility develops and implements the Plan of Correction (POC) and the facility's Quality Assurance monitors the effectiveness of the systemic changes. Findings include: A review of the Comprehensive Care Plan Guidelines, dated 09/2008, revealed it did not address the implementation of the care plan. Review of the facility's Smoking Policy, dated 07/01/12, revealed all residents who smoke will be screened using the safe smoking evaluation form upon admission, quarterly, and with a significant change in condition to determine any special smoking needs. Residents may only smoke under staff supervision, in designated smoking area and at times established by the facility. All residents who smoke will have all their smoking materials stored in a secure area at the nurse's station or other location designated by the facility. If a resident wishes to smoke at a non-scheduled time under the supervision of a visitor, he or she may only do so if the visitor consults with staff and signs a an Agreement to Accept Responsibility for Resident Smoking prior to taking the resident to smoke. Review of facility Situation, Background, Assessment and Request (SBAR) form, dated 12/21/12, revealed Resident #1 was found outside in his/her wheelchair and was barely responsive. The Background information was [MEDICAL CONDITION] and Wounds (Pressure Sore). The vital signs were 64% oxygen saturation on room air, heart rate of 64 and respirations of 10. Review of the Notes section revealed "Found outside in motorized wheelchair, slumped to left and back. Sternal rub with loud commands to awaken. Returned to room. Transferred via lift to bed. Started on oxygen at 5/liters, Catheter flowing freely, Bilateral pupils barely responsive to light, mouth dry, 911 activated for transfer to ER, physician notified per phone, report call to ER at 12:40 PM". Record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment, dated 07/30/12, revealed the facility had assessed Resident #1 without cognitive impairment, he/she required extensive assist with bed mobility, transfers, dressing and personal hygiene, was incontinent of bowel and bladder, had decreased sensory perception, and had functional limitation in range of motion for bilateral upper and lower extremities. A review of the face sheet for Resident #1 revealed Resident #1 was his/her own responsible party. Review of the most recent Smoking Safety Data Collection and Assessment, dated 07/08/11, revealed the facility assessed Resident #1 as a dependent smoker due to the resident not being able to hold a cigarette safely, to light his/her cigarette safely, and to let go of the cigarette and then retrieve it appropriately. Review of the Comprehensive Care Plan for Fall/Injury, last updated 07/2012, revealed smoking would be supervised by staff, smoking materials would be kept at the nursing station, and to monitor compliance to smoking policy. However, record review revealed Resident #1 had a history of [REDACTED]. Review of a Nurse's Note, dated 07/03/12, revealed Resident #1 was outside smoking at 12:30 AM. A Nurse's Note, dated 07/22/12 late entry, revealed Resident #1 was outside smoking from 12:25 AM till 1:30 AM and was non-compliant with the facility's smoking policy. Review of Nurse's Notes, dated 10/21/12 and 10/22/12 revealed Resident #1 went out of the facility constantly and continued to get up during the night to go out of facility several times to smoke. Interviews with staff revealed Resident #1 required assistance to exit the building; however, would be left outside unsupervised to smoke. Interviews revealed the resident could smoke off the facility property without supervision because the resident was his/her own reponsible party. Interview with Certified Nurse Aide (CNA) #2, on 12/28/12 at 9:00 AM, revealed Resident #1 would go outside because he/she could not smoke on the property when it was not smoking time. The CNA stated the resident usually would go out of the parking lot and down the road a little bit or in the field to smoke. He was aware Resident #1 required supervision when smoking but stated the resident could do what he/she wanted when off of the facility grounds. Interview with CNA #1, on 12/28/12 at 10:30 AM, revealed she was aware Resident #1 required supervision when smoking but stated the resident could do what he/she wanted when off of the facility grounds. Interview with Licensed Practical Nurse (LPN) #2, on 12/28/12 at 10:49 AM, revealed Resident #1 liked to smoke and he/she smoked outside off of the property most days. Interview with the Medical Records/Central Supply Clerk, on 12/28/12 at 11:08 AM, revealed Resident #1 would go outside alone and go to the grassy area to smoke. Interview with LPN #5, on 12/30/12 at 6:45 AM, revealed Resident #1 went out of the facility constantly and would knock on the door when ready to re-enter the facility. LPN #5 was aware Resident #1 required supervision when smoking but the resident could do what he/she wanted when off of the facility grounds. Interview with LPN #6, on 01/01/13 at 7:00 AM, revealed when leaving for home in the mornings would see Resident #1 smoking in a gravel area by the road behind the facility. LPN #6 was aware Resident #1 required supervision when smoking but the resident could do what he/she wanted when off of the facility grounds. Interview with LPN #3, on 01/01/13 at 2:20 PM, revealed it was normal for Resident #1 to stay outside for extended periods of time unsupervised and that she was unaware of where all he/she went. LPN #3 was aware Resident #1 required supervision when smoking but that the resident could do what he/she wanted when off of the facility grounds. Interview with CNA #3, on 01/04/13 at 3:15 PM, revealed the resident would go out alone after dark. The night shift staff told her the resident would get up at night and go outside to smoke all the time. Further interview revealed the resident would also go off the property. Interview with the Director of Nursing (DON), dated 01/03/13 at 9:40 AM, revealed the resident was supposed to smoke supervised; however, the resident was alert and oriented and maded his/her own decisions. Interview with the Administrator, on 01/03/13 at 4:14 PM, revealed staff was aware that Resident #1 was assessed and care planned for requiring supervision when smoking; however, Resident #1 had the right to exit the facility and if he/she smoked while outside of the facility, it was his/her choice. **The facility implemented the following actions to abate the Immediate Jeopardy: *All current residents were reviewed by the Director of Nursing, Assistant Director of Nursing, Unit managers, MDS Coordinator, Social Services Director, Activity Director, Dietary Services