Every finding on record at Lake Way Rehabilitation and Healthcare Center

Based on interviews and review of facility policies, the facility failed to have a designated Infection Preventionist (IP) who was responsible for the facility's Infection Control Program which had the potential to affect 84 of 84 residents. The findings include:During the entrance conference on [DATE] at 9:21 AM, the Administrator stated the facility had an Infection Preventionist (IP).Review of the facility policy titled, Infection Prevention and Control Program dated 04/2023, revealed, the Infection Prevention and Control Program (IPCP) of the facility was designated to establish and maintain an effective program that provided a safe, sanitary and comfortable environment. Further review revealed the facility's IPCP attempted to prevent the development and the transmission of diseases and infections. Review of the facility policy titled, Infection Control Preventionist dated 04/2023, revealed the facility would designate an Infection Control Preventionist (ICP) in compliance with federal, state, or local laws. Continued review revealed, the responsibilities of the ICP were listed as follows: performance of surveillance for the identification, investigation, and documentation of facility-acquired infections, and reviewing and analyzing facility data. Further review revealed the ICP's responsibilities also included: reporting infections to the appropriate local or state agency as required, and providing measures to prevent common infection in nursing home residents and/or staff. In interview with the Administrator on [DATE] at 10:32 AM, he stated the facility did not currently have a designated ICP. He stated the former ICP's spouse died unexpectedly, and she resigned on [DATE]. The Administrator reported the facility did not have a designated person for the ICP at that time. He stated he thought that the MDS nurse had taken over as she had been the ICP previously, but just learned that the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) were overseeing the ICP duties. He said he had set the Assistant Director of Nursing (ADON) up to take the infection control prevention classes for specialized training. He further stated the facility was currently using the Infection Control (IC) Nurse at the county health department when needed. On [DATE] at 8:40 AM, the Administrator provided documentation dated [DATE] at 8:08 AM, which showed the ADON had been registered for ICP training.The State Survey Agency (SSA) Surveyor requested to review the facility's Infection Control information on [DATE] at 10:50 AM. However, the facility did not provide that information until [DATE] at approximately 1:25 PM.Review of the monthly Infection Tracking Logs, provided on [DATE], revealed for timeframe of April-June of 2025, no concerns with infection monitoring on the part of the facility were identified.In interview with the Director of Nursing (DON) on [DATE] at 3:44 PM, she stated the facility did not currently have a designated ICP. She stated the former ICP resigned following the sudden death of her spouse last month ([DATE]). She stated she and the ADON were doing the tracking of infections. The DON said the facility followed guidelines, Centers for Disease and Control (CDC) guidelines, followed facility polices and utilized McGreers Criteria to determine infections. She reported infections in the facility were reviewed monthly and quarterly during the facility's Quality Assurance Performance Improvement (QAPI) meetings. The DON further stated the ICP role was important for the health of the facility's residents and staff.In interview with the Administrator on [DATE] at 4:39 PM, he stated the facility had hired nurses in the past for its ICP role; however, those nurses did not stay. He reported he had also signed up the facility's new Staff Development Coordinator (SDC) for the ICP classes as well so that the facility would have a back-up person for the ADON. The Administrator further stated it was extremely important to have an ICP for the health and safety of the facility's residents and staff.