Manager, and Facility Rehab Coordinator, a licensed nurse and a nursing assistant to determine appropriate supervision in and outside of the facility. This was completed on 01/03/13. *All residents who wish to smoke were reviewed by the Director of Nursing, Assistant Director of Nursing, Unit managers, MDS Coordinator, Social Services Director, Activity Director, Dietary Services Manager, and Facility Rehab Coordinator, a licensed nurse and a nursing assistant. New smoking assessments were completed on all residents. Any changes were addressed in the residents' care plans to determine appropriate supervision in and outside of the facility. This was completed on 01/03/13. *There are no current residents who leave the facility unsupervised. *All staff were re-educated on 01/03/13 by the Director of Nursing, Assistant Director of Nursing, Administrator, Unit manager or Education and Training Director on the smoking policy to include reporting to the licensed nurse any resident who appears to have difficulty smoking or unsafe smoking practices such as difficulty holding their own cigarette, dropping ashes on themselves and/or burning themselves or clothing. No staff will work after 01/03/13 without having completed this re-education. *All staff were re-educated on 01/03/13 by the Director of Nursing, Assistant Director of Nursing, Administrator, Unit manager or Education and Training Director on all resident who leave the facility must be reported to the Nurse responsible for caring for the resident who will assure appropriate supervision. No staff will work after 01/03/13 without having completed this re-education. *All Licensed Staff were re-educated on 01/03/13 on the revised facility policy for temporary leave of absence to include: any resident who leaves the facility the Licensed Nurse must evaluate the resident's supervision needs to include at a minimum medical condition, mental status, equipment needs, weather conditions and appropriate attire, as well as reviewing the resident's care plan for supervision. This policy also includes documentation on the leave of absence form when a resident leaves the facility and when the resident returns, and communication between shifts of what residents are still out of the facility at change of shift to include documentation on the 24 hour report. No Licensed Staff will work after 01/03/13 without having completed this re-education. *Residents smoking assessments will be completed by the Director of Nursing, Assistant Director of Nursing or Unit Manager, MDS Coordinator and Training Director beginning 01/04/13 and going forward. The Director of Nursing, Assistant Director of Nursing, Unit Manager, MDS Coordinator and Training Director were educated on completion of Smoking Assessments by the Director of Nursing. *An ad hoc Quality Assurance Committee (QPI) was held on 01/03/13 to review the alleged deficient practice as well as the plan for removal. In attendance were the Medical Director, Administrator, Director of Nursing, Assistant Director of Nursing, Unit Manager and MDS Coordinator. No further recommendations were made by the committee. *Monitoring of the plan of correction will be performed by the following: The Director of Nursing, the Assistant Director of Nursing, Unit Manager, MDS Coordinators, Administrator or Director of Education will contact the facility each shift to review with licensed staff to determine that residents who left the facility or are leaving the facility have been assessed by the licensed nurse to have appropriate supervision as well as any resident requiring increased supervision. This will occur daily on each shift for three weeks, then five times per week for three weeks, then three time a week for three weeks, then weekly for three weeks and substantial compliance. If at any time concerns are identified, a Quality Assurance Committee Meeting will be convened to make further recommendations. In addition, a Department Head will monitor two smoke breaks per day until substantial compliance to assure resident smoking safety interventions are in place. If at any time concerns are identified, a Quality Assurance Committee Meeting will be convened to make further recommendations. The Department Heads consist of the Administrator, Director of Nursing, Assistant Director of Nursing, Dietary Services Manager, Social Services Director, Activity Director, Maintenance Director, Business Office Manager, Medical Records and the MDS Coordinators. The Director of Nursing, the Assistant Director of Nursing, MDS Coordinators, Unit Manager, Administrator, or the Director of Education will review the Leave of Absence book to assure completion and review the twenty four hour report daily to assure documentation of any resident who remains on Leave of Absence at change of shift. this review will occur daily for four weeks followed by five time a week for eight weeks. If at any time concerns are identified, a Quality Assurance Committee Meeting will be convened to make further recommendations. The Quality Assurance Committee will meet weekly until substantial compliance is achieved. The Quality Assurance Committee will consist at a minimum the Medical Director, the Director of Nursing, the Administrator and the Education and Training Director. *Failure to comply with any of the above will result in individual re-training and as appropriate, disciplinary action. The surveyors validated the corrective action taken by the facility as follows: Record review for sampled residents revealed the residents' were reviewed on 01/03/13 to determine the appropriate level of supervision in and outside of the facility and the residents' care plans were updated. The residents who wished to smoke were reviewed for safety with smoking and new smoking assessments were completed for each resident. The care plans were updated, if needed. Record review validated the completion of all training of staff on 01/03/13 related to the smoking policy, reporting to nurse when a resident is leaving the building so the nurse can determine the appropriate supervision needed, the revised leave of absence policy, and how to complete the smoking assessment. A review of the leave of absence policy and procedure, dated 01/03/13, revealed it was revised to include that any resident who leaves the facility the Licensed Nurse must evaluate the resident's supervision needs to include at a minimum medical condition, mental status, equipment needs, weather conditions and appropriate attire, as well as reviewing the resident's care plan for supervision. This policy also includes documentation on the leave of absence form when a resident leaves the facility and when the resident returns, and communication