Based on interview, record review, facility policy review, and review of the facility's investigation, it was determined the facility failed to have an effective system to ensure residents were free from abuse for two (2) of three (3) sampled residents (Resident #1, Resident #2). Review of the facility investigations revealed on 04/03/2022, State Registered Nurse Aide (SRNA) #1 was observed by Housekeeper #1 placing her hands over the mouth of Resident #2 and told the resident to shut up. Additionally, on 04/03/2022, SRNA #1 was observed by SRNA #2 and SRNA #3 to roughly transfer Resident #1 from the bed to the wheelchair and stated, Why won't you fucking turn? Resident #1 also sustained a skin tear during the transfer. Though SRNA #1 was observed to be physically and verbally abusive to Resident #1 and Resident #2, staff failed to report the allegations of abuse and allowed SRNA #1 to continue to work her scheduled shift, which compromised the safety and well-being of all the facility's residents. The facility's failure to have an effective system in place to ensure residents were free from abuse, has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on 11/10/2022 and was determined to exist on 04/03/2022 in the areas 42 CFR 483.12 Freedom from Abuse (F600 and F609) at a S/S of J. The facility was notified of the IJ on 11/10/2022. The facility provided an acceptable Immediate Jeopardy Removal Plan on 11/23/2022, alleging removal of the Immediate Jeopardy on 04/15/2022. The State Survey Agency (SSA) determined the IJ had been removed on 04/15/2022, as alleged, prior to exit on 11/23/2022. The facility implemented corrective action which was completed prior to the State Survey Agency's investigation. Based on validation of the facility's corrective actions it was determined to be Past Jeopardy. Refer to F609 The findings include: Review of the facility's policy, Abuse, Neglect, or Misappropriation of Resident Property Policy, revision date of 10/15/2022, revealed residents had the right to be free from abuse, neglect, involuntary seclusion, exploitation, or misappropriation of property. The facility would do whatever was in its control to prevent mistreatment, neglect, exploitation and abuse of residents or misappropriation of their property. Any employee who witnessed or suspected abuse, neglect, exploitation or misappropriation of property had occurred would immediately report the incident to the Administrator. Failure to report any concern related to neglect, exploitation, abuse, or misappropriation of property would result in disciplinary action and possible termination of employment. Additional review of the policy, revealed the definition of abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm or pain or mental anguish or deprivation by an individual, including a caretaker, or goods or services that were necessary to attain or maintain physical, mental and psychosocial well-being. This presumed that instances of abuse of residents, even those in a coma, could cause physical harm, pain, or mental anguish to the residents. Abuse included verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facility or enabled through the use of technology. Continued review of the policy further revealed the definition of verbal abuse as any use of oral, written, or gestured language that willfully included disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse included but were not limited to: threats of harm; saying things to frighten a resident, such as telling a resident that he/she will never be able to see his/her family again; using derogatory language; or ignoring residents while care was being provided. Physical abuse included hitting, slapping, pinching, and kicking. 1. Closed clinical record review revealed the facility admitted Resident #2 on 08/27/2021 with diagnoses which included Cerebral Infarction, Major Depressive Disorder, Symptoms and Signs Involving Cognitive Functions and Awareness. The resident was discharged from the facility on 06/10/2022. Review of Resident #2's Quarterly Minimum Data Set (MDS) Assessment, dated 02/14/2022, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of six (6) out of fifteen (15), indicating severely impaired cognition. Review of Resident #2's Comprehensive Care Plan, dated 04/11/2022, revealed the resident had ineffective coping which elicits behaviors of repetitive actions such as repeating words and counting over and over again. Further review of the care plan revealed an intervention to distract the resident to break the repetitive cycle. Review of State Registered Nurse Aide (SRNA) #1's personnel file revealed the employee was hired on 08/06/2020. A criminal background was completed and there was no evidence of disciplinary action noted in the employee's file. SRNA #1 was suspended on 04/04/2022 and resigned from her position on 04/08/2022. Review of the facility investigation, dated 04/08/2022, completed by the Nurse Consultant and the Administrator, related to Resident #2, revealed the investigation was initiated on 04/07/2022 after learning of the abuse allegation made by Housekeeper #1 to the Administrator. The investigation revealed on 04/03/2022 at 10:00 AM, SRNA #1 walked up behind Resident #2 and placed her hands over the resident's mouth and told the resident to shut up. At the conclusion of their investigation, the facility reported based on a thorough investigation including chart reviews, resident interviews, resident assessments, staff interviews and observation, the facility was unable to substantiate the allegation of abuse at that time. Review of the Witness Statement by Housekeeper #1, dated 04/07/2022 at 1:45 PM, revealed she witnessed SRNA #1 walk behind Resident #2, putting her hands over the resident's mouth and telling the resident to shut up. A couple of minutes later the housekeeper witnessed SRNA #1 push the resident's arm down and told the resident to shut up and stop yelling, it's annoying. Interview with SRNA #1, on 10/31/2022 at 1:37 PM, revealed it was reported she had been cursing at Resident #2. The SRNA reported she had asked the resident to be quiet but had not laid a hand on the resident. The incident was reported on 04/07/2022. She revealed she was suspended the morning of 04/04/2022. The SRNA revealed she had been educated on abuse in orientation and is aware abuse should be reported as soon as you see it. Interview with Housekeeper #1, on 11/01/2022 at 1:35 PM, revealed she witnessed SRNA #1 put her hands over Resident #2's mouth and told the resident to shut up on 04/03/2022 at 10:00 AM. The resident was sitting in the wheelchair in the common area. The Housekeeper revealed that she had received a little information on abuse prior to the incident when she was hired and reported she had since received in depth abuse education. The allegation of abuse was reported by Housekeeper #1, on 04/07/2022 to the Administrator. 2. Closed clinical record review revealed the facility admitted Resident #1 on 07/07/2021 with diagnoses which included Violent Behavior, Dementia with Behavioral Disturbance, and Disorientation. The resident was discharged from the facility on 06/05/2022. Review of Resident #1's Quarterly MDS, dated [DATE], revealed the facility assessed the resident as having a BIMS score of zero zero (00), indicating severe cognitive impairment. Review of the facility's Investigation dated 04/04/2022, and completed by the Nurse Consultant, revealed the Director of Nursing (DON) received an allegation of abuse, on 04/04/2022 at 7:00 AM, from State Registered Nurse Aide (SRNA) #2 regarding abuse of Resident #1 by SRNA #1, which occurred on 04/03/2022 at 3:30 PM. The investigation revealed SRNA #1 was rough with Resident #1 during a transfer. Further review of the investigation revealed the resident's responsible party and physician were notified of the incident. The resident had sustained a skin tear to the left arm after sitting on his/her own hand. Care was provided to Resident #1's skin tear by Licensed Practical Nurse (LPN) #1, who assessed the area and carried out the orders from the physician which included a dressing and geri sleeves. Involved staff were interviewed and statements were received. When SRNA #1 arrived to work on 04/04/2022 at 8:00 AM, she gave a statement and was suspended pending the outcome of the abuse investigation. After the facility finished its investigation, they concluded that based on the assessment of the resident, interviews with staff members, record review, employee file review, and a review of the timeline of events, the facility determined they were unable to substantiate an allegation of abuse. Review of State Registered Nurse Aide (SRNA) #2's witness statement provided on 04/04/2022 to the DON, revealed she was transferring Resident #1 to the wheelchair when the alarm sounded and SRNA #1 and SRNA #3 entered the room to assist. SRNA #2 alleged SRNA #1 went over to Resident #1 and pulled the resident away from SRNA #2 and sat the resident in the wheelchair roughly while making the statement, why won't you fucking turn? SRNA #2 revealed the resident sat on his/her own hand causing a skin tear. Review of the State Registered Nurse Aide (SRNA) #1's time sheet revealed the SRNA worked from 6:03 AM and clocked out at 5:56 PM on 04/03/2022, the date of the incident. Interview with SRNA #1, on 10/31/2022 at 1:37 PM, revealed on 04/03/2022 at 3:30 PM, SRNA #2 was getting Resident #1 up and she along with SRNA #3 entered the room to assist. She stated she was assisting SRNA #2 with the transfer of the resident from the bed to the wheelchair and during the transfer the resident sustained a skin tear to his/her left forearm arm after getting his/her hand caught under himself/herself. SRNA #1 stated she reported the skin tear immediately to Licensed Practical Nurse (LPN) #1. SRNA #1 denied being rough with the resident. Per the interview, SRNA #1 stated the resident did not yell out while being assisted into the wheelchair. SRNA #1 revealed she resigned on 04/08/2022. The State Survey Agency (SSA) Surveyor attempted telephone contact with SRNA #2 on 10/30/2022 at 2:04 PM, 10/31/2022 at 11:32 AM, 10/31/2022 at 2:14 PM, and 11/04/2022 at 11:37 AM; however, there was no response or a callback. Interview with SRNA #3, on 11/02/2022 at 1:22 PM, revealed she and SRNA #1 went to assist SRNA #2 with the transfer of Resident #1 after hearing the resident's bed alarm. She stated SRNA #1 took over the transfer, and independently transferred the resident from his/her bed to his/her wheelchair, when she entered the room. State Registered Nurse Aide (SRNA) #3 revealed the resident sustained a skin tear to the arm, during the transfer, and stated she heard SRNA #1 curse, but did not recall exactly what was stated. She revealed SRNA #1 had an attitude, at times. The SRNA revealed she reported the incident to Licensed Practical Nurse (LPN) #1. Interview with Licensed Practical Nurse (LPN) #1, on 11/01/2022 at 10:46 AM and on 11/04/2022 at 12:10 PM, revealed SRNA #1 had reported the skin tear to Resident #1's arm. She revealed she notified the resident's responsible party, and the physician of the skin tear and treatment orders were obtained. LPN #1 stated when she asked SRNA #2 and SRNA #3 if they felt like the incident was abuse, both SRNAs were unsure, but reported it had been a rough transfer. LPN #1 revealed SRNA #2 believed SRNA #1 abused Resident #1. Further, she stated it was abuse and SRNA #3 was not sure. LPN #1 stated she reported the incident to the Assistant Director of Nursing (ADON) on 04/03/2022 at 5:48 PM followed by the DON. Interview with the former Director of Nursing (DON), on 11/01/2022 at 10:07 AM, revealed she was called the evening of 04/03/2022 about the possible abuse by the Assistant Director of Nursing (ADON) about the rough transfer with a skin tear. On the morning of 04/04/2022, the DON revealed SRNA #2 reported to her that SRNA #1 was observed to be abusive towards Resident #1, the day before, on 04/03/2022. Continued interview with the DON revealed she realized SRNA #1 finished her shift. Per the interview with the DON, she began the investigation and suspended SRNA #1, to protect the residents from potential abuse, while conducting the investigation. Interview with the Director of Nursing (DON), on 11/01/2022 at 9:40 AM, revealed she had only worked at the facility for a few months and was not employed at the facility when the abuse allegations occurred. However, she revealed she would expect staff to ensure the safety of the resident and immediately notify their supervisor, and if the supervisor did not report, then staff were expected to go up the chain to report the incident Interview with the Interim Administrator, on 11/02/2022 at 2:48 PM, revealed he expected staff to keep the residents safe and if there was an abuse allegation that it would be reported to the DON/Administrator immediately. He further stated an investigation would be started and the allegation would be reported to the State Agency. The facility provided an acceptable Immediate Jeopardy Removal Plan on 11/23/2022, alleging removal of the Immediate Jeopardy on 04/15/2022. Review of the Immediate Jeopardy Removal Plan revealed the facility implemented the following: 1. On 04/04/2022, Licensed nursing staff completed skin assessments of 100% of cognitively impaired resident with a Brief Interview for Mental Status (BIMS) of less than eight (8). 2. On 04/04/2022, the Social Service Director (SSD) completed resident interviews with 100% of alert and oriented residents with a BIMS above (8) eight. No residents voiced any concerns of abuse, and no areas of concern were identified. 3. On 04/05/2022, the Facility Consultant reviewed 100% of grievances for January, February, and March 2022, to ensure all reportable allegations were reported and investigated. 4. The Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON) and the Facility Consultant conducted 100% staff interviews regarding allegations of abuse to determine if any were not reported. This was completed by 04/05/2022. As of 04/08/2022, any staff member who had not been interviewed was not allowed to work until interviews were completed. On 04/07/2022 an issue was identified. This situation involved the same staff member who was already suspended based on the first investigation. The second incident was reported to the appropriate state agencies. 5. On 04/05/2022, the Facility Consultant did in-service with the Administrator, DON, ADON and Unit Manager (UM). The abuse policy was reviewed, reporting immediately, within two (2) hours and within twenty-four (24) hours was discussed. They also went over the types of abuse, The Elderly Justice Acts and required postings in the facility, protecting the residents immediately and the suspension of the alleged perpetrator. 6. Nursing management staff to include the UM, ADON, DON and Facility Consultant completed re-education with 100% of facility staff to include as needed staff. The facility did not use agency or temporary staff at the time of this re-education. All education was completed by 04/08/2022. Education was provided on the abuse policy, reporting all allegations of abuse immediately to the supervisor, the types of abuse, the Elderly Justice Act, protection of the residents and suspension of the alleged perpetrator. 7. The Facility Consultant, DON, ADON, UM and Administrator conducted quizzes with 100% of staff currently employed at the facility. This was completed 04/08/2022. 8. On 04/07/2022, the Administrator educated Housekeeper #1 regarding the abuse policy, types of abuse, timely reporting of abuse and immediate protection of the resident. Housekeeper #1 was no longer employed at the facility. 9. Any staff that could not be reached on scheduled workday or by phone was sent a certified letter explaining the expectation for reeducation. 10. All new staff since 04/08/2022 were educated upon hire on the abuse policy with a focus on timely reporting of abuse. 11. The Facility Consultant attempted to report on 04/11/2022 to the State Board of Nursing and Community College that SRNA #2 had been substantiated for abuse. 12. Starting 04/15/2022, the facility would interview five (5) staff members to determine if any new allegations of abuse were not reported, when it required reporting and to whom. This was conducted by the DON, ADON, UM and/or the Administrator. Staff were selected randomly, to account for different shifts and different units with the focus on direct care staff members. Audits of five (5) staff per week were completed for four (4) weeks, two (2) staff per week for two (2) weeks, one (1) staff per week for two (2) weeks and one (1) staff per month for two (2) months. 13. Starting 04/15/2022, the facility had five (5) staff members complete an Abuse Quiz which was administered by the DON, ADON, UM and/or Administrator for four (4) weeks. Then two (2) staff for two (2) weeks, one (1) staff for two (2) weeks and one (1) staff for two (2) months. This was used to ensure the staff were maintaining what they learned through the re-education. Any staff member who did not obtain 100% were retrained on the spot. 14. Starting 04/15/2022, five (5) residents per week for four (4) weeks with a BIMS greater than eight (8) were randomly selected for interviews by the SSD. She used the Safe Survey to identify if resident had any concerns about how they were treated by staff in the facility. The facility continued to do this assessment of two (2) residents for two (2) weeks, one (1) resident for two (2) weeks and then one (1) resident for two (2) months. No concerns were identified. 15. The Quality Assurance Performance Improvement (QAPI) team met on 04/04/2022 to put a plan of action together once concerns of abuse had been identified. Present at the initial meeting were the Administrator, the DON, Dietary Manager, Facility Consultant, Rehabilitation Director, Unit Manager, SSD, and the Minimum Data Set Nurse. The Medical Director was present on the phone but did not offer any new suggestions. The last QAPI meeting reviewing the performance improvement plan was held on 07/27/2022 with no new issues identified since the initiation of the improvement plan. Members present included the Administrator, DON, Medical Director via phone, Environmental Services Director, SSD, MDS Nurse, and the Quality Improvement Nurse. The State Survey Agency validated the implementation of the facility's IJ Removal Plan as follows: 1. Review of Skin Assessments as compared to the Brief Interview for Mental Status (BIMS) listing for the time of this event validated each resident with a BIMS less than (8) had a skin assessment. No signs or symptoms of abuse were identified by the facility and after review, none were identified by the surveyor. 2. Review of the interview questionnaire of residents with a BIMS of eight (8) or greater completed on 04/04/2022, revealed no residents voiced any concerns regarding abuse through the interviews conducted by the SSD. Interview with Resident #6 on 11/21/2022 at 9:35 AM, revealed the resident felt very safe at the facility, staff were kind and took good care of her/her. The resident also stated the staff never talked bad or mistreated him/her in any way. Resident #6 reported he/she would talk to the Director of Nursing (DON) or the SSD if there were any concerns and felt things would be taken care of. Interview with Resident #4, on 11/21/2022 at 10:00 AM, revealed staff treated him/her very well. The resident revealed he/she felt very safe at the facility and the staff were wonderful and kind. Interview with Resident #7, on 11/21/2022 at 10:35 AM, revealed staff were really good and provided great care. Resident #7 revealed staff were very busy but were still able to meet his/her needs. The resident stated he/she was very outspoken and had no problem reporting any concerns to the staff. 3. Interview with the Facility Consultant on 11/23/2022 at 6:00 PM, revealed she reviewed each entry into the grievance log for January, February, and March 2022 as alleged. She revealed however, a formal documented audit did not occur. She wrote a signed statement to show she reviewed the grievance log information and had not found any concerns. The State Survey Agency (SSA) Surveyor reviewed all the facility's grievance logs from April 2022 to the current date and discovered eight (8) areas the facility called care delivery concerns. Based on review of those eight (8) cases residents were interviewed and either could not recall the event, or no longer had any concerns regarding the issue. Interview on 11/21/2022 at 10:45 AM, with Resident #7 revealed he/she no longer had any care concerns. 4. Review of the facility's documentation of the abuse questions completed by staff compared to the staff roster revealed one hundred and one (101) staff's name present, which was 100% of the facility's staff at that time, documented as having completed the training as alleged. Additionally, interviews were 11/22/2022: with SRNA #6 at 1:45 PM; SRNA #7 at 1:30 PM; SRNA #8 at 2:35 PM; SRNA #12 at 12:40 PM; SRNA #13 at 1:50 PM; and SRNA #14 at 2:55 PM. All the SRNAs revealed they were interviewed about any allegations of abuse or concerns of abuse, how and when abuse was to be reported to the DON and/or the Facility Consultant. Interview on 11/22/2022: with Housekeeper #1 at 12:05 PM; Housekeeper #2 at 12:15 PM; and a laundry staff person at 12:30 PM revealed all had been interviewed by the DON and/or the Facility Consultant about when to report abuse, to whom to report abuse and the different kinds of abuse. All staff interviewed revealed it was not up to them to determine if a situation was abuse or not, they were just to report it immediately to management. 5. Interview with Licensed Practical Nurse (LPN) #7/Unit Manager on 11/22/2022 at 3:00 PM, revealed she had been provided education by the Facility Consultant on the abuse policy; reporting immediately, within two (2) hours and within twenty-four (24) hours; the types of abuse; the Elderly Justice Acts; required postings in the facility; protecting the residents immediately and suspension of the alleged perpetrator. LPN #7 stated she had to pass a quiz covering all those subjects. Interview with the ADON on 11/23/2022 at 5:45 PM, revealed she was provided education by the Facility Consultant on the abuse policy; reporting immediately, within two (2) hours and within twenty-four (24) hours; the types of abuse; the Elderly Justice Acts; required postings in the facility; protecting the residents immediately and suspension of the alleged perpetrator. The ADON stated she was required to take a quiz and pass it with 100%. Interview with the DON on 11/23/2022 at 6:00 PM, revealed the Facility Consultant provided in-services on the abuse policy; reporting immediately, within two (2) hours and within twenty-four (24) hours; the types of abuse; the Elderly Justice Acts; required postings in the facility; protecting the residents immediately and suspension of the alleged perpetrator. Interview with the Administrator on 11/23/2022 at 6:15 PM, revealed the Facility Consultant covered the abuse policy; reporting immediately, within two (2) hours and within twenty-four (24) hours; the types of abuse; the Elderly Justice Acts; required postings in the facility; protecting the residents immediately and suspension of the alleged perpetrator with him. 6. Review of the facility's sign in sheets for the in-services provided for staff revealed one hundred and one (101) staff's names, which represented 100 % of the facility's staff employed at that time. Per review, all education was completed by 04/08/2022. Interviews conducted with thirty-four (34) facility staff on 11/22/2022 through 11/23/2022, revealed very staff member interviewed was able to name the seven (7) types of abuse, when to report incidents (immediately), who to report to incidents to (their direct supervisor), the DON, and the Administrator. In addition, all staff interviewed were able to identify that resident safety was the number one (1) priority, and the alleged perpetrator would be suspended pending investigation. Further interview revealed staff also expressed understanding that it was not up to them to decide if a situation was abuse or not, it had to be reported so management could investigate. Interview with the Facility Consultant, on 11/23/2022 at 6:00 PM, revealed she provided reeducation to the Administrator and all staff were provided education on 04/04/2022. Interview revealed she immediately activated the Performance Improvement Plan (PIP) and started doing quizzes with staff. According to the Facility Consultant, all staff were present and took the quiz and were required to get 100%. She stated if the staff member did not get 100% score, reeducation was conducted on the spot and the quiz was taken again until 100% was achieved. 7. Interview with the Facility Consultant on 11/23/2022 at 6:20 PM, revealed she was present for the quizzes for the majority of staff members. She revealed she was at the door where the quiz was given and graded it on the spot. Continued interview revealed any missed items were immediately reviewed with the staff member and then the staff member had to take the quiz again until 100% was achieved. She further stated staff were not scheduled to work again until the task was completed. 8. Review of the facility's signed document revealed the Administrator completed the alleged education for Housekeeper #1 regarding the abuse policy, types of abuse, timely reporting of abuse and immediate protection of the resident listed on 04/07/2022. Per review, Housekeeper #1 was disciplined, and warning disciplinary action was validated by the SSA Surveyor. Interview with the Administrator on 11/23/2022 at 4:30 PM, revealed he provided the re-education for Housekeeper #1 back in April 2022, when the incidents arose. He revealed he went over the F600 regulation with the staff member and a warning disciplinary action was given to the Housekeeper #1. 9. Review of the facility's certified mail receipts revealed letters were sent as alleged, and the card received back prior to 04/15/2022. The review revealed no concerns were noted. 10. Review of the last five (5) staff hired revealed the abuse packet in orientation and review of the policy to ensure new staff were educated and understood the expectation. Interview on 11/22/2022, with Housekeeper #2 and Housekeeper #3, Laundry Staff #1, Cook, and Nurse Aide Student revealed all the staff each knew the seven (7) types of abuse; knew to make sure the resident was safe; to report to management immediately; and that they did not determine what was or was not abuse. Interview with the Staff Development Coordinator on 11/23/2022 at 1:25 PM, revealed she had helped with ongoing training for new staff in orientation. She revealed all staff were trained on abuse before they access the floor, and this had included her. Per the SDC, the Facility Consultant did the orientation with her and went over the facility policies and procedures since she was new to this agency. She revealed she had been doing on going education with staff on abuse. Interview with the DON on 11/23/2022 at 1:40 PM revealed she was provided education when she came on board with the facility. 11. Interview with the Facility Consultant on 11/23/2022 at 6:00 PM, revealed she called the State Board of Nursing and was informed they were not where that information needed to be reported to. She stated she was told to contact the State Community College to make the report. Per interview she called the State Community College and was informed they did not take that type of report either. She called back to the Board of Nursing, and they did not have a different answer. Further interview revealed the Facility Consultant had a signed form to account for the phone calls she had made regarding determining the correct reporting path, which she had been unable to do. 12. Starting 04/15/2022, the facility will interview five (5) staff members to determine if any new allegations of abuse were not reported, when it required reporting and to whom. This was conducted by the DON, ADON, UM and/or the Administrator. Staff were selected randomly, to account for different shifts and different units with the focus on direct care staff members. Audits of five (5) staff per week were completed for four (4) weeks, two (2) staff per week for two (2) weeks, one (1) staff per week for two (2) weeks and one (1) staff per month for two (2) months. Review of the facility's audits revealed the facility interviewed staff members as alleged in the IJ Removal Plan within the specified timeframes and no concerns were noted. Interviews with staff conducted between 11/22/2022 and 11/23/2022 revealed thirty-four (34) staff plus management staff, to include housekeepers, laundry, maintenance, dietary staff, nurse aides and licensed nurses were able to account for each subject they received education on. Each staff member could report the seven (7) types of abuse, identify they were to keep the resident safe, and report immediately to management. Also, staff reported it was not up to them to decide if something was abuse or not, just report anything that was a concern. It was determined through these interviews, two (2) staff members could use a bit more education on the exact requirements, but they knew the basics. The facility was made aware of the concerns. This does not put them to a later compliance date because of the special needs of those two (2) staff members. Interview with the MDS Coordinator on 11/23/2022 at 1:00 PM, revealed she helped with in-services and did pop up interviews on staff randomly and ask them abuse questions. Further interview revealed she felt the facility had done a great job making sure everyone knew the expectation on abuse and what had to happen. 13. Review of the facility's documentation of staff audits revealed the number of staff audits was provided and noted to be accounted for each timeframe represented above. Per review, the staff interviewed were able to verbalize the seven (7) types of abuse, state they were to report incidents immediately and to keep the residents safe. Further review revealed as of 11/22/2022, the facility had provided much abuse training for many staff regarding the ongoing education over the months by all management staff, with no concerns found. 14. Interview with Resident #4 on 11/22/2022 at 10:00 AM, revealed the facility had interviewed him/her, and he/she felt safe in the facility. Resident #4 stated staff treated him/her well and if there were any concerns, he/she knew to report to the charge nurse or the DON. Interview with Resident #7 on 11/22/2022 at 10:35 AM, revealed the facility had interviewed him/her and he/she felt safe in the facility. The resident revealed staff were kind and provided good care and if there were any concerns, he/she would report it to the DON and/or Administrator. Interview with the Social Services Director (SSD) on 11/23/2022 at 12:40 PM, revealed she helped with the facility's removal plan and completed the Safe Surveys with residents and no concerns were found. 15. Review of the facility's QAPI minutes documentation and sign in sheet for 04/04/2022 revealed the Facility Consultant, Dietary Manager, Unit Manager, Social Service Director, and Administrator were present. Per review, they identified the abuse [TRUNCATED]

Based on interview, record review and a review of the facility's policy, it was determined the facility failed to have an effective system in place to ensure allegations of abuse were reported immediately to state agencies for two (2) of three (3) residents (Residents #1 and #2). Review of the facility's abuse investigations, dated 04/04/2022 and 04/07/2022 revealed the facility failed to report allegations of abuse in a timely manner, less than two (2) hours. Staff's failure to report two (2) allegations of abuse in a timely manner, presented a delay in the onset of the abuse investigations, which allowed State Registered Nurse Aide (SRNA) #1 to abuse Resident #1 the same afternoon as the abuse of Resident #2. Staff witnessed SRNA #1 cover the mouth of Resident #2 and told the resident to shut up and later in the day two (2) other staff witnessed SRNA #1 roughly transfer Resident #1 from the bed to the chair, and stated, Why won't you fucking turn?. Resident #1 sustained a skin tear to the left arm during the transfer after the resident's arm was caught under him/her. Review of the facility's investigations, dated 04/03/2022 at 10:00 AM, revealed Resident #2 was in the common area and was repetitively counting when Housekeeper #1 witnessed SRNA #1 place her hands over the resident's mouth and stated, shut up. The abuse allegation was not reported until 04/07/2022 at 1:45 PM by SRNA Housekeeper #1 to the Administrator. Review of the facility's investigation, on 04/03/2022 at 3:30 PM, SRNA #2 and SRNA #3 witnessed SRNA #1 roughly transfer Resident #1 from the bed to the chair. The resident sustained a skin tear to the left arm during the transfer after his/her hand was caught under the resident. The abuse allegation was not reported until 04/04/2022 at 7:00 AM to the Director of Nursing (DON) by State Registered Nurse Aide (SRNA) #2. The facility's failure to have an effective system in place to ensure the reporting of abuse allegations to the state agency in a timely manner, less than two (2) hours, has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 11/10/2022, and was determined to exist on 04/03/2022, at CFR 483.12 Freedom from abuse (F600, F609). The facility was notified of Immediate Jeopardy on 11/10/2022. The State Survey Agency validated the removal of the Immediate Jeopardy, as alleged, on 04/15/2022. The facility provided an acceptable Immediate Jeopardy Removal Plan on 11/23/2022, alleging removal of the Immediate Jeopardy on 04/15/2022. The State Survey Agency (SSA) determined the IJ had been removed on 04/15/2022, as alleged, prior to exit on 11/23/2022. The facility implemented corrective action which was completed prior to the State Survey Agency's investigation. Based on validation of the facility's corrective actions it was determined to be Past Jeopardy. The findings include: Review of facility policy, titled Abuse, Neglect, or Misappropriation of Resident Property Policy, revision date of 10/15/2022, revealed any employee who witnessed or suspected that abuse, neglect, exploitation, or misappropriation of property had occurred would immediately report the alleged incident to their supervisor, who would immediately report the incident to the Administrator. Further review of the policy revealed the Administrator was responsible for ensuring that complaints of abuse, neglect, exploitation, or misappropriation of property and injuries of unknown origin were investigated. Measures would be initiated to prevent any further potential abuse while the investigation was in progress. The Administrator was responsible to review the results of the investigation and report the alleged incident to the appropriate agencies in accordance with state and federal regulations. Further, the Administrator would ensure the Division of Licensure and Regulation would be notified immediately of all complaints of abuse, and neglect, including injuries of unknown origin, misappropriation of resident property. Employees would immediately report such allegations to the Administrator who would ensure the Cabinet was notified in accordance with KRS 209.030, as amended. All such allegations would be investigated and action taken as necessary to prevent further potential abuse while the investigation was in progress. 1. Closed clinical record review revealed the facility admitted Resident #2 on 08/27/2021 with diagnoses which included Major Depressive Disorder, Cerebrovascular Disease (CVD), Disorientation and Other Symptoms and Signs Involving Cognitive Functions and Awareness. The resident was discharged from the facility on 06/10/2022. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of six (6), indicating severe cognitive impairment. Review of the facility investigation completed by the Nurse Consultant and the Administrator, revealed the incident occurred on 04/03/2022 at 10:00 AM. SRNA #1 placed her hands over Resident #2's mouth and told the resident to shut up while the resident was sitting in the common area. The incident was not reported to the Administrator until 04/07/2022 at 1:45 PM. The State Agency was notified on 04/08/2022 at 2:58 PM, over 24 hours after the allegation was received by the Administrator. Review of the witness statement for Housekeeper #1, on 04/03/2022 at 10:00 AM, revealed she witnessed SRNA #1 walk up behind Resident #2, putting her hands over the resident's mouth and said to the resident to shut up. The resident had been counting repetitively. A couple of minutes later the housekeeper witnessed SRNA #1 push the resident's arm down and told the resident to shut up and stop yelling, it's annoying. The resident was sitting in the common area. The Housekeeper reported the abuse allegation on 04/07/2022 at 1:45 PM to the Administrator. Interview with the State Registered Nurse Aide (SRNA) #1, on 10/31/2022 at 1:37 PM, revealed someone had reported she had cursed at Resident #2. The SRNA reported she simply asked the resident to be quiet and never touched the resident. Interview with Housekeeper #1, on 11/01/2022 at 1:35 PM, revealed she witnessed SRNA #1 put her hands over Resident #2's mouth and told the resident to shut up while the resident was sitting in the common area. The Housekeeper stated she was not sure if what she saw was abuse until she was in an abuse training being done by the facility. She revealed that she had received a little information on abuse when she was hired and reported she had since received in-depth abuse education. She did not report the allegation immediately. The abuse allegation was reported to the Administrator on 04/07/2022 at 1:45 PM, four (4) days after SRNA #1 was witnessed being abusive to Resident #2. 2. Closed clinical record review revealed the facility admitted Resident #1 on 07/07/2021 with diagnoses which included Violent Behavior, Dementia with Behavioral Disturbance and Disorientation. The resident was discharged from the facility on 06/05/2022. Review of Resident #1's Quarterly MDS, dated [DATE], revealed the facility assessed the resident as having a BIMS score of zero zero (00), indicating severe cognitive impairment. Review of the investigation, dated 04/04/2022, revealed the allegation of abuse for Resident #1 was formally made to the former DON on 04/04/2022 at 7:00 AM, at which time the abuse investigation was initiated. The staff had reported a rough transfer with a skin tear by SRNA #1. The resident's hand became caught underneath him/her during the transfer. The State Agency was notified on 04/04/2022 at 9:18 AM. The alleged abuse occurred on 04/03/2022 at 3:30 PM. SRNA #1 arrived to work on 04/04/2022 at 8:00 AM, gave a statement of the events and she was then suspended pending the outcome of the investigation. The SRNA resigned her position on 04/08/2022. The State Survey Agency (SSA) Surveyor, attempted to telephone contact with State Registered Nurse Aide (SRNA) #2; on 10/30/2022 at 2:04 PM, 10/31/2022 at 11:32 AM, 10/31/2022 at 2:14 PM, and 11/04/2022 at 11:37 AM; however, was unsuccessful. Interview with SRNA #1, on 10/31/2022 at 1:37 PM, revealed she was assisting SRNA #2 to transfer Resident #1 from the bed to the wheelchair. The resident sustained a skin tear to the left arm when the resident's arm was caught under the resident while he/she was being transferred. SRNA #1 denied being rough with the resident. After the transfer, SRNA #1 took Resident #1 to be seen by LPN #1 for treatment of the skin tear. Interview with State Registered Nurse Aide (SRNA) #3, on 11/02/2022 at 1:22 PM, revealed she and SRNA #1 had heard Resident #1's alarm sound so they went into the room to assist. SRNA #1 went to the side of the bed where SRNA #2 was to assist. The resident was transferred from the bed to the chair. SRNA #3 described the transfer as being rough. She also overheard SRNA #1 curse at the resident but could not remember exactly what she said. The resident sustained a skin tear to the arm during the transfer when the resident's arm got under him/her. She revealed that she did not report the incident immediately, but then talked with Licensed Practical Nurse (LPN) #1 about the incident and was unsure if the incident was abuse. Interview with Licensed Practical Nurse (LPN) #1, on 11/04/2022 at 12:10 PM, revealed she spoke with SRNA #2 and SRNA #3 regarding the incident as they reported it was a rough transfer. The LPN revealed she asked the SRNAs if they felt what had happened was abuse. Per the LPN, SRNA #2 felt like it was abuse and SRNA #3 wasn't sure and thought it was a rough transfer. The LPN stated SRNA #2 and SRNA #3 did not want SRNA #1 to get into trouble. LPN #1 reported the possible allegation of abuse to the Assistant Director of Nursing (ADON) who notified the DON. Interview with the Director of Nursing (DON), on 11/01/2022 at 9:40 AM, revealed she had only been in her role for a few months and she was not working in the facility at the time of either of the abuse allegations but that it was her expectation that the regulations and policies be followed. Interview with the former Director of Nursing (DON), on 11/01/2022 at 10:07 AM, revealed she was called the evening of 04/03/2022 about the possible abuse of Resident #1 and it was described as a rough transfer to her. However, per the interview, on the morning of 04/04/2022, SRNA #2 reported to her that Resident #1 was observed to be verbally and physically abused by SRNA #1. The former DON revealed she did not begin investigating the abuse until SRNA #2's report. The former DON revealed she suspended SRNA #1, pending the outcome of the abuse investigation. Interview with the Interim Administrator, on 11/02/2022 at 2:48 PM, revealed he was not working in the facility at the time of the allegations. He stated his expectations regarding abuse, were to keep the resident safe and if abuse was suspected, the resident's safety would be ensured and the allegations of abuse should be reported immediately to the DON and Administrator. Interview with the Administrator, on 11/18/2022 at 12:04 PM, revealed it was his expectation that allegations of abuse would be reported to state agencies, as per the facility's policy. He further stated, the facility had not followed the regulation as written, but should have. The facility provided an acceptable Immediate Jeopardy Removal Plan on 11/23/2022, alleging removal of the Immediate Jeopardy on 04/15/2022. Review of the Immediate Jeopardy Removal Plan revealed the facility implemented the following: 1. On 04/04/2022, Licensed nursing staff completed skin assessments of 100% of cognitively impaired resident with a Brief Interview for Mental Status (BIMS) of less than eight (8). 2. On 04/04/2022, the Social Service Director (SSD) completed resident interviews with 100% of alert and oriented residents with a BIMS above (8) eight. No residents voiced any concerns of abuse, and no areas of concern were identified. 3. On 04/05/2022, the Facility Consultant reviewed 100% of grievances for January, February, and March 2022, to ensure all reportable allegations were reported and investigated. 4. The Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON) and the Facility Consultant conducted 100% staff interviews regarding allegations of abuse to determine if any were not reported. This was completed by 04/05/2022. As of 04/08/2022, any staff member who had not been interviewed was not allowed to work until interviews were completed. On 04/07/2022 an issue was identified. This situation involved the same staff member who was already suspended based on the first investigation. The second incident was reported to the appropriate state agencies. 5. On 04/05/2022, the Facility Consultant did in-service with the Administrator, DON, ADON and Unit Manager (UM). The abuse policy was reviewed, reporting immediately, within two (2) hours and within twenty-four (24) hours was discussed. They also went over the types of abuse, The Elderly Justice Acts and required postings in the facility, protecting the residents immediately and the suspension of the alleged perpetrator. 6. Nursing management staff to include the UM, ADON, DON and Facility Consultant completed re-education with 100% of facility staff to include as needed staff. The facility did not use agency or temporary staff at the time of this re-education. All education was completed by 04/08/2022. Education was provided on the abuse policy, reporting all allegations of abuse immediately to the supervisor, the types of abuse, the Elderly Justice Act, protection of the residents and suspension of the alleged perpetrator. 7. The Facility Consultant, DON, ADON, UM and Administrator conducted quizzes with 100% of staff currently employed at the facility. This was completed 04/08/2022. 8. On 04/07/2022, the Administrator educated Housekeeper #1 regarding the abuse policy, types of abuse, timely reporting of abuse and immediate protection of the resident. Housekeeper #1 was no longer employed at the facility. 9. Any staff that could not be reached on scheduled workday or by phone was sent a certified letter explaining the expectation for reeducation. 10. All new staff since 04/08/2022 were educated upon hire on the abuse policy with a focus on timely reporting of abuse. 11. The Facility Consultant attempted to report on 04/11/2022 to the State Board of Nursing and Community College that SRNA #2 had been substantiated for abuse. 12. Starting 04/15/2022, the facility will interview five (5) staff members to determine if any new allegations of abuse were not reported, when it required reporting and to whom. This was conducted by the DON, ADON, UM and/or the Administrator. Staff were selected randomly, to account for different shifts and different units with the focus on direct care staff members. Audits of five (5) staff per week were completed for four (4) weeks, two (2) staff per week for two (2) weeks, one (1) staff per week for two (2) weeks and one (1) staff per month for two (2) months. 13. Starting 04/15/2022, the facility had five (5) staff members complete an Abuse Quiz which was administered by the DON, ADON, UM and/or Administrator for four (4) weeks. Then two (2) staff for two (2) weeks, one (1) staff for two (2) weeks and one (1) staff for two (2) months. This was used to ensure the staff were maintaining what they learned through the re-education. Any staff member who did not obtain 100% were retrained on the spot. 14. Starting 04/15/2022, five (5) residents per week for four (4) weeks with a BIMS greater than eight (8) were randomly selected for interviews by the SSD. She used the Safe Survey to identify if resident had any concerns about how they were treated by staff in the facility. The facility continued to do this assessment of two (2) residents for two (2) weeks, one (1) resident for two (2) weeks and then one (1) resident for two (2) months. No concerns were identified. 15. The Quality Assurance Performance Improvement (QAPI) team met on 04/04/2022 to put a plan of action together once concerns of abuse had been identified. Present at the initial meeting were the Administrator, the DON, Dietary Manager, Facility Consultant, Rehabilitation Director, Unit Manager, SSD, and the Minimum Data Set Nurse. The Medical Director was present on the phone but did not offer any new suggestions. The last QAPI meeting reviewing the performance improvement plan was held on 07/27/2022 with no new issues identified since the initiation of the improvement plan. Members present included the Administrator, DON, Medical Director via phone, Environmental Services Director, SSD, MDS Nurse, and the Quality Improvement Nurse. The State Survey Agency validated the implementation of the facility's IJ Removal Plan as follows: 1. Review of Skin Assessments as compared to the Brief Interview for Mental Status (BIMS) listing for the time of this event validated each resident with a BIMS less than (8) had a skin assessment. No signs or symptoms of abuse were identified by the facility and after review, none were identified by the surveyor. 2. Review of the interview questionnaire of residents with a BIMS of eight (8) or greater completed on 04/04/2022, revealed no residents voiced any concerns regarding abuse through the interviews conducted by the SSD. Interview with Resident #6 on 11/21/2022 at 9:35 AM, revealed the resident felt very safe at the facility, staff were kind and took good care of her/her. The resident also stated the staff never talked bad or mistreated him/her in any way. Resident #6 reported he/she would talk to the Director of Nursing (DON) or the SSD if there were any concerns and felt things would be taken care of. Interview with Resident #4, on 11/21/2022 at 10:00 AM, revealed staff treated him/her very well. The resident revealed he/she felt very safe at the facility and the staff were wonderful and kind. Interview with Resident #7, on 11/21/2022 at 10:35 AM, revealed staff were really good and provided great care. Resident #7 revealed staff were very busy but were still able to meet his/her needs. The resident stated he/she was very outspoken and had no problem reporting any concerns to the staff. 3. Interview with the Facility Consultant on 11/23/2022 at 6:00 PM, revealed she reviewed each entry into the grievance log for January, February, and March 2022 as alleged. She revealed however, a formal documented audit did not occur. She wrote a signed statement to show she reviewed the grievance log information and had not found any concerns. The State Survey Agency (SSA) Surveyor reviewed all the facility's grievance logs from April 2022 to the current date and discovered eight (8) areas the facility called care delivery concerns. Based on review of those eight (8) cases residents were interviewed and either could not recall the event, or no longer had any concerns regarding the issue. Interview on 11/21/2022 at 10:45 AM, with Resident #7 revealed he/she no longer had any care concerns. 4. Review of the facility's documentation of the abuse questions completed by staff compared to the staff roster revealed one hundred and one (101) staff's name present, which was 100% of the facility's staff at that time, documented as having completed the training as alleged. Additionally, interviews were 11/22/2022: with SRNA #6 at 1:45 PM; SRNA #7 at 1:30 PM; SRNA #8 at 2:35 PM; SRNA #12 at 12:40 PM; SRNA #13 at 1:50 PM; and SRNA #14 at 2:55 PM. All the SRNAs revealed they were interviewed about any allegations of abuse or concerns of abuse, how and when abuse was to be reported to the DON and/or the Facility Consultant. Interview on 11/22/2022: with Housekeeper #1 at 12:05 PM; Housekeeper #2 at 12:15 PM; and a laundry staff person at 12:30 PM revealed all had been interviewed by the DON and/or the Facility Consultant about when to report abuse, to whom to report abuse and the different kinds of abuse. All staff interviewed revealed it was not up to them to determine if a situation was abuse or not, they were just to report it immediately to management. 5. Interview with Licensed Practical Nurse (LPN) #7/Unit Manager on 11/22/2022 at 3:00 PM, revealed she had been provided education by the Facility Consultant on the abuse policy; reporting immediately, within two (2) hours and within twenty-four (24) hours; the types of abuse; the Elderly Justice Acts; required postings in the facility; protecting the residents immediately and suspension of the alleged perpetrator. LPN #7 stated she had to pass a quiz covering all those subjects. Interview with the ADON on 11/23/2022 at 5:45 PM, revealed she was provided education by the Facility Consultant on the abuse policy; reporting immediately, within two (2) hours and within twenty-four (24) hours; the types of abuse; the Elderly Justice Acts; required postings in the facility; protecting the residents immediately and suspension of the alleged perpetrator. The ADON stated she was required to take a quiz and pass it with 100%. Interview with the DON on 11/23/2022 at 6:00 PM, revealed the Facility Consultant provided in-services on the abuse policy; reporting immediately, within two (2) hours and within twenty-four (24) hours; the types of abuse; the Elderly Justice Acts; required postings in the facility; protecting the residents immediately and suspension of the alleged perpetrator. Interview with the Administrator on 11/23/2022 at 6:15 PM, revealed the Facility Consultant covered the abuse policy; reporting immediately, within two (2) hours and within twenty-four (24) hours; the types of abuse; the Elderly Justice Acts; required postings in the facility; protecting the residents immediately and suspension of the alleged perpetrator with him. 6. Review of the facility's sign in sheets for the in-services provided for staff revealed one hundred and one (101) staff's names, which represented 100 % of the facility's staff employed at that time. Per review, all education was completed by 04/08/2022. Interviews conducted with thirty-four (34) facility staff on 11/22/2022 through 11/23/2022, revealed very staff member interviewed was able to name the seven (7) types of abuse, when to report incidents (immediately), who to report to incidents to (their direct supervisor), the DON, and the Administrator. In addition, all staff interviewed were able to identify that resident safety was the number one (1) priority, and the alleged perpetrator would be suspended pending investigation. Further interview revealed staff also expressed understanding that it was not up to them to decide if a situation was abuse or not, it had to be reported so management could investigate. Interview with the Facility Consultant, on 11/23/2022 at 6:00 PM, revealed she provided reeducation to the Administrator and all staff were provided education on 04/04/2022. Interview revealed she immediately activated the Performance Improvement Plan (PIP) and started doing quizzes with staff. According to the Facility Consultant, all staff were present and took the quiz and were required to get 100%. She stated if the staff member did not get 100% score, reeducation was conducted on the spot and the quiz was taken again until 100% was achieved. 7. Interview with the Facility Consultant on 11/23/2022 at 6:20 PM, revealed she was present for the quizzes for the majority of staff members. She revealed she was at the door where the quiz was given and graded it on the spot. Continued interview revealed any missed items were immediately reviewed with the staff member and then the staff member had to take the quiz again until 100% was achieved. She further stated staff were not scheduled to work again until the task was completed. 8. Review of the facility's signed document revealed the Administrator completed the alleged education for Housekeeper #1 regarding the abuse policy, types of abuse, timely reporting of abuse and immediate protection of the resident listed on 04/07/2022. Per review, Housekeeper #1 was disciplined, and warning disciplinary action was validated by the SSA Surveyor. Interview with the Administrator on 11/23/2022 at 4:30 PM, revealed he provided the re-education for Housekeeper #1 back in April 2022, when the incidents arose. He revealed he went over the F600 regulation with the staff member and a warning disciplinary action was given to the Housekeeper #1. 9. Review of the facility's certified mail receipts revealed letters were sent as alleged, and the card received back prior to 04/15/2022. The review revealed no concerns were noted. 10. Review of the last five (5) staff hired revealed the abuse packet in orientation and review of the policy to ensure new staff were educated and understood the expectation. Interview on 11/22/2022, with Housekeeper #2 and Housekeeper #3, Laundry Staff #1, Cook, and Nurse Aide Student revealed all the staff each knew the seven (7) types of abuse; knew to make sure the resident was safe; to report to management immediately; and that they did not determine what was or was not abuse. Interview with the Staff Development Coordinator on 11/23/2022 at 1:25 PM, revealed she had helped with ongoing training for new staff in orientation. She revealed all staff were trained on abuse before they access the floor, and this had included her. Per the SDC, the Facility Consultant did the orientation with her and went over the facility policies and procedures since she was new to this agency. She revealed she had been doing on going education with staff on abuse. Interview with the DON on 11/23/2022 at 1:40 PM revealed she was provided education when she came on board with the facility. 11. Interview with the Facility Consultant on 11/23/2022 at 6:00 PM, revealed she called the State Board of Nursing and was informed they were not where that information needed to be reported to. She stated she was told to contact the State Community College to make the report. Per interview she called the State Community College and was informed they did not take that type of report either. She called back to the Board of Nursing, and they did not have a different answer. Further interview revealed the Facility Consultant had a signed form to account for the phone calls she had made regarding determining the correct reporting path, which she had been unable to do. 12. Starting 04/15/2022, the facility would interview five (5) staff members to determine if any new allegations of abuse were not reported, when it required reporting and to whom. This was conducted by the DON, ADON, UM and/or the Administrator. Staff were selected randomly, to account for different shifts and different units with the focus on direct care staff members. Audits of five (5) staff per week were completed for four (4) weeks, two (2) staff per week for two (2) weeks, one (1) staff per week for two (2) weeks and one (1) staff per month for two (2) months. Review of the facility's audits revealed the facility interviewed staff members as alleged in the IJ Removal Plan within the specified timeframes and no concerns were noted. Interviews with staff conducted between 11/22/2022 and 11/23/2022 revealed thirty-four (34) staff plus management staff, to include housekeepers, laundry, maintenance, dietary staff, nurse aides and licensed nurses were able to account for each subject they received education on. Each staff member could report the seven (7) types of abuse, identify they were to keep the resident safe, and report immediately to management. Also, staff reported it was not up to them to decide if something was abuse or not, just report anything that was a concern. It was determined through these interviews, two (2) staff members could use a bit more education on the exact requirements, but they knew the basics. The facility was made aware of the concerns. This does not put them to a later compliance date because of the special needs of those two (2) staff members. Interview with the MDS Coordinator on 11/23/2022 at 1:00 PM, revealed she helped with in-services and did pop up interviews on staff randomly and ask them abuse questions. Further interview revealed she felt the facility had done a great job making sure everyone knew the expectation on abuse and what had to happen. 13. Review of the facility's documentation of staff audits revealed the number of staff audits was provided and noted to be accounted for each timeframe represented above. Per review, the staff interviewed were able to verbalize the seven (7) types of abuse, state they were to report incidents immediately and to keep the residents safe. Further review revealed as of 11/22/2022, the facility had provided much abuse training for many staff regarding the ongoing education over the months by all management staff, with no concerns found. 14. Interview with Resident #4 on 11/22/2022 at 10:00 AM, revealed the facility had interviewed him/her, and he/she felt safe in the facility. Resident #4 stated staff treated him/her well and if there were any concerns, he/she knew to report to the charge nurse or the DON. Interview with Resident #7 on 11/22/2022 at 10:35 AM, revealed the facility had interviewed him/her and he/she felt safe in the facility. The resident revealed staff were kind and provided good care and if there were any concerns, he/she would report it to the DON and/or Administrator. Interview with the Social Services Director (SSD) on 11/23/2022 at 12:40 PM, revealed she helped with the facility's removal plan and completed the Safe Surveys with residents and no concerns were found. 15. Review of the facility's QAPI minutes documentation and sign in sheet for 04/04/2022 revealed the Facility Consultant, Dietary Manager, Unit Manager, Social Service Director, and Administrator were present. Per review, they identified the abuse allegation, the resident involved, the staff members named as perpetrator and witness and an investigation was started. Review revealed audits tools were created and education was started, with quizzes given to all staff present at the facility and staff who were not present were called and asked to come in for education. Interview with the Quality Improvement (QI) Nurse, on 11/23/2022 at 12:20 PM, revealed she was a floor nurse before she was selected for the QI Nurse position after the 04/04/2022 QAPI. She revealed in the QAPI meetings she attended, the Administrator, DON, ADON, both UM, Housekeeping Manager, Maintenance Director, Dietary, SSD, MDS staff had all been present. She revealed the Medical Director was present on the phone or sometimes present in person. Per interview, abuse prevention and awareness were ongoing. Interview with the Social Services Director (SSD) on 11/23/2022 at 12:40 PM, revealed she had been present at the 04/04/2022 QAPI meeting. She revealed in the QAPI meeting they had gone over the allegation of abuse, and it was determined at that time to put a plan in place. Continued interview revealed they discussed new admissions, discharges and discussed any other corrective plans that might be in place or needed. The SSD stated the Administrator, DON, Housekeeping Manager, Maintenance Director, Dietary, QI Nurse, UM, ADON, MDS, SDC, and the Medical Director attended the QAPI meetings. Further interview revealed the Medical Director had been present via the phone. Interview with the MDS Coordinator on 11/23/2022 at 1:00 PM, revealed she had attended every QAPI meeting except one (1). She stated the main focus had been abuse, the process and why it was important to report within the necessary timeframe. Continued interview revealed in the QAPI meetings, they discussed concerns that some staff might not identify certain things as abuse, but they had been educated to make sure they reported everything and anything that was of c [TRUNCATED]