between shifts of what residents are still out of the facility at change of shift to include documentation on the 24 hour report Interviews with the Education Training Director, the Dietary Manager, Assistant Director of Nursing, Unit Manager #1, Activity Assistant, Maintenance Manager, Business Office Assistant, RN #2, LPN #7, LPN #8, CNA #7, CNA #8, CNA #9, CNA #10, CNA #11, Nurse Aide (NA) #1, Dietary Aide (DA) #1 and DA #2, on 01/04/13 revealed the staff received the training related to the smoking policy, reporting to nurse when a resident is leaving the building so the nurse can determine the appropriate supervision needed, the revised leave of absence policy, and how to complete the smoking assessment. Interviews with the Medical Director, Administrator and Director of Nursing, on 01/04/13, confirmed there was an ad hoc QPI meeting held on 01/03/13 to review the alleged deficient practice as well as the plan for removal and no further recommendations were identified. A review of the monitoring calendar revealed the dates were marks for the days any reviews should be conducted according to the monitoring schedule.

Based on interview, record review, review of facility policies, it was determined the facility failed to have an effective system to ensure resident safety through monitoring and supervision for one resident (#1), in the selected sample of nine residents. Resident #1 was a forty-two year old Quadriplegic who utilized a motorized wheelchair and had functional limitation in range of motion in bilateral upper and lower extremities. The resident was his/her own responsible party. The facility assessed Resident #1 as a dependent smoker and developed a plan of care for supervised smoking. However, record review and interview revealed staff would assist the resident out of the facility and the resident was allowed to leave facility property to smoke unsupervised. Interview revealed the facility was not responsible for the resident if he/she was off the property due to the resident being his/her own responsible party, even though the facility assessed Resident #1 required supervision. On 12/21/12, Resident #1 exited the facility with the assistance of staff at an undetermined time, was left outside unsupervised, and was found off the facility property by a staff member who was leaving the facility for lunch at approximately 12:00 PM. The resident was found unresponsive in his/her motorized wheelchair, on a two lane residential side street, in front of a parked Semi truck. The resident was assessed by facility staff to have a body temperature of 85.4 degrees Fahrenheit (F), an oxygen saturation of 60% on 5 liters of oxygen, and a heart rate of 58. The Emergency Medical Services was notified at 12:40 PM and the resident was transported to the emergency room and assessed to have a core temperature of 91.5 degrees F at 1:40 PM; a warming blanket was utilized; and the resident was admitted to the Intensive Care Unit with a [DIAGNOSES REDACTED]. The facility's failure to have an effective system to ensure Resident #1's safety through monitoring and supervision while the resident was smoking, has caused or is like to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 01/03/13 and was determined to exist on 12/21/12. The facility was notified of the Immediate Jeopardy on 01/03/13. An acceptable Allegation of Compliance (AoC) was received on 01/04/13 and the State Survey Agency validated that the Immediate Jeopardy was removed on 01/04/13 as alleged. The scope and severity was lowered to a "D" while the facility develops and implements the Plan of Correction (POC) and the facility's Quality Assurance monitors the effectiveness of the systemic changes. Findings include: A review of the facility Smoking Policy, dated 07/01/12, revealed the facility permitted smoking in a designated area outside of the facility, subject to certain requirements and restrictions set forth including: 1) All residents who smoke will be screened using the Safe Smoking Evaluation form upon admission, quarterly, and with a significant change in condition to determine any special smoking needs; 2) Residents may only smoke under staff supervision, in designated smoking area and at times established by the facility; 3) All residents who smoke will have all their smoking materials stored in a secure area at the nurse's station or other location designated by the facility; 4) If a resident wishes to smoke at non-scheduled time under the supervision of a visitor, he she may only do so if the visitor consults with staff and signs an Agreement to Accept Responsibility for Resident Smoking form prior to taking the resident to smoke. For purposes of this policy, a visitor is a competent individual who is 18 or older and has approved by the Guardian/Legal Representative for the resident; and, 5) Residents who fail to comply with the facility's smoking policy may be deemed to be subject to discharge, consistent with applicable regulatory requirements governing discharge of residents. Review of a facility form titled, Agreement to Accept Responsibility for Resident, undated, revealed it had a place for signature of resident or person accepting responsibility for resident. There was a section for a printed name, date and time of expected return and contact number. The form included a Signing In section with date, time and signature. Per staff interview, this form was utilized for documenting the date and time for residents exiting and entering the facility. Record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of an annual Minimum Data Set (MDS) assessment, dated 07/30/12 , revealed the facility had assessed the resident without cognitive impairment, decreased sensory perception and requiring extensive assistance with two staff for bed mobility, transfers, dressing and personal hygiene, was incontinent of bowel, had functional limitation in range of motion to bilateral upper and lower extremities, and had a suprapubic catheter. Resident #1 utilized a motorized wheelchair for mobility and was his/her own responsible party. Review of facility Situation, Background, Assessment and Request (SBAR) form, dated 12/21/12, revealed Resident #1 was found outside in his/her wheelchair and was barely responsive. The Background information was Quadriplegia and Wounds (Pressure Sore). The vital signs were 64% oxygen saturation on room air, heart rate of 64 and respirations of 10. Review of the Notes section revealed "Found outside in motorized wheelchair, slumped to left and back. Sternal rub with loud commands to awaken. Returned to room. Transferred via lift to bed. Started on oxygen at 5/liters, Catheter flowing freely, Bilateral pupils barely responsive