Based on observation, interview, and review of the facility's policy, and the Centers for Disease and Prevention (CDC) guidelines it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases, including COVID-19. Observation on 09/01/2021 at 2:40 PM, revealed Licensed Practical Nurse (LPN) #1 sitting at the nursing station with her face mask underneath her chin, leaving her nose and mouth not covered. The findings include: Review of the facility's policy titled, Guidelines on Latest Approach to PPE Use During COVID-19 Pandemic, updated 06/21/2021, revealed employees should wear masks when entering and leaving the facility. Further review of the policy revealed staff must wear face mask protection at all times. Observation on 09/01/2021 at 2:40 PM, on the East Unit, revealed LPN #1 had her mask pulled down underneath her chin while sitting at the nursing station with two (2) other staff members, which left her nose and mouth not covered. Interview with LPN #1, on 09/01/2021 at 2:40 PM, revealed she pulled her face mask down when she made a phone call and did not cover her nose and mouth when the call was completed. Interview revealed it the facility's policy for staff to wear a mask covering the nose and mouth while in the facility. She stated I was educated within the last month on proper placement of Personal Protective Equipment (PPE) by the Staff Development Coordinator (SDC). Interview with the Infection Preventionist (IP), on 09/01/2021 at 3:01 PM, revealed face masks should be worn at all times while in resident care areas and the mask should cover the nose and mouth. She further stated all staff have been educated on proper placement of PPE and the importance of wearing the masks to prevent the spread of any possible COVID-19. Interview with the Director of Nursing (DON), on 09/01/2021 at 5:17 PM, revealed she expected staff to wear PPE properly, per the CDC guidelines and facility policy, to prevent the spread of infectious diseases, such as COVID-19. Interview with the Administrator, on 09/01/2021 at 5:17 PM, revealed he expected all staff to wear a face mask to cover the nose and mouth.

Based on observation, interview, and review of the facility's policy, and the Centers for Disease and Prevention (CDC) guidelines it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases, including COVID-19. Observation on 07/14/2021 at 11:54 AM, on the East Unit revealed State Registered Nurse Aide (SRNA) #1 and #2, with their mask below their nose while removing trays from the meal cart during a meal service. The findings include: Review of the facility's policy titled, Guidelines on Latest Approach to PPE Use During COVID-19 Pandemic, updated 06/21/2021, revealed employees should wear masks when entering and leaving the facility. Further review of the policy revealed staff must wear face mask protection at all times. Observation on 07/14/2021 at 11:54 AM, on the East Unit revealed State Registered Nurse Aides (SRNA) #1 and #2, with their mask below their nose while removing trays from the meal cart during a meal service. Interview with SRNA #1 on 07/14/2021 at 11:54 AM, revealed her face masks should be worn properly to cover her mouth and nose to prevent the spread of infection. She further stated she was hot and failed to have the mask properly in place. Interview with SRNA #2 on 07/15/2021 at 11:07 AM, revealed she failed to have her face mask on properly to cover her mouth and nose. She further revealed a staff member had recently tested positive for COVID-19 and wearing mask would help protect staff and residents from the spread of infections. Interview with the Infection Preventionist (IP) on 07/15/2021 at 11:55 AM, revealed face masks should be worn at all times while in resident care areas and the mask should cover the nose and mouth. She further revealed all staff have been educated on the importance of wearing the masks to prevent the spread of any possible COVID-19. Interview with Director of Nursing (DON) on 07/15/2021 at 1:06 PM, revealed she expected staff to wear all appropriate PPE (personal protective equipment) properly, per the CDC guidelines and facility policy, to prevent the spread of infectious diseases such as COVID-19. Interview with the Administrator on 07/15/2021 at 2:09 PM, revealed he expected staff to follow Infection Control guidelines to decrease the potential spread of infection.

Based on interview, record review, review of the facility investigation, and facility policy review, it was determined the facility failed to ensure medications were not misappropriated for two (2) of three (3) sampled residents (Resident #47 and Resident #57). On 05/20/2020, Licensed Practical Nurse (LPN) #1 notified the Director of Nursing that they were unable to reorder narcotic's for Resident #47 and Resident #57, because the pharmacy stated they had already sent them out on 04/13/2020 and 05/08/2020. The findings include: Review of the facility policy titled, Abuse, Neglect, or Misappropriation of Resident Property Policy, last revised 03/10/2017, revealed the facility believes residents have the right to be free from abuse, neglect, involuntary seclusion, exploitation, or misappropriation of property. The facility will do whatever is in its control to prevent mistreatment, neglect, exploitation, and abuse of our residents or misappropriation of their property. 1. Record review revealed the facility admitted Resident #47 on 08/22/2013 with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment, dated 09/11/2020, revealed the facility assessed Resident #47's cognition as intact with a Brief Interview of Mental Status (BIMS) score of fifteen (15), which indicated the resident was interviewable. Review of Resident # 47's May 2020 Physician Orders revealed an order for [REDACTED]. Interview with Resident #47 on 10/07/2020 at 11:09 AM, revealed he/she had never missed any pain medication and the current pain medication that he/she is taking takes care of the pain issues he/she has. 2. Record review revealed the facility admitted Resident #57 on 01/03/2018 with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment, dated 09/24/2020, revealed the facility assessed Resident #57's cognition as intact with a BIMS score of fifteen (15), which indicated the resident was interviewable. Review of Resident #57's April 2020 Physician Orders revealed an order for [REDACTED]. (by mouth) QID (four {4} times a day) at six (6), twelve (12), six (6) and ten (10). Interview with Resident #57 on 10/08/2020 at 10:45 AM, revealed he/she had never missed any pain medication and the current pain medication that he/she is taking takes care of the pain issues he/she has. Review of the facility final investigation dated 05/27/2020, revealed on 05/20/2020, it was discovered, when trying to reorder narcotics for Resident #47 and #57 there were sixty (60) narcotics missing for each resident. Two (2) count sheets and the corresponding cards of thirty (30) narcotics were missing for each resident. Both residents resided on the East Wing and had their medications stored on the same cart. An investigation was immediately initiated; and physician, Law enforcement and Office of Inspector were notified. The investigation included review of controlled substance count sheets, narcotic shift change sheets, resident medication administration records (MAR's), nurse progress notes, witness statements, and staff assignment sheets. It was noted staff were not consistently logging new controlled substances count sheets when delivered from the pharmacy. Through its investigation, the facility was unable to locate the missing narcotics, and unable to determine what had happened to them. The facility replaced the missing narcotics at the expense of the facility. The investigation determined nurses and KMA's were not consistently logging the number of new declining count sheets for new prescriptions and not consistently counting narcotic declining count sheets at shift change. A Performance Improvement Plan (PIP) was developed for the identified root cause and monitoring is in place. Interview with Licensed Practical Nurse (LPN) #1 on 10/06/2020 at 7:10 PM, revealed she had called the pharmacy on 05/20/2020 to inquire about Resident #57's [MEDICATION NAME], and to see when they would be coming in. LPN #1 stated the pharmacy lady told her it was to soon to re-order because they had already been ordered. She could not recall the date the pharmacy person told her;however, she did recall the person telling her it was too soon to re-order the medication. She revealed she knew something was not right, so she went to tell the Director of Nursing (DON), about her concern. She called the pharmacy back to ask for a copy of the pharmacy slip, and when she was on the phone with pharmacy, the pharmacy lady stated, while I have you on the phone I wanted to let you know we can not fill Resident #47's narcotics as well, as it is too soon to fill them too. She stated she went back to the DON, and made her aware what the pharmacy had just told her regarding Resident #47's narcotics. Interview with the Pharmacy Entry Consultant on 10/07/2020 at 11:24 AM, revealed the facility had called on 05/20/2020 to inquire about refilling Resident #57's [MEDICATION NAME] 10-325 and she had told them they had been filled on 05/04/2020, and had sent one-hundred twenty (120) tablets which was thirty (30) days worth of medications for Resident #57. She stated the facility was wanting them filled sixteen (16) days early. She further revealed the facility also asked her about Resident #47's [MEDICATION NAME]/APAP 10-325 which had been filled on 05/07/2020, and the pharmacy had sent one-hundred twenty (120) for thirty (30) days worth of medication for Resident #47. She stated the facility was wanting them to be filled fifteen (15) days early. She revealed the Pharmacy contacted the physician on 05/20/2020, to make him aware of the concern and obtained a new script, so neither of the residents missed any medications. Interview with the Director of Nursing on 10/06/2020 at 9:54 AM, revealed LPN #1 made her aware there was a concern with Resident #57 [MEDICATION NAME] not being able to be refilled, and then shortly thereafter, there was a concern with Resident #47's missing [MEDICATION NAME] 10 mg tablets. The DON stated LPN #1 had tried to re-order them and the pharmacy had told LPN #1 it was too soon to reorder them. The DON revealed this was early in the day maybe around 1:15 PM, and she contacted the Administrator to let him know of the concern, and immediately started an investigation into the missing medication. She stated the facility's lengthy investigation determined two (2) count sheets and the corresponding cards of narcotics were missing for each resident. She stated the investigation determined nurses and Kentucky Medication Aides (KMA's) were not consistently counting narcotics at shift change so a Performance Improvement Plan (PIP) was developed for the identified root cause. Interview with Medical Director on 10/08/2020 at 11:45 AM, revealed he did recall attending a Quality Assurance (QA) meeting back in early part to mid part of May regarding some missing narcotic's. There was an extensive audit of all the narcotics in entire the building and new plan put in to place to help ensure this would not happen again. The facility took immediate action as they should have and implemented new measures, and an action plan was put into place. Interview with the Administrator on 10/08/2020 at 12:00 PM, revealed he was made aware of the missing narcotic concern by the Director of Nursing back in May 2020 regarding Resident #47 and Resident #57. The facility immediately notified local Law enforcement, Office of Inspector General, Department of Community Based Services (DCBS) and immediately began their investigation. He felt the DON, and her team had done a thorough in depth investigation, and left no stone unturned. Neither of the residents were without their medications, and neither were billed for the missing medications. They have QA'd the concern and been monitoring the concern. Let me assure you we took this matter very seriously. *** The facility implemented the following actions to correct the deficient practice: 1. On 05/20/2020, Medication Administration Records (MAR's) were reviewed for Resident #47 and #57 to identify pain medication's were administered per physician orders. 2. On 05/20/2020, progress notes were reviewed for Resident #47 and #57 for complaints for complaints or signs of symptoms for pain. 3. On 05/20/2020, Resident # 47 and #57 were assessed for pain with no concerns. 4. On 05/20/2020 the Director of Nursing (DON), Assistant of Nursing (ADON), and Quality Assurance (QA) Nurse completed a narcotic documentation audit of the east long hall medication carts. 5. On 05/20/2020 the DON, Unit Manager completed an audit of packing slips for the entire building. 6. On 05/20/2020, ADON and Staff Development Coordinator (SDC) initiated education. The topics included narcotic count, medication administration (from the pharmacy manual), signing packing slips, and logging narcotics into the book. 100% completed on 06/12/2020 7. Beginning on 05/20/2020, the administration nurse's and nurse supervisor will complete random medication pass audits and medication cart audits. The audits will be completed (3) times a week for (6) weeks and will be completed on different medication carts and different nurses and medication aides. 8. Beginning on 05/20/2020, the DON, Administrative Nurse's will reconcile the narcotic packing slips to the narcotic slips received three (3) times a week for (6) weeks to ensure the correct number was logged into the narcotic count book and the number of declining count sheets was updated. 9. Beginning on 05/20/2020, the DON, Administrator nurse will review the medication documenation to include declining count sheets, MAR's, shift change count sheets, and wasted narcotics, three (3) times a week for six (6) weeks. 10. On 05/21/2020, all five (5) medication carts were audited in the building to verify the sheets matched the narcotics. 11. On 05/21/2020, a Quality Assurance Meeting was held with Medical Director, Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator , Administrator, and Quality Assurance Nurse, to discuss the concerns related the missing narcotics, and the action plan they were putting in place. 12. On 05/28/2020, Misappropriation education was provided to all licensed staff who pass medications by the Staff Development Coordinator. **The State Survey Agency validated the facility's plan of action was carried out by: 1. Review of printed out copies of Resident #47's and 57's MAR's revealed Resident #47's and 57's MAR's were reviewed on 05/20/2020. 2. Review of printed out copies of Resident #47's and 57's progress notes for Resident #47 and #57 were reviewed for complaints or signs of symptoms for pain on 05/20/2020. 3. Review of printed out copies of pain assessments revealed Resident # 47 and #57 were assessed for pain with no concerns identified on 05/20/2020. 4. Review of audit log revealed the East hall medication carts were reconciled with no concerns on 05/20/2020. 5. Review of a binder with the Director of Nursing revealed packing slips for entire building were reviewed on 05/20/2020. 6. Review of Education Sheets revealed all licensed staff were educated and the education was completed on 06/12/2020. Interviews on 10/06/2020 with Registered Nurse (RN) #1 at 10:10 AM, Licensed Practical Nurse (LPN) #1 at 7:10 PM, and LPN #2 at 2:20 PM; and on 10/07/2020 with LPN #3 at 1:58 PM, LPN #4 at 2:24 PM, LPN #5 at 2:37 PM, and LPN # 6 at 4:49 PM, revealed education was provided by the Staff Development Coordinator regarding narcotic reconciliation. included narcotic count, medication administration (from the pharmacy manual) signing packing slips and logging narcotics into the book, and misappropriation of residents property. 7. Review of Audit binder with the Director of Nursing (DON) revealed medication pass audits and medication cart audits were completed (3) times a week for (6) weeks and were completed as of 07/01/2020. 8. Review of Audit binder with Director of Nursing (DON) revealed the narcotic packing slips were reconciled with the narcotic slips three (3) times a week for (6) weeks to ensure the correct number was logged into the narcotic count book and the number of declining count sheets was updated. These were completed 07/01/2020 9. Review of Audit binder with Director of Nursing (DON) revealed audits were completed on declining count sheets, MAR's shift change count sheets, and wasted narcotics, three (3) times a week for six (6) weeks. These were completed on 07/21/2020. 10. Review of audit tool/sheet, revealed all five (5) medication carts were audited to verify the sheets matched the narcotics on 05/21/2020. 11. Interview with the Medical Director on 10/08/2020 at at 11:45 AM, revealed he did recall attending a Quality Assurance (QA) meeting back in early part to mid part of May regarding some missing narcotics. He stated there was an extensive audit of all of the narcotics in the entire building and a new plan was put in to place to help ensure this would not happen again. He revealed the facility took immediate action as they should have and implemented new measures, and an action plan was put into place. 12. Interview with the Staff Development Coordinator on 10/08/2020 at 4:24 PM, revealed she immediately started all education on 05/20/2020, and it was all completed by 06/12/2020. She stated the education was related to medication administration, control substances, pain assessments, signing out narcotic's, resident rights, and misappropriation and reporting allegations. She revealed it took a while to get all the staff educated, and she had to come in on different shifts, but it was all completed by 05/28/2020, as the staff were not allowed to work until they were all educated. She stated she even had to meet them at the time clock to provide the education before they could clock in prior to their shift. She revealed continued monitoring of the education will be done by having the staff who pass medication review the policy on a quarterly basis to ensure they understand the policy. She stated the facility reviews abuse and neglect policy almost at every staff meeting.

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure expired medications were not stored and accessible in one (1) of three (3) medication storage carts. The findings include: Review of the facility policy titled, Provider of Pharmaceutical Services, dated September 2020, revealed the facility and(NAME)Medical Group shall provide appropriate methods and procedures for the accurate acquiring, receiving, dispensing, and administering of drugs and biologicals to meet the needs of each resident. Pharmaceutical services are provided in accordance with accepted professional standards and appropriate federal, state and local laws. Consulting and clinical services shall be provided by(NAME)Medical Group. Review of facility policy titled, Return of Unused Medications dated September 2020, revealed medications may be returned to(NAME)Medical Group for reasons that a medication reached its expiration date. The policy outlined appropriate procedure for returning non-controlled substances back to the pharmacy which included removing the medication from the medication cart and locking the medications in the medication delivery tote to be collected by the courier. Observation of the West Hall medication cart on 10/06/2020 at 10:43 AM with Licensed Practical Nurse (LPN) #8 revealed there were approximately fifteen (15) Lorpermide ([MEDICATION NAME])2 milligrams (mg) capsules individually wrapped in a medication box and in a resident's drawer with an expiration date of 05/27/2020. Interview with LPN #8 on 10/06/2020 at 10:43 AM, revealed expired medications should not have been in medication cart available to dispense to any resident. She stated all medications should be checked for expiration dates prior to being dispensed to residents; however she was unaware of any facility policy related to checking the medication storage cart periodically because pharmacy personnel generally do this when they deliver medications to the facility. Interview with Registered Nurse (RN) #1 on 10/06/2020 at 11:40 AM, revealed she did not know of any facility policy regarding nurses doing checks specifically for expired medications in the medication cart except in middle of medication pass. She stated standards of care entails checking every medication for expiration date before giving to residents. Interview with Director of Nursing (DON) with the facility Consultant present, on 10/07/2020 at approximately 10:30 AM, revealed there is no facility policy on auditing medication carts. DON stated she expected pharmacy services to do the auditing of medication carts, however the visitor restrictions related to Covid-19 have delayed some services the pharmacy personnel usually provide. She further revealed she expected nursing staff to check all medications for expiration date before dispensing to any resident and to send expired medications back to pharmacy and reorder. She stated expired medications should not be in medication cart, however the resident records did indicate the [MEDICATION NAME] had not been dispensed to resident since before the expired date of 05/27/2020.