to light, mouth dry, 911 activated for transfer to ER, physician notified per phone, report call to ER at 12:40 PM". Review of weather history for the area on 12/21/12 between the hours of 9:55 AM and 11:55 AM revealed the average for seven readings was : Temperature 34.8 degrees F., wind chill average was 22.8 degrees F and the average wind gust was 31.5 miles per hour. Review of a Resident Transfer form, dated 12/21/12 (no time), revealed Resident #1's vital signs as blood pressure 129/77, heart rate 58, respirations 18 and temperature of 85.4 degrees F. Review of hospital records, dated 12/21/12, revealed emergency room admission time of 1:17 PM and that the resident was found outside, decreased responsiveness, cold to touch with a core temperature of 91.5 degrees F. General comments section included "Patient brought by EMS. EMS states patient was found slumped over in a wheelchair outside in the road. Patient was barely responsive to light. Lips were blue and patient was placed on 5/liters of oxygen. Patient not responsive to voice. Placed on Bair Hugger (warming device)". Two liters of Normal Saline on warmer Intravenous (IV) was ordered. At 2:00 PM, an additional third liter of warmed Normal Saline was initiated per IV. Resident #1 was sent to the assigned unit at 3:40 PM. Review of the Nursing Note, dated 12/21/12 at 5:00 PM, revealed Resident #1 had been admitted to the hospital Intensive Care Unit with a [DIAGNOSES REDACTED]. Resident #1 was discharged back to the facility on [DATE]. Review of the hospital History and Physical, dated 12/22/12, revealed the physician documented the [DIAGNOSES REDACTED]. The Treatment Plan section revealed "The patient was treated with warming blanket. He/she is doing better now and should be able to be transferred back to the nursing home. I did speak to the nursing home staff about how to avoid this in the future when the weather is bad and he/she is going outside, to send a staff member with him/her". Interview with Licensed Practical Nurse (LPN) #2, on 12/28/12 at 11:10 AM, revealed on 12/21/12 sometime around noon as she was leaving for lunch she had observed Resident #1 outside on the street at the back of the building. Resident #1 was on the street by the employee parking area and in front of a semi truck that was parked along the street (facing away from the building) as supplies were being delivered to the facility. LPN #2 stated Resident #1 was unresponsive and slumped in the wheelchair. She ran to the therapy department (located toward the back of the building) and called for help. Resident #1 was taken into the facility and assessed and an ambulance was called. Interview with Unit Manager #1, on 12/28/12 at 10:40 AM, revealed she was in her office and LPN #2 came in the building around lunch time and said something was wrong with Resident #1. Unit Manager #1 ran outside to help and Resident #1 was not responding, eyes were closed and had an ashen color. Interview with LPN #3, on 01/01/13 at 2:20 PM, revealed on 12/21/12 sometime around noon other facility staff had brought Resident #1 into the facility from outside. LPN #3 stated Resident #1 looked terrible and had pin point pupils. LPN #3 assisted with obtaining vital signs and obtained a temperature for the resident that was 85.4 degrees F. She told the staff to put blankets on Resident #1 while waiting for EMS to arrive. She stated she was unaware of any staff documentation of his/her whereabouts when he/she was outside. Interview with Certified Nurse Aide (CNA) #2, on 12/28/12 at 9:00 AM, revealed he was not assigned to Resident #1 on 12/21/12 but he had assisted to provide care for the resident. CNA #2 revealed Resident #1 has very limited movement of shoulders, arms and hands. Resident #1 was transferred from the bed to the electric wheel chair by two staff and was usually up every morning by 7:00 AM to 7:30 AM and would be assisted outside to smoke. CNA #2 stated Resident #1 had to go off the facility property to smoke unsupervised, and did not think he/she could physically light a cigarette. A form was signed by facility staff when residents left the facility and CNA #2 thought the nurses monitored that form. He was aware Resident #1 required supervision when smoking but the resident could do what he/she wanted when off of the facility grounds because the resident was his/her responsible party. Interview with CNA #1, on 12/28/12 at 10:30 AM, revealed on 12/21/12 Resident #1 had already been assisted up earlier in the morning and she and another staff had assisted the resident back to bed to provide care sometime before 9:00 AM. CNA #1 stated Resident #1 was assisted back to the wheelchair after the care was provided and she had placed a blue coat on the resident. The CNA then went to the resident dining room to assist in serving breakfast to other residents. The last time she saw Resident #1 that morning was about 9:00 AM as he/she was propelling down the hall in his/her motorized wheelchair where a ramp transitioned down to an exit door at the side of the building on Hall 2. Resident #1 frequently exited the facility through that door with the assistance of staff. CNA #1 was aware Resident #1 required supervision when smoking but the resident could do what he/she wanted when off of the facility grounds, since the resident was his/her responsible party. Interview with LPN #3, on 01/01/13 at 2:20 PM, revealed she had given Resident #1 his/her medications about 8:30 AM to 9:00 AM on 12/21/12 and then let him/her out the door to outside. Resident #1 had knocked on the door about fifteen minutes after that to get assistance to retrieve his/her cell phone which had fallen on the ground and had a lit cigarette at that time. Resident #1 lit his/her own cigarettes. LPN #3 stated it was normal for Resident #1 to stay outside for extended periods of time and that she was unaware of where he/she went. LPN #3 was aware Resident #1 required supervision when smoking but the resident could do what he/she wanted when off of the facility grounds because he/she was his/her own responsible party. Interview with LPN #1, on 12/28/12 at 12:40 PM, revealed she last saw Resident #1 on 12/21/12 about 11:00 AM as she had changed a wound vac and dressing. However, review of the Resident's Treatment Administration Record (TAR) revealed documentation stating the procedure had not been completed as Resident #1 was out of the facility. Interview conducted on 12/28/12 at 8:30 AM with Resident #1 revealed he/she had went outside with the assistance of staff on 12/21/12 sometime before breakfast as he/she did every morning and had told staff to sign him/her out. He/she stated he/she was in the parking area in the back of the