Based on interview, record review, and facility policy review, it was determined the facility failed to ensure medical records, were complete and accurately documented for one (1) of three (3) sampled residents (Resident #30). The findings include: Review of facility policy titled, Medication Administration Person-Centered Care, last revised September 2020, revealed the facility guidelines was medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Further review of facility policy revealed the individual who administers the medication dose records the administration on the resident's Medication Administration Report (MAR) at the time of administration. At the end of each medication pass, the person administering the medications reviews the MAR indicated [REDACTED]. In no case should the individual who administered the medications report off-duty without first recording the administration of any medications. Record review revealed the facility admitted Resident #30 on 03/11/2020 with [DIAGNOSES REDACTED]. Review of Resident #30's Quarterly Minimum Data Set (MDS) assessment, dated 09/01/2020 revealed the facility assessed Resident #30's cognition as intact with a Brief Interview of Mental Status score (BIMS) of fifteen (15), which indicated the resident was interviewable. Review of Resident #30's May 2020 physician's orders [REDACTED]. Further review of physician's orders [REDACTED]. Review of Resident #30's Controlled Substance Count Sheets dated 03/17/2020 and dated 05/02/2020 revealed [MEDICATION NAME]/APAP was administered to Resident #30 on 04/01/2020, 04/26/2020, 04/27/2020, 04/30/2020, 05/01/2020, 05/07/2020, 05/08/2020, 05/09/2020, 05/10/2020, 05/19/2020, 06/01/2020, 06/02/2020, 06/05/2020, 06/06/2020, 06/07/2020, 06/09/2020, and 09/12/2020. However, review of Resident #30's April, May, June, and September 2020 MAR's, revealed there was no documented evidence the [MEDICATION NAME]/APAP tabs were administered on those dates and times. Interview with Licensed Practical Nurse (LPN) #9 on 10/07/2020 at 2:52 PM, revealed she administered [MEDICATION NAME]/APAP tabs pain medication to Resident #30 on 04/26/2020, 04/30/2020, 05/08/2020, 05/09/2020, 05/10/2020, 05/19/2020, 06/01/2020, 06/02/2020, 06/05/2020, 06/06/2020, 06/07/2020. and 06/09/2020; however she was not aware she failed to document the administrations on the resident's MAR. She stated the facility policy required documentation in resident's nursing notes and MAR's on all medications and treatments administered to Residents. She revealed if she failed to document on the MAR indicated [REDACTED]. She stated the failure to document on the MAR indicated [REDACTED]. Interview with LPN #6 on 10/06/2020 at 2:45 PM, revealed she administered [MEDICATION NAME]/APAP tabs to Resident #30 on 04/01/2020, 04/11/2020, and 05/27/2020, however she was not aware she had failed to document the administrations on the resident's MAR. She stated facility policy required documentation in resident's nursing notes and MAR's on all medications and treatments administered to Residents. Interview with Registered Nurse (RN) #1 on 10/07/20 01:43 PM, revealed the facility policy required documentation on narcotic count sheets in addition to resident's nursing notes and MAR's on all medications and treatments administered to Residents. Interview with Director of Nursing (DON) on 10/07/2020 at 9:46 AM, revealed the facility policy was to document the administration of medications in residents' nursing progress notes and MAR. She stated RN #2 had been terminated from employment with facility on 06/11/2020 related to not following waste procedures of controlled substances; however, she was not aware of missing documentation in MAR's for the months of April, May, June and September 2020. Interview with the Administrator, on 10/07/2020 at 3:55 PM, revealed he expected standards of practices related to medical records and documentation to be correct and complete and he expected nursing staff to finish the documentation of pain medications and just signing the narcotic sheet is not sufficient documentation. He stated he is not a nurse and defers standards of practice to his DON but expected correct and complete documentation for medication administration.

Based on observation, interview, record review, and facility policy review, it was determined four (4) licensed staff failed to ensure professional standards of practice related to not signing out narcotics when given for five (5) of six (6) sampled residents. The findings include: Interview on 12/06/19 at 5:47 PM with the Director of Nursing and Administrator revealed they could not find a policy or standard of practice that states when to sign out narcotics and it was common practice to sign out the medication when it was given. 1. Record review revealed the facility admitted Resident #2 on 10/11/19 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's December 2019 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . capsule twice daily, which was initiated on 10/14/19. Observation of a Narcotic Count with Licensed Practical Nurse (LPN) #2 on 12/06/19 at 12:45 PM revealed [MEDICATION(S)] 7.5 milligram (mg.) capsule was not signed out for the 7:00 AM dose for Resident #2. Interview with LPN #2 on 12/06/19 at 12:45 PM revealed narcotics are to be signed out as soon as obtained from the drawer, but he had not been inserviced or received any training regarding this. 2. Record review revealed the facility admitted Resident #3 on 05/29/19 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #3's December 2019 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation of a Narcotic Count with LPN #3 on 12/06/19 at 10:05 AM revealed Oxycodone 5-325 mg was not signed out for 6:00 AM dose for Resident #3. 3. Record review revealed the facility admitted Resident #4 on 01/28/19 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #4's December 2019 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation of a Narcotic Count with LPN #3 on 12/06/19 at 10:05 AM revealed Resident #4's [MEDICATION(S)] MS-[MEDICATION(S)] 15 mg extended release (ER) was not signed out for the 8:00 AM dose. Interview on 12/06/19 at 10:05 AM with LPN #3 revealed she would have signed out Resident #3's and Resident #4's narcotics before she completed the narcotic count at shift change. She stated she was training LPN #4. 4. Record review revealed the facility admitted Resident #5 on 02/19/16 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #5's December 2019 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] Review of a Narcotic Count with Registered Nurse (RN) #1 on 12/06/19 at 10:40 AM revealed Resident #5's [MEDICATION(S)] 100 mg was not signed out for the 9:00 AM dose. Interview on 12/06/19 at 10:40 AM with RN #1 revealed that he did not sign out [MEDICATION(S)] 100 mg for Resident #5's 9:00 AM dose, but should have. 5. Record review revealed the facility admitted Resident #6 on 10/20/15 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #6's December MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation of a Narcotic count with RN #2 on 12/06/19 at 10:50 AM revealed Resident #6's [MEDICATION(S)] 0.5 mg was not signed out for the 8:00 AM dose. Interview with RN #2 on 12/06/19 at 10:50 AM revealed she was supposed to sign out narcotics when she takes it out of card and gives to resident. She stated she did not sign it at that time because she was trying to get all her medications administered timely. Interview with Staff Development Coordinator (SDC) on 12/06/19 at approximately 1:00 PM, revealed during orientation, nursing staff are in-serviced on medication administration, signing narcotics book for count during shift change, and narcotics signed out when pulled for resident administration. Interview with the Director of Nursing (DON) on 12/06/19 at 4:50 PM revealed she expected staff to sign out narcotics when administered. Interview with Administrator on 12/06/19 at 4:45 PM revealed she expected narcotics to be signed out when given.

Based on interview, record review and review of facility policy, it was determined the facility failed to ensure that each resident was free from mistreatment, abuse or neglect for one (1) sampled resident out of a selected sample of twenty-four (24) residents (Resident #17). Resident #17 alleged State Registered Nurse Aide (SRNA) #1 made rude or demeaning comments to him/her and he/she felt bullied. On [DATE], State Registered Nurse Aide (SRNA) #1 made the statement towards Resident #17 Gahh, Attitude much during lunch time tray pass. Resident #17's family member #1 reported the incident to Licensed Practical Nurse (LPN) #1 who then reported the incident to Registered Nurse (RN) #3 the on duty weekend supervisor. However, RN #3 did not report the incident to the Administrator. Resident #17 stated SRNA #1's behavior causes him/her a significant amount of anxiety and made him/her feel helpless. Resident #17 was tearful when explaining the effects these interactions had on him/her. The findings include: Review of facility policy titled Abuse, Neglect, Or Misappropriation of Resident Property Policy, last revised [DATE], revealed the facility believes that our residents have the right to be free from abuse, neglect, involuntary seclusion, exploitation, or misappropriation of property. The facility will do whatever is in its control to prevent mistreatment, neglect, exploitation, and abuse or of our residents or misappropriation of their property. Further review of this policy, revealed any employee who witnesses or suspects abuse, neglect, exploitation, or misappropriation of property has occurred will immediately report the alleged incident to their supervisor, who will immediately report the incident to the Administrator. Failure to report any concern related to neglect, exploitation, abuse, or misappropriation of property will result in disciplinary action and possible termination of employment. Record review, revealed the facility admitted Resident #17 on [DATE] with [DIAGNOSES REDACTED]. Review of Quarterly Minimum Data Set (MDS) assessment, dated [DATE], revealed the facility assessed this resident's Brief Interview for Mental Status (BIMS) score as a fifteen (15), which indicated this resident was cognitively intact and interviewable. Interview with Resident #17 on [DATE] at approximately 1:45 PM, revealed State Registered Nurse Aide (SRNA) #1 would make rude or demeaning comments to him/her and he/she felt bullied. Resident #17 stated on or around [DATE] Registered Nurse (RN) #1 was in the room with him/her when SRNA #1 came into his/her room and asked him/her if he/she wanted a lunch tray. Resident #17 stated he/she replied no, then yes and SRNA #1 asked is it yes or no. Resident #17 revealed he/she replied yes and SRNA #1 said Ugh, got attitude much, grabbed the curtain and closed it hastily, and left the room. Resident #17 stated he/she was so upset by the remark that he/she told RN #1 he/she no longer wanted SRNA #1 to come back into his/her room. Resident #17 revealed there was an ongoing issue of SRNA #1 mocking him/her and making rude and insulting comments. Resident #17 stated it's very upsetting and causes him/her a significant amount of anxiety because he/she is completely dependent on the staff's care and when SRNA #1 makes mean comments to him/her it makes him/her feel so helpless. Resident #17 could be seen becoming tearful while explaining the effects these interactions have on her/him. Resident #17 stated he/she feels like he/she is in the movie Mean Girls in which he/she is targeted by certain other girls because he/she is not good enough and does not deserve to be treated fairly or with respect. Resident #17 stated SRNA #1 no longer provides direct care to him/her but he/she feels uncomfortable when SRNA #1 comes into his/her room to provide care for his/her roommate. Interview with Registered Nurse (RN) #1 on [DATE] at approximately 9:15 AM revealed on [DATE] she was in Resident #17's room when SRNA #1 came into the room to bring the lunch tray. RN #1 stated SRNA #1 asked Resident #17 if he/she wanted the lunch tray and the resident said 'no then yes and SRNA #1 told the resident Gahh, attitude much and left the room. RN #1 stated the resident told her he/she did not like SRNA #1's attitude and did not want SRNA #1 back in his/her room to provide him/her care. RN #1 further revealed she told the resident it was his/her right to request that SRNA #1 no longer provide care to him/her. RN #1 stated it was her professional opinion it was inappropriate for staff to say Gahh, attitude much to a resident and did not report the incident at the time it occured. Interview with Resident #17's family member #2 on [DATE] at approximately 4:15 PM revealed the resident told her of many unpleasant interactions with SRNA #1. Family member #2 stated she is concerned about the resident due to to the resident calling her on several occasions distraught over how SRNA #1 has spoken to him/her. Family member #2 stated SRNA #1 makes the resident feel like its burdensome or annoying for SRNA #1 to have to provide care to him/her. Family member #2 stated the resident is here because he/she needs help and it is not fair for SRNA #1 to make the resident feel like she does not deserve the same quality of care as everyone else. Interview with Resident #17's family member #1 on [DATE] at approximately 4:15 PM revealed the resident had ongoing concerns with SRNA #1. Family Member #1 stated Resident #17 told her SRNA #1 is verbally abusive towards him/her and the resident has cried when discussing his/her interactions with SRNA #1 and has expressed it causes the resident increased anxiety. Family member #1 stated the resident told her of many incidents in which SRNA #1 speaks to him/her in a rude and condescending manner and that it makes him/her feel lesser than or beneath SRNA #1. Family member #1 stated the facility is the resident's home and SRNA #1 makes the resident feel unwelcome in her/his own home. Family Member #1 stated she called the facility and reported the resident no longer wanted SRNA #1 to provide him/her direct care after the last incident that occurred on [DATE]. Interview with LPN #1 on [DATE] at approximately 2:30 PM revealed on [DATE], he received a call from a family member of Resident #17 stating Resident #17 no longer wanted SRNA #1 providing her/him care. LPN #1 stated he informed the weekend supervisor (RN #3) of the family's concern. LPN #1 stated RN #3 and RN #1 spoke with the resident. Interview with SRNA #1 on [DATE] at approximately 1:50 PM revealed she went into Resident #17's room to ask him/her if she wanted his/her lunch tray and the resident got an attitude with her. SRNA #1 stated she did not say anything inappropriate to Resident #17 and RN #1 was also in the room and observed the interaction. SRNA #1 revealed someone called the facility and spoke with LPN #1 and she was told to keep her distance from Resident #17 for a while. SRNA #1 stated she was told by RN #3 to keep her distance from Resident #17. SRNA #1 stated she does not have any issues with any residents and the only resident that has an issue with her is Resident #39. SRNA #1 denied saying attitude much at any time to Resident #17. SRNA #1 admitted she would get short tempered with residents due to staff shortage and her perceived undervaluing of her in general. SRNA stated she becomes frustrated and short with residents when there is not enough staff to provide care to the residents. SRNA #1 stated she does not feel supported by upper management at the facility and that is frustrating and causes her to be short tempered. Interview with Resident #58 (BIMS:15) on [DATE] at approximately 2:30 PM revealed SRNA #1 would make fun of and belittle his/her prior roommate who is now deceased . Resident #58 stated he/she brought it up during resident council and SRNA #1 would not speak to him/her for a long time. Resident #58 stated SRNA #1 kept saying to his/her prior roommate whats wrong with you? Dont you know how to work a remote, over and over. Interview with Resident #39 (BIMS:14) on [DATE] at approximately 9:45 AM revealed he/she felt that anything that SRNA #1 said to residents was derogatory or negative. Resident #39 stated SRNA #1 is very rough with him/her when turning in bed and shoves him/her against the bed rails on the side of the bed. Resident #39 stated SRNA #1 breeds contempt in her heart but Resident #39 did not give any examples of what she meant by derogatory & negative. Interview with Administrator and DON on [DATE] at approximately 4:45 PM revealed the Administrator and DON denied any knowledge of any concerns between Resident #17 and SRNA #1. The Administaror stated staff are trained and aware to report any incidents of alleged abuse to their supervisor immediately who will then report it to the Administrator immediately after they become aware of the alleged incident.