building by the road and no one else was there. Resident #1 recalled smoking the second of two cigarettes, had felt warm and may have fallen asleep. Further interview at 2:15 PM revealed Resident #1 stated the only time he/she went outside on 12/21/12 was in the morning before breakfast. He stated he was supposed to be supervised when smoking but when he/she went off the property he/she could smoke unsupervised if he/she wanted. Per interview, the resident went "down the road" where the employees parked to smoke unsupervised. If not, he/she would have to smoke at designated smoking times and in designated areas at the facility. Interview with Resident #1's physician, on 01/02/13 at 1:30 PM, revealed Resident #1 could not determine the temperature and had autonomic instability. The physician stated the [DIAGNOSES REDACTED]. The physician additionally felt the facility was responsible to monitor the resident and he had called the facility related to the resident being outside with no supervision. Review of the Agreement to Accept Responsibility for Resident form utilized for Resident #1, revealed no documentation Resident #1 had been signed out of the facility on 12/21/12. The form was incomplete. Additionally, the review revealed thirty six (36) different entries on the form for Resident #1, dated 12/03/12 through 12/27/12. Of those entries, twenty three (23) had no contact information, twenty three (23) had no expected return date or time, eighteen (18) had no return date or time and twenty two (22) had no signature or mark for the person accepting responsibility. Review of the Comprehensive Care Plan for Fall/Injury, last updated 07/2012, revealed smoking would be supervised by staff, smoking materials would be kept at the nursing station, and to monitor compliance to smoking policy. In addition, the care plan stated Resident #1 was not signing self out when leaving the facility and propelling wheelchair after hours outside; however, there were no interventions to address the resident's failure to sign out and how the facility was going to monitor the resident's whereabouts and safety. Record review and interview revealed the resident had a history of [REDACTED]. Staff would let the resident out of the facility and the resident would knock on the door when he/she wanted to come back in the facility. Review of the nursing note, dated 07/03/12 at 2:30 AM, revealed "the resident remains non-compliant with smoking policy as does not sign self out and does not always go off of facility property at night". A Nursing Note, dated 07/22/12 at 12:25 AM, revealed "Resident #1 went outside to smoke, continuing non-compliance with smoking policy. The resident remained outside until around 1:30 AM". Review of a Nursing Note, dated 10/21/12 at 4:00 AM, revealed "Resident requested to get out of bed and up in wheelchair at this time" and at 12:45 AM the note stated "Resident has went out of facility constantly to smoke". On 10/22/12 at 6:30 AM, a Nursing Note revealed "Continues to get up during the night and to go out of facility several times to smoke". Interview with LPN #5, on 12/30/12 at 6:45 AM, revealed Resident #1 did not rest at night and usually requested to be assisted into the electric wheelchair about 12:00 AM to 12:45 AM most mornings. Resident #1 went out of the facility constantly and would knock on the door when ready to re-enter the facility and staff could not get their work done. LPN #5 stated she has seen him/her in the field behind the building and staff did not document if there was any monitoring of Resident #1 when outside. Resident #1 kept a cigarette lighter on his/her person and gave the staff "a hard time about it". LPN #5 was aware Resident #1 required supervision when smoking but the resident could do what he/she wanted when off of the facility grounds because he/she was his/her own responsible party. Interview with LPN #6, on 01/01/13 at 7:00 AM, revealed she had always assisted Resident #1 to exit the facility to smoke during the night and had never seen him/her exit or enter the facility unassisted. Resident #1 did not sleep well at night and watched TV and used a lap top computer during the night and felt he/she was a night person. LPN #6 worked nights and when leaving for home in the mornings would see Resident #1 in a gravel area by the road behind the facility. LPN #6 stated she would see Resident #1 with his/her eyes closed dozing off. Resident #1 liked to be in the sun and had a "great suntan". LPN #6 was aware Resident #1 required supervision when smoking but the resident could do what he/she wanted when off of the facility grounds because he/she was his/her own responsible party. She stated she would see the resident smoking in the gravel area. Interview with the Director of Nursing (DON), dated 01/03/13 at 9:40 AM, revealed there was no system to monitor the resident visually when the resident went outside the facility. She stated the resident was supposed to smoke supervised; however, the resident was alert and oriented and made his/her own decisions. Per interview, based on the resident's rights, he/her had those choices, since the resident was his/her own responsible party. Interview with the Administrator, on 01/03/13 at 4:14 PM, revealed staff was aware that Resident #1 was assessed and care planned for requiring supervision when smoking; however, Resident #1 had the right to exit the facility and if he/she smoked while outside of the facility, it was his/her choice. Per interview, the facility was not responsible for the resident when he/she was off facility property because the resident was his/her own responsible party. **The facility implemented the following actions to abate the Immediate Jeopardy : *All current residents were reviewed by the Director of Nursing, Assistant Director of Nursing, Unit managers, MDS Coordinator, Social Services Director, Activity Director, Dietary Services Manager, and Facility Rehab Coordinator, a licensed nurse and a nursing assistant to determine appropriate supervision in and outside of the facility. This was completed on 01/03/13. *All residents who wish to smoke were reviewed by the Director of Nursing, Assistant Director of Nursing, Unit managers, MDS Coordinator, Social Services Director, Activity Director, Dietary Services Manager, and Facility Rehab Coordinator, a licensed nurse and a nursing assistant. New smoking assessments were completed on all residents. Any changes were addressed in the residents' care plans to determine appropriate supervision in and outside of the facility. This was completed on 01/03/13. *There are no current residents who leave the facility unsupervised. *All staff were re-educated on 01/03/13 by the Director