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety. Kitchen observations on [DATE], revealed expired foods were being kept in the walk-in refrigerator, Cook #1 used her bare hand to place hard boiled eggs on a resident's lunch tray, and the side oven was visibly dirty with build up. In addition, observations of staff during dining room observation, revealed staff were handling residents' rolls, bread and straws with their bare hands. Review of the Census and Condition, dated [DATE], revealed seventy-five (75) of seventy-seven (77) residents received their food from the kitchen. The findings include: 1. Review of facility policy titled, Use and Storage of Leftovers, last revised [DATE], revealed each day staff will check leftovers and throw out any foods that have been kept up to the maximum length of time allowed. Observation of the kitchen on [DATE] at 09:27 AM, revealed in the walk-in refrigerator a container of tea with a use by date of [DATE] and a container of beans with a use by date of [DATE]. 2. Review of facility policy titled, Resident Meal Service, version (MONTH) 2013, revealed staff are to use single-use gloves for one task and if the gloves are soiled the gloves must be discarded and hands must be washed between glove changes. Observation of lunch trayline on [DATE] at 11:16 AM, revealed Cook #1 handled multiple dishes, utensils and equipment with gloved hands and then handled hard boiled eggs with her same gloved hands and placed the eggs on a resident's tray for lunch. 3. Review of facility policy titled, Cleaning Procedures, version ,[DATE], revealed ovens will be cleaned with oven cleaner to clean the interior and a damp cloth used to wipe the interior part of the oven clean. Observation of the kitchen on [DATE] at 11:18 AM, revealed the side oven had a visible build up of dry, crusted, black material all over the inside bottom area of the oven. Interview with Dietary Manager on [DATE] at 10:25 AM, revealed she expected all expired foods to be discarded so staff do not accidentally use them. She stated she expected staff to use utensils and not handle ready to eat foods with gloved hands that may be soiled or contaminated. She also stated she expected staff to clean the oven as they go and after spill overs or drips. 4. Review of the Facility Policy, Resident Meal Service revealed plastic gloves are to be worn when handling any ready to eat foods. Use single-use gloves for one task. Observation on [DATE] at 11:30 AM revealed Certified Nurse Aide (CNA) #9 and CNA #8 were placing rolls and straws with bare hands onto residents' trays. On [DATE] at 1:59 PM, interview with CNA #8 and #9 revealed they should have handled the food with gloved hands or removed it from the package without touching the food. CNA #8 revealed education for handling food revealed to never touch the food with bare hands. Observation on [DATE] at 5:07 PM revealed General Care Assistant (GCA) #2 was carrying stirring straws with bare hands over to two (2) residents who had requested them for their coffee and hot chocolate. Interview with GCA #2 on [DATE] at 5:30 PM revealed she should not use her bare hands to touch foods or anything that would come in contact with the resident's mouth. Interview with the Director of Nursing on [DATE] at 5:50 PM revealed she expected all staff to use gloves when handling ready to eat foods or they may use the no touch method to place food on the plate by dumping the food directly from the package. She stated all staff had been instructed to correctly deliver and set up foods for residents.

Based on interview, record review and review of facility policy, it was determined the facility failed to have evidence allegations of abuse, or mistreatment, were thoroughly investigated by the facility or prevent further potential abuse while investigation in progress for one (1) of twenty-four (24) sampled residents (Resident #17) and three (3) unsampled residents (Residents #14, #58 and #46). Resident #17's Family Member #1 reported to Licensed Practical Nurse (LPN) #1 that State Registered Nurse Aide (SRNA) #1 made a rude and belittling comment to Resident #17. LPN #1 reported the alleged abuse/mistreatment to Registered Nurse (RN) #3, the weekend supervisor, on 12/22/18; however, RN #3 did not report the incident to the Administrator. The facility failed to remove SRNA from resident care and investigate the incident. SRNA was not removed from resident care until 01/08/19 at approximately 6:00 PM (approximately seventeen {17} days later). In addition, Resident #14 expressed concerns with aides shoving residents to hurry them up during resident council on 9/21/18. However, the Director of Nursing (DON) did not speak to the resident until 9/25/18 and there was no documented evidence interviews were conducted with other residents to identify if they had concerns with aides shoving residents. Resident #46 reported concerns in resident council stating concerns with aides shoving you down when assisting residents on the toilet on 11/16/18; however, further review revealed there was no documented evidence additional residents were interviewed related to how the aides treated them when toileting. Resident #58 also expressed concerns in Resident Council with SRNA #1 being rude and belittling to his/her roommate; however, the Administrator never spoke to Resident #58, did not interview SRNA #1 until 10/01/18, and failed to interview other staff and residents to identify if they had any concerns with how SRNA #1 treated the residents. The findings include: Review of facility policy Titled Abuse, Neglect, Or Misappropriation of Resident Property Policy, Revision 03/10/2017, revealed the facility believes that our residents have the right to be free from abuse, neglect, involuntary seclusion, exploitation, or misappropriation of property. The facility will do whatever is in its control to prevent mistreatment, neglect, exploitation, and abuse or of our residents or misappropriation of their property. Further review of this policy, revealed any employee who witnesses or suspects abuse, neglect, exploitation, or misappropriation of property has occurred will immediately report the alleged incident to their supervisor, who will immediately report the incident to the Administrator. Failure to report any concern related to neglect, exploitation, abuse, or misappropriation of property will result in disciplinary action and possible termination of employment. The Facility shall take whatever steps are necessary to prevent further acts of abuse, neglect, misappropriation of property, drug diversion, or fraud while the investigation is in progress. Employees accused of being directly involved in allegations of abuse, neglect, exploitation, or misappropriation of property will be suspended immediately from duty pending the outcome of the investigation. Allegations of abuse will be investigated by the facility and the administrator is responsible to direct the investigation process and to ensure that appropriate agencies are notified as indicated. The Administrator is responsible to ensure that incidents of abuse are reported to the appropriate local/state/federal agencies including the state Nurse Aide Registry. Further review of the policy revealed the Administrator will ensure that the Division of Licensure and Regulation, Department of Social Services and Adult Protective Services will be notified immediately of all complaints of abuse. 1. Record review revealed the facility admitted Resident #17 on 05/19/16 with [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set (MDS) assessment, dated 10/30/18, revealed the facility assessed Resident #17's cognition as intact with a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated the resident was interviewable. Interview with Resident #17 on 01/08/2019 at approximately 1:45 PM, revealed he/she and Registered Nurse (RN) #1 were in his/her room on 12/22/18 when State Registered Nurse Aide (SRNA) #1 entered the room and asked Resident #17 if he/she wanted a lunch tray. Resident #17 stated she replied no but then stated yes and SRNA #1 asked him/her is it yes or no. The resident stated yes and SRNA #1 said, Ugh, got attitude much and left the room. Resident #17 stated he/she told RN #1 he/she no longer wanted SRNA #1 to come back into his/her room. Resident #17 stated there has been an ongoing issues with SRNA #1 mocking him/her and making rude and insulting comments. Resident #17 stated it's very upsetting to him/her and causes him/her a significant amount of anxiety because he/she is completely dependent on the staff's care. Interview with Resident #17's family members #1 and #2, on 01/08/19 at approximately 4:15 PM revealed the resident had many unpleasant interactions with SRNA #1. The family members stated the resident cried when discussing his/her interactions with SRNA #1 and it caused the resident to be anxious. They stated they had not reported any of the interactions to staff. Family Member #1 stated they called and reported to the facility that Resident #17 no longer wanted SRNA #1 to provide him/her direct care after the last incident on 12/22/18. Interview with LPN #1 on 01/09/19 at approximately 2:30 PM revealed on 12/22/18 he received a call from a family member of Resident #17 stating Resident #17 no longer wanted SRNA #1 to provide him/her care. LPN #1 stated the family stated Resident #17 contacted them about an incident that occurred that day in which SRNA #1 make a rude and belittling comment to Resident #17 during tray pass. LPN #1 stated she informed the weekend supervisor (Registered Nurse {RN} #3) of the family's concern. LPN #1 stated if he was handling the situation, he would have immediately removed SRNA #1 from her duties temporarily, reported the complaint to administrative staff, talked to the resident, and informed family of how the incident was handled. Interview with RN #3 on 01/09/19 at approximately 3:00 PM revealed she was the weekend supervisor on 12/22/18 when LPN #1 reported Resident #17's family called with concerns. RN #3 stated LPN #1 reported to her Resident #17's family member called and stated that Resident #17 felt like he/she was disrespected by SRNA #1. RN #3 stated she spoke with Resident #17 along with RN #1 regarding the complaint. RN #3 stated Resident #17 stated SRNA #1 came into his/her room and asked about the lunch tray. RN #3 stated Resident #17 reported SRNA #1 asked him/her if he/she was hungry or not and SRNA #1 was short and snippy with him/her. RN #3 stated Resident #17 informed her that he/she did not want SRNA #1 to provide care to him/her anymore. RN #3 stated she spoke with RN #1 and RN #1 stated she did not feel like SRNA #1 was inappropriate with Resident #17. RN #3 stated RN #1 was present during the verbal interaction between Resident #17 and SRNA #1. RN #3 stated she made the decision SRNA would not go into Resident #17's room for the remainder of the weekend. RN #3 stated she did not feel what SRNA #1 did was abusive therefore she did not report the incident to the Administrator or remove SRNA #1 from providing care to residents. 2. Record review, revealed the facility admitted Resident #14 on 11/10/16 with [DIAGNOSES REDACTED]. Review of Quarterly MDS assessment, dated 10/26/18, revealed the facility assessed Resident #14's cognition as intact with a BIMS score of fourteen (14), which indicated the resident was interviewable. Review of facilities Resident Council Minutes dated 09/21/18 revealed during the new business portion of the meeting Resident #14 reported concerns with aides taking too long to answer call lights and aides shoving residents to hurry them up. However, the facility was unable to provide documented evidence the allegation was investigated per the facility's policy and procedure. Interview with Resident #14 on 01/10/19 at approximately 10:30 AM revealed he/she has concerns with aides taking too long to answer call lights and with shoving residents to hurry them up. Resident #14 stated there is one aide in particular that has a nasty attitude but she did not remember the aide's name but stated the aide's mother is also an employee at the facility. Resident #14 stated he/she had not spoken with Administration directly but that he/she voiced concerns during resident council meetings. Resident #14 stated the issue with aides shoving residents is still about the same and has not been resolved. Resident #14 stated staff at the facility have not spoken with him/her about his/her concerns. 3. Record review revealed the facility admitted Resident #46 on 07/03/18 with [DIAGNOSES REDACTED]. Review of a Quarterly MDS assessment, dated 12/05/18, revealed the facility assessed Resident #46's cognition as intact with a BIMS score of fifteen (15), which indicated the resident was interviewable. Review of facility's Resident Council Minutes dated 11/16/18 revealed during the new business portion of the meeting Resident #46 stated concerns with aides shoving you down when assisting residents on the toilet. Review of facility's resident council-grievance follow-up dated 11/16/18 revealed the Social Service Director (SSD) spoke with Resident #46 who stated aides rush him/her when assisting with sitting on and standing up from the toilet. Review of facilities resident council-grievance follow-up dated 11/16/18 was not followed up by DON until 11/20/18 (four days later) in which it revealed when Resident #46 was interviewed by the DON, Resident #46 no longer expressed any concerns with staff being inappropriate or shoving him/her while assisting with toileting. The DON documented he/she observed aides assisting with toileting on 11/26/18 and 11/28/18 and observed no concerns. However, further review revealed there was no documented evidence additional residents were interviewed related to how the aides treated them when toileting. Interview with Resident #46 on 01/10/19 at approximately 3:00 PM revealed he/she expressed concerns during resident council about aides shoving him/her down when the aides assist him/her onto the toilet. The resident stated the aides are in a rush and push or drop him/her onto the toilet. The resident further revealed the issue was not resolved and it was still an ongoing issue. Resident #46 stated staff have never spoken with her about the issue. Interview with Resident #46's family member #4 on 01/10/19 at approximately 3:10 PM revealed he had prior and current concerns with how the aides assist Resident #46 during toileting. Family member #4 stated the aides do not put Resident #46 on the toilet right. Family Member #4 stated he has observed this while he is visiting with Resident #46 in her/his room. Family Member #4 stated Resident #46 has a bad shoulder and the aides handle Resident #46 rough when they are assisting him/her onto the toilet and the aides just drop Resident #46 onto the toilet seat from a standing position. Family Member #4 stated he had spoken with the Administrator and reported his/her concerns and observations. Family Member #4 stated the issues have not been resolved since talking with the Administrator and the same concerns are still ongoing. Interview with DON and Administrator 1/10/19 at approximately 6:44 stated any allegation of staff shoving would be considered abuse and it would be investigated. 4. Record review revealed the facility admitted Resident #58 on 04/16/18 with [DIAGNOSES REDACTED]. Review of a Quarterly MDS assessment, dated 12/11/18, revealed the facility assessed Resident #58's cognition as intact with a BIMS score of fifteen (15), which indicated the resident was interviewable. Review of facilities Resident Council Minutes dated 09/21/18 revealed during the new business portion of the meeting Resident #58 stated concerns about an aide being rude and belittling to her/his roommate over roommates use of a remote. Review of facilities resident council-grievance follow-up dated 09/21/18 revealed the SSD spoke with Resident #58 who stated SRNA #1 was rude to his/her roommate on 09/20/18. Further review revealed the SSD also spoke with Resident #58's roommate who reported no problems other than with general health. SRNA #1 was identified by Resident #58 as the staff member who was rude to roommate. Review of facilities resident council-grievance follow-up dated 09/21/18, by the Administrator dated 10/01/18 revealed the Administrator spoke with SRNA #1 who denied being rude to resident and Administrator spoke with roommate of Resident #58 who stated no concerns. Further review revealed it was also noted the Activity Assistant overheard the conversation but was not alarmed. However, further review revealed there was no documented evidence interviews were conducted with staff or other residents to determine if they had any concerns of how SRNA #1 treated the residents. Interview with Resident #58 on 01/09/19 at 4:40 PM, revealed SRNA #1 would make fun of and belittle his/her prior roommate. She stated SRNA #1 would pick on his/her prior roommate due to the prior roommate had trouble working the bed controls and SRNA #1 would pick on him/her and belittle him/her related to the inability to properly use the bed remote. Resident #58 stated SRNA #1 kept saying You don't know how to use a remote to his/her prior roommate over and over again belittling the resident. Resident #58 stated he/she brought this up in resident council and SRNA #1 would not speak to him/her because he/she had brought this up. Resident #58 stated it was hisher opinion that SRNA #1 gets away with stuff due to her mother also being an employee at the facility. Surveyor confirmed SRNA#1's mother is an employee at the facility. Interview with SSD on 01/10/19 at approximately 9:48 AM revealed she is usually present during the resident council meetings at the facility and she records her own notes from the meetings. The SSD stated when resident's voice concerns during those meetings, she takes that information directly to the Administrator. The SSD stated she spoke with Resident #58's prior roommate at the time regarding the incident Resident #58 brought up in resident council and he/she expressed no concerns and there was no additional follow-up. The SSD stated the Administrator guides him/her on all investigations. The SSD stated in her/his professional opinion staff being rude and belittling residents is inappropriate and falls under an issue with dignity. Interview with Administrator and DON on 01/10/19 at approximately 6:44 PM revealed the DON stated she expected allegations of abuse made by a resident to be investigated. The Administrator stated she expected at minimum a thorough investigation to be completed for any allegations of abuse and for all staff to follow policy and procedures related to allegations of abuse or mistreatment.