of Nursing, Assistant Director of Nursing, Administrator, Unit manager or Education and Training Director on the smoking policy to include reporting to the licensed nurse any resident who appears to have difficulty smoking or unsafe smoking practices such as difficulty holding their own cigarette, dropping ashes on themselves and/or burning themselves or clothing. No staff will work after 01/03/13 without having completed this re-education. *All staff were re-educated on 01/03/13 by the Director of Nursing, Assistant Director of Nursing, Administrator, Unit manager or Education and Training Director on all resident who leave the facility must be reported to the Nurse responsible for caring for the resident who will assure appropriate supervision. No staff will work after 01/03/13 without having completed this re-education. *All Licensed Staff were re-educated on 01/03/13 on the revised facility policy for temporary leave of absence to include: any resident who leaves the facility the Licensed Nurse must evaluate the resident's supervision needs to include at a minimum medical condition, mental status, equipment needs, weather conditions and appropriate attire, as well as reviewing the resident's care plan for supervision. This policy also includes documentation on the leave of absence form when a resident leaves the facility and when the resident returns, and communication between shifts of what residents are still out of the facility at change of shift to include documentation on the 24 hour report. No Licensed Staff will work after 01/03/13 without having completed this re-education. *Residents smoking assessments will be completed by the Director of Nursing, Assistant Director of Nursing or Unit Manager, MDS Coordinator and Training Director beginning 01/04/13 and going forward. The Director of Nursing, Assistant Director of Nursing, Unit Manager, MDS Coordinator and Training Director were educated on completion of Smoking Assessments by the Director of Nursing. *An ad hoc Quality Assurance Committee (QPI) was held on 01/03/13 to review the alleged deficient practice as well as the plan for removal. In attendance were the Medical Director, Administrator, Director of Nursing, Assistant Director of Nursing, Unit Manager and MDS Coordinator. No further recommendations were made by the committee. *Monitoring of the plan of correction will be performed by the following: The Director of Nursing, the Assistant Director of Nursing, Unit Manager, MDS Coordinators, Administrator or Director of Education will contact the facility each shift to review with licensed staff to determine that residents who left the facility or are leaving the facility have been assessed by the licensed nurse to have appropriate supervision as well as any resident requiring increased supervision. This will occur daily on each shift for three weeks, then five times per week for three weeks, then three time a week for three weeks, then weekly for three weeks and substantial compliance. If at any time concerns are identified, a Quality Assurance Committee Meeting will be convened to make further recommendations. In addition, a Department Head will monitor two smoke breaks per day until substantial compliance to assure resident smoking safety interventions are in place. If at any time concerns are identified, a Quality Assurance Committee Meeting will be convened to make further recommendations. The Department Heads consist of the Administrator, Director of Nursing, Assistant Director of Nursing, Dietary Services Manager, Social Services Director, Activity Director, Maintenance Director, Business Office Manager, Medical Records and the MDS Coordinators. The Director of Nursing, the Assistant Director of Nursing, MDS Coordinators, Unit Manager, Administrator, or the Director of Education will review the Leave of Absence book to assure completion and review the twenty four hour report daily to assure documentation of any resident who remains on Leave of Absence at change of shift. this review will occur daily for four weeks followed by five time a week for eight weeks. If at any time concerns are identified, a Quality Assurance Committee Meeting will be convened to make further recommendations. The Quality Assurance Committee will meet weekly until substantial compliance is achieved. The Quality Assurance Committee will consist at a minimum the Medical Director, the Director of Nursing, the Administrator and the Education and Training Director. *Failure to comply with any of the above will result in individual re-training and as appropriate, disciplinary action. The surveyors validated the corrective action taken by the facility as follows: Record review for sampled residents revealed the residents were reviewed on 01/03/13 to determine the appropriate level of supervision in and outside of the facility and the residents' care plans were updated. The residents who wished to smoke were reviewed for safety with smoking and new smoking assessments were completed for each resident. The care plans were updated, if needed. Record review validated the completion of all training of staff on 01/03/13 related to the smoking policy, reporting to nurse when a resident is leaving the building so the nurse can determine the appropriate supervision needed, the revised leave of absence policy, and how to complete the smoking assessment. A review of the leave of absence policy and procedure, dated 01/03/13, revealed it was revised to include that any resident who leaves the facility the Licensed Nurse must evaluate the resident's supervision needs to include at a minimum medical condition, mental status, equipment needs, weather conditions and appropriate attire, as well as reviewing the resident's care plan for supervision. This policy also includes documentation on the leave of absence form when a resident leaves the facility and when the resident returns, and communication between shifts of what residents are still out of the facility at change of shift to include documentation on the 24 hour report Interviews with the Education Training Director, the Dietary Manager, Assistant Director of Nursing, Unit Manager #1, Activity Assistant, Maintenance Manager, Business Office Assistant, RN #2, LPN #7, LPN #8, CNA #7, CNA #8, CNA #9, CNA #10, CNA #11, Nurse Aide (NA) #1, Dietary Aide (DA) #1 and DA #2, on 01/04/13 revealed the staff received the training related to the smoking policy, reporting to nurse when a resident is leaving the building so the nurse can determine the appropriate supervision needed, the revised leave of absence policy, and how to complete the smoking assessment. Interviews with the Medical Director, Administrator and Director of Nursing, on 01/04/13, confirmed there was an ad hoc QPI meeting held on 01/03/13 to review the alleged deficient practice as well as the plan for removal and no further recommendations were identified. A review of the monitoring calendar revealed the dates were marks for the days any reviews should be conducted according to the monitoring schedule.

Based on interview, record review and review of facility policy and Administrators job description it was determined the facility failed to be administered in a manner which enabled it to use it's resources effectively and and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being for one resident (#1), in the selected sample of nine residents. The facility failed to have an effective system to ensure the safety and welfare of one resident (#1), in the selected sample of nine. The Administrator failed to ensure Resident #1 was appropriately supervised according to the facility's assessment, care plan and facility policies. Resident #1 was a forty-two year old Quadriplegic with functional limitation in range of motion in bilateral upper and lower extremities and who utilized a motorized wheelchair. The resident was his/her own responsible party. The facility assessed Resident #1 as a dependent smoker and developed a plan of care for supervised smoking. However, record review and interview revealed staff would assist the resident out of the facility and the resident was allowed to leave facility property to smoke unsupervised. Interviews revealed the resident would either go to a gravel area by the road or field beside the facility to smoke. Interviews revealed the facility was not responsible for the resident if he/she was off the property due to the resident being his/her own responsible party, even though the facility assessed Resident #1 required supervision. Resident #1 was found outside, unresponsive on 12/21/12 in cold weather with a body temperature of 85.4 degrees F, and was admitted to the hospital Intensive Care Unit with a [DIAGNOSES REDACTED].#1 when smoking per the smoking assessment and care plan. This failure to administer the facility effectively and efficiently to attain or maintain each resident's highest practicable physical, mental and psychosocial well-being has caused or is like to cause serious injury, harm, impairment or death to a resident. The facility was notified of the Immediate Jeopardy on 01/03/13. An acceptable Allegation of Compliance (AoC) was received on 01/04/13 and the State Survey Agency validated that the Immediate Jeopardy was removed on 01/04/13 as alleged. The scope and severity was lowered to a "D" at 42 CFR 483.20 Resident Assessment, F282, 42 CFR 483.25 Quality of Care F323, and 42 CFR 483.75 Administration, F490 while the facility develops and implements the Plan of Correction (POC) and the facility's Quality Assurance monitors the effectiveness of the systemic changes. Findings include: A review of the Administrator's Job Description, dated 10/01/12, revealed the purpose of the position as: To direct the day-to-day functions of the facility in accordance with the current federal, state and local standards, guidelines and regulations that govern Nursing facilities to assure that the highest degree of quality care can be provided residents at all times. Essential function of the position included: Ensure excellent care for residents is maintained by overseeing and monitoring patient care services delivered. (Refer to F282 & F323) Resident #1 was mobile per a motorized wheelchair and would enter and exit the facility with staff assistance. The facility had assessed and care planned Resident #1 as a dependent smoker and required supervision for smoking. On 12/21/12, Resident #1 was found outside unresponsive, after smoking unsupervised, with a body temperature of 85.4 F; was admitted to the hospital Intensive Care Unit; and, diagnosed with [REDACTED]. Interviews revealed the resident would either go to a gravel area by the road or field beside the facility to smoke. An interview with the Administrator, on 01/02/13 at 4:10 PM and on 01/03/13 at 2:20 PM, revealed Resident #1 was assessed and care planned for requiring supervision when smoking. However, he stated the resident was his own responsible party and it was his/her right to smoke unsupervised when the resident was off the property. Further interview revealed the Agreement to Accept Responsibility for Resident form, which was utilized for residents to be signed out and back into the facility, was the facility system for monitoring residents when exiting and re-entering the facility. Nurses were responsible to ensure that form was completed; however, the Administrator stated he rarely looked at it. A review conducted on 12/28/12 of the facility Agreement to Accept Responsibility for Resident form utilized for Resident #1, revealed no documentation Resident #1 had been signed out of the facility on 12/21/12. The form was incomplete. Additionally, the review revealed thirty six (36) different entries on the form for Resident #1, dated 12/03/12 through 12/27/12. Of those entries twenty three (23) had no contact information, twenty three (23) had no expected return date or time. Eighteen (18) had no return date or time and twenty two (22) had no signature or mark for the person accepting responsibility. **The facility implemented the following actions to abate the Immediate Jeopardy : *All current residents were reviewed on 01/03/13 by the Director of Nursing, Assistant Director of Nursing, Unit managers, MDS Coordinator, Social Services Director, Activity Director, Dietary Services Manager, and Facility Rehab Coordinator, a licensed nurse and a nursing assistant to determine appropriate supervision in and outside of the facility. This was completed on 01/03/13. *All residents who wish to smoke were reviewed 01/03/13 by the Director of Nursing, Assistant Director of Nursing, Unit managers, MDS Coordinator, Social Services Director, Activity Director, Dietary Services Manager, and Facility Rehab Coordinator, a licensed nurse and a nursing assistant. New smoking assessments were completed on all residents. Any changes were addressed in the residents' care plans to determine appropriate supervision in and outside of the facility. This was completed on 01/03/13. *There are no current residents who leave the facility unsupervised. *All staff were re-educated on 01/03/13 by the Director of Nursing, Assistant Director of Nursing, Administrator, Unit manager or Education and Training Director on the smoking policy to include reporting to the licensed nurse any resident who appears to have difficulty smoking or unsafe smoking practices such as difficulty holding their own cigarette, dropping ashes on themselves and/or burning themselves or clothing. No staff will work after 01/03/13 without having completed this re-education. *All staff were re-educated on 01/03/13 by the Director of Nursing, Assistant Director of Nursing, Administrator, Unit manager or Education and Training Director on all resident who leave the facility must be reported to the Nurse responsible for caring for the resident who will assure appropriate supervision. No staff will work after 01/03/13 without having completed this re-education. *All Licensed Staff were re-educated on 01/03/13 on the revised facility policy for temporary leave of absence to include: any resident who leaves the facility the Licensed Nurse must evaluate the resident's supervision needs to include at a minimum medical condition, mental status, equipment needs, weather conditions and appropriate attire, as well as reviewing the resident's care plan for supervision. This policy also includes documentation on the leave of absence form when a resident leaves the facility and when the resident returns, and communication between shifts of what residents are still out of the facility at change of shift to include documentation on the 24 hour report. No Licensed Staff will work after 01/03/13 without having completed this re-education. *Residents smoking assessments will be completed by the Director of Nursing, Assistant Director of Nursing or Unit Manager, MDS Coordinator and Training Director beginning 01/04/13 and going forward. The Director of Nursing, Assistant Director of Nursing, Unit Manager, MDS Coordinator and Training Director were educated on completion of Smoking Assessments by the Director of Nursing. *An ad hoc Quality Assurance Committee (QPI) was held on 01/03/13 to review the alleged deficient practice as well as the plan for removal. In attendance were the Medical Director, Administrator, Director of Nursing, Assistant Director of Nursing, Unit Manager and MDS Coordinator. No further recommendations were made by the committee. *Monitoring of the plan of correction will be performed by the following: The Director of Nursing, the Assistant Director of Nursing, Unit Manager, MDS Coordinators, Administrator or Director of Education will contact the facility each shift to review with licensed staff to determine that residents who left the facility or are leaving the facility have been assessed by the licensed ruse to have appropriate supervision as well as any resident requiring increased supervision. This will occur daily on each shift for three weeks, then five times per week for three weeks, then three time a week for three weeks, then weekly for three weeks and substantial compliance. If at any time concerns are identified, a Quality Assurance Committee Meeting will be convened to make further recommendations. In addition, a Department Head will monitor two smoke breaks per day until substantial compliance to assure resident smoking safety interventions are in place. If at any time concerns are identified, a Quality Assurance Committee Meeting will be convened to make further recommendations. The Department Heads consist of the Administrator, Director of Nursing, Assistant Director of Nursing, Dietary Services Manager, Social Services Director, Activity Director, Maintenance Director, Business Office Manager, Medical Records and the MDS Coordinators. The Director of Nursing, the Assistant Director of Nursing, MDS Coordinators, Unit Manager, Administrator, or the Director of Education will review the Leave of Absence book to assure completion and review the twenty four hour report daily to assure documentation of any resident who remains on Leave of Absence at change of shift. this review will occur daily for four weeks followed by five time a week for eight weeks. If at any time concerns are identified, a Quality Assurance Committee Meeting will be convened to make further recommendations. The Quality Assurance Committee will meet weekly until substantial compliance is achieved. The Quality Assurance Committee will consist at a minimum the Medical Director, the Director of Nursing, the Administrator and the Education and Training Director. *Failure to comply with any of the above will result in individual re-training and as appropriate, disciplinary action. The surveyors validated the corrective action taken by the facility as follows: Record review for sampled residents revealed the residents' were reviewed to determine the appropriate level of supervision in and outside of the facility and the residents' care plans were updated. The residents who wished to smoke were reviewed for safety with smoking and new smoking assessments were completed for each resident. The care plans were updated, if needed. Record review validated the completion of all training of staff related to the smoking policy, reporting to nurse when a resident is leaving the building so the nurse can determine the appropriate supervision needed, the revised leave of absence policy, and how to complete the smoking assessment. A review of the leave of absence policy and procedure, dated 01/03/13, revealed it was revised to include that any resident who leaves the facility the Licensed Nurse must evaluate the resident's supervision needs to include at a minimum medical condition, mental status, equipment needs, weather conditions and appropriate attire, as well as reviewing the resident's care plan for supervision. This policy also includes documentation on the leave of absence form when a resident leaves the facility and when the resident returns, and communication between shifts of what residents are still out of the facility at change of shift to include documentation on the 24 hour report Interviews with the Education Training Director, the Dietary Manager, Assistant Director of Nursing, Unit Manager #1, Activity Assistant, Maintenance Manager, Business Office Assistant, RN #2, LPN #7, LPN #8, CNA #7, CNA #8, CNA #9, CNA #10, CNA #11, Nurse Aide (NA) #1, Dietary Aide (DA) #1 and DA #2, on 01/04/13 revealed the staff received the training related to the smoking policy, reporting to nurse when a resident is leaving the building so the nurse can determine the appropriate supervision needed, the revised leave of absence policy, and how to complete the smoking assessment. Interviews with the Medical Director, Administrator and Director of Nursing, on 01/04/13, confirmed there was an ad hoc QPI meeting held on 01/03/13 to review the alleged deficient practice as well as the plan for removal and no further recommendations were identified. A review of the monitoring calendar revealed the dates were marks for the days any reviews should be conducted according to the monitoring schedule.