Based on observation, interview, record review and review of facility policy, it was determined the facility failed to ensure one (1) of twenty-four (24) sampled residents (Resident #17) and five (5) unsampled residents (Resident #35, Resident #34, Resident #39, Resident #70 and Resident #37) residents were treated with dignity and respect . On 12/22/18, a staff member asked Resident #17 if he/she wanted a lunch tray and the resident responded yes, then no, then yes and the staff member responded inappropriately by saying to the resident gahh, Attitude much. In addition, observations on 01/09/19 revealed a staff member entered Resident #35's, Resident #34's, Resident #39's, Resident #70's and Resident #37's rooms without knocking and/or identifying herself to residents before entering. The findings include: Review of the facility policy, Dignity, dated (MONTH) 2013, revealed residents are given care and treatment in a manner that helps preserve their dignity, self-esteem, and self-respect. Each resident is valued as an individual. Further review of the facility's policy revealed, Examples of Dignity Issues, Staff interactions with residents are respectful. Staff members speak to residents in a respectful tone of voice and avoid teasing-type interactions which may be misinterpreted. Resident's space and property are treated with respect by knocking before entering rooms and waiting/asking for permission to enter. 1. Record review, revealed the facility admitted Resident #17 on 05/19/16 with [DIAGNOSES REDACTED]. Review of Quarterly Minimum Data Set (MDS) assessment, dated 10/30/18, revealed the facility assessed Resident #17's cognition as intact with a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated this resident interviewable. Interview with Resident #17 on 01/08/2019 at approximately 1:45 PM, revealed on or around 12/22/18 hi/her and Registered Nurse (RN) #1 were in his/her room SRNA #1 came into the room to bring his/her lunch tray. Resident #17 stated then SRNA #1 asked him/her if he/she wanted the lunch tray and he/she replied no but then stated yes. SRNA #1 asked Resident #17 is it yes or no and he/she replied yes. Resident #17 stated at that time SRNA #1 said to her/him Ugh, got attitude much and grabbed the curtain and closed it hastily and left the room. Resident #17 stated she/he was so upset by the remark that he/she told RN#1 he/she no longer wanted SRNA#1 to come back into her/his room. Resident #17 stated there was an ongoing issue with SRNA #1 mocking him/her and making rude and insulting comments. Resident #17 stated it causes him/her a significant amount of anxiety because he/she is completely dependent on the staff's care and when SRNA #1 makes mean comments to him/her, he/she feels helpless. Resident #17 was becoming tearful while explaining the effects these interactions had on her/him. Interview with RN #1 on 01/09/19 at approximately 9:15 AM revealed on 12/22/18 she was in Resident #17's room when SRNA #1 came into the room to bring the lunch tray. RN #1 stated SRNA #1 asked Resident #17 if he/she wanted the lunch tray and the resident said 'no but then stated yes and SRNA #1 responded, Gahh, attitude much and left the room. RN #1 revealed Resident #17 told her he/she did not like SRNA #1's attitude and did not want SRNA #1 back into his/her room to provide him/her care. RN #1 stated it was her/his professional opinion that it was inappropriate for staff to say Gahh, attitude much to a resident. Interview with Administrator and Director of Nursing (DON) on 01/10/19 at approximately 6:44 PM revealed the DON and Administrator expected all staff to treat all residents with respect and dignity and that rude or belittling remarks were unacceptable. 2. Surveyor was standing in the 100 hallway on 01/09/19 at approximately 11:30 AM when Surveyor observed GCA #1 passing out water cups to residents in that section of the hallway. Further observation of GCA #1 revealed she walked into room [ROOM NUMBER], then room [ROOM NUMBER], then room [ROOM NUMBER], without stopping to knock on the door, and without announcing herself or asking resident for permission to enter room. Residents #35, #34, #39, #70, and Resident #37 resided in these rooms. Interview with General Care Assistant (GCA) #1 on 01/10/19 at approximately 1:45 PM revealed on 01/09/19 when she was passing out water to the residents she was by herself and she was in a hurry to get finished. GCA #1 stated she never stopped to knock on any of the residents room while she passed water due to being in a hurry to get the waters passed out. GCA #1 revealed in the future she will make sure to take her time and knock on all residents doors, identify herself and allow the resident an opportunity to answer before entering the room. She stated she was trained that the proper procedure when entering a resident's room was to knock on the resident's door, identify herself and wait for a response from the resident before entering the room. Interview with Administrator on 01/10/19 at approximately 6:44 PM revealed she expected staff to knock on all residents' doors and wait to be invited into the room by the resident before entering the room.

Based on interview, observation, record review and facility policy review, it was determined the facility failed to ensure services provided or arranged by the facility were provided according to accepted standards of clinical practice for one (1) of twenty-four (24) sampled residents (Resident #65). Observation of a medication pass on 01/09/19 revealed staff crushed Do Not Crush medication and administered it to Resident #65. The findings include: Review of facility policy titled, Crushing of Tablets and Emptying of Capsules, last revised 01/01/14, revealed the solid dosage forms of many medications should not be crushed or chewed for a variety of reasons and if crushing is contraindicated the nurse should consult the pharmacist for assistance in obtaining the medication in and alternate formulation, if possible. Record review revealed the facility admitted Resident #65 to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #65's Quarterly Minimum Data Set (MDS) assessment, dated 12/24/18, revealed the facility assessed Resident #65's cognition as moderately impaired with a Brief Interview for Mental Status (BIMS) score of eight (8), which indicated the resident was interviewable. Review of Resident #65's (MONTH) 2019 Medication Administration Record [REDACTED]. However, observation revealed Registered Nurse (RN) #2 crushed this medication and administered this medications to Resident #65 on 01/09/19 at 8:38 AM. Interview with RN #2 on 01/09/19 at 8:51 AM, revealed he should not have crushed the 'do not crush' [MEDICATION NAME] 60 milligrams (mg) Extended Release medication and this was an error. Interview with the Director of Nursing (DON) on 01/09/19 at 9:11 AM, revealed she expected medications that are a 'do not crush' to not be crushed.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure they developed and/or implemented a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for three (3) of twenty-four (24) sampled residents, (Residents #15, #18, and #75). Staff failed to ensure Resident #15 was wearing bunny boot to left heel to prevent pressure ulcers and Resident #75 was wearing Multi Podus AFO boots to prevent foot drop; on 01/08/19 and 01/09/19, per care plan. In addition, the facility failed to develop a person-centered plan of care for infections although, Resident #18 had been hospitalized twice for a UTI, treated once for fever of unknown origin, and twice for an abscess to his/her right cheek. The findings include: Review of the facility's policy, Resident Care Plan, revised 11/13/17, revealed it is the policy of the facility to provide a written resident-centered care plan based upon physician's orders [REDACTED]. Development and implementation of the resident's care plan will occur by participating disciplines available in the facility at a team conference under the direction of the RN Coordinator. Any new problem or need of the resident, which is identified between his/her scheduled care plan review, will be addressed on the care plan by the appropriate disciplines and brought to the next scheduled care plan meeting to inform the Interdisciplinary Care Plan (ICP) team of its addition. 1. Record review revealed the facility admitted Resident #15 on 06/14/18 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 10/26/18, revealed the facility assessed Resident #15's cognition as intact with a Brief Interview of Mental Status (BIMS) score of fifteen (15), which indicated the resident was interviewable. Review of Resident #15's Comprehensive Care Plan, Potential or Actual Skin Integrity Impairment, last revised 10/16/18, revealed an intervention for Specialty boots or pressure relieving (bunny) boot to left heel as tolerated. However, observations of Resident #15 on 01/08/19 at 4:49 PM and 01/09/19 at 9:30 AM, revealed the resident sitting up in wheelchair at bedside with left foot on floor without pressure relieving (bunny) boot on. Interviews on 01/10/19 with Certified Nursing Assistant (CNA) #6 at 10:05 AM, and CNA #5 at 10:09 AM, revealed it is the staff's responsibility to put on Resident #15's bunny boot per care plan. Interview with Registered Nurse (RN) #2, on 01/10/19 at 10:06 AM, revealed Resident #15 is to wear pressure relieving (bunny) boot to left foot as tolerated. RN #2 stated the resident is monitored by staff during rounds and when providing care; and it is the responsibility of all staff to ensure the intervention is followed. Interview with Director of Nursing, on 01/10/19 at 7:20 PM, revealed she expected staff to implement interventions related Resident #15's wound care. 2. Record review revealed the facility readmitted Resident #75 on 12/05/18 with [DIAGNOSES REDACTED]. Review of Resident #75's Comprehensive Care Plan, Risk for Falls, last revised 01/09/19, revealed an intervention for Multi Podus AFO boots to bilateral lower extremities while in bed and up in chair as tolerated. However, observations of Resident #75 on 01/08/19 at 9:34 AM, 2:43 PM, and 5:47 PM; and, on 01/09/19 at 9:29 AM, revealed there were no Multi Podus AFO boots on the resident. Interview with RN #2, Unit Manager, on 01/09/19 at 4:15 PM, revealed he would expect the staff to put Podus boots on Resident #75 as indicated on the resident's care guide and care plan to minimize potential for any further foot drop. Interview with the Administrator and Director of Nursing (DON), on 01/10/19 at 7:20 PM, revealed the Administrator and DON expected staff to follow Resident #75's care plan regarding the Podus boots in treating the resident's bilateral foot drop. 3. Record review revealed the facility admitted Resident #18 on 08/01/18 with [DIAGNOSES REDACTED]. Review of the Admission MDS assessment, dated 08/08/18, revealed the facility assessed Resident #18's cognition as intact with a BIMS score of fourteen (14) which indicated the resident was interviewable. Review of Resident 18's medical record revealed the resident was hosptalized on [DATE] and 10/04/18 with right-sided pneumonia. Further review of Resident #18's physician orders [REDACTED]. Review of Resident #18's Comprehensive Care Plan, last revised 11/05/18, revealed the facility failed to develop a care plan to address the resident's risk for infections. Interview with the Director of Nursing (DON), on 01/10/19 at 7:20 PM, revealed she expected staff to develop a care plan with interventions to provide care and services to Resident #18 related to the resident's history of infections.

Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to ensure a resident with pressure ulcers receives the necessary treatment and services to promote healing, and prevent new ulcers from developing unless clinically unavoidable for one (1) of twenty-four (24) sampled residents (Resident #15). Resident #15 was assessed by the facility to have an unstageable Pressure Ulcer to the left heel on 10/25/18 with an intervention to place specialty pressure relieving (bunny) boot to left heel as tolerated; however, observations on 01/08/19 and 01/09/19 revealed the boot was not on the resident's left heel. The findings include: Review of the facility's policy, Wound/Ulcer Treatment, dated 05/22/18, revealed the rationale is to provide guidelines for care and treatment of [REDACTED]. Record review revealed the facility admitted Resident #15 on 06/14/18 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 10/26/18, revealed the facility assessed Resident #15's cognition as intact with a Brief Interview of Mental Status (BIMS) score of fifteen (15), which indicated the resident was interviewable. Further review of the MDS: Section M-Skin Conditions; revealed the facility assessed Resident #15 at risk for pressure ulcers and identified the resident had one (1) Unstageable Pressure Wound. Review of Resident #18's Comprehensive Care Plan, Potential or Actual Skin Integrity Impairment, last revised 10/16/18, revealed an intervention for Specialty boots or pressure relieving (bunny) boot to left heel as tolerated. Review of Resident #15's Wound Ulcer Flowsheet, dated 10/25/18, revealed the facility identified an Unstageable Pressure Wound to left heel measuring 0.3 centimeters (cm) in length by 2.9 cm in width with black eschar to wound bed. Further review revealed the wound treatment was to cleanse with soap and water, apply Santyl ointment (topical [MEDICATION NAME] agent) and cover with [MEDICATION NAME], change daily and as needed. Observations of Resident #18 on 01/08/19 at 4:49 PM and 01/09/19 at 9:30 AM, revealed the resident sitting up in wheelchair at bedside with left foot on floor without pressure relieving (bunny) boot on. Interviews with Resident #15, on 01/08/19 at 4:49 PM, and 01/09/19 at 9:30 AM revealed he/she had been to [MEDICAL TREATMENT] on 01/08/19 and wore a shoe rather than the bunny boot and stated on 01/09/19 that we just forgot it this morning. The resident stated the staff do put on his/her bunny boot. Observation of Resident #15's wound care to left heel, on 01/09/19 at 9:35 AM, by Licensed Practical Nurse (LPN) #2, Wound Care Nurse (WCN), revealed a circular unstageable wound measuring 5.1 cm in length by 6.5 cm in width. The wound bed was covered with black eschar with slightly macerated edges; and periwound was intact, blanched slightly,with eschar moveable. LPN #2 cleansed the wound with soap and water, applied Santyl ointment to wound bed and [MEDICATION NAME] gauze dressing to secure wound. Interviews on 01/10/19 with Certified Nursing Assistant (CNA) #6, at 10:05 AM, and CNA #5 at 10:09 AM, revealed it is the CNA's responsibility to put on Resident #15's bunny boot. Interview with LPN #2, on 01/09/19 at 10:05 AM, revealed Resident #15's wound was identified as an unstageable pressure wound and the wound was acquired in the facility. LPN #2 stated Resident #15's physician visited on 01/01/19 and an order was obtained for consult with Wound Care for ongoing treatment. LPN #2 further revealed in addition to wound care, the resident was to wear a pressure relieving (bunny) boot to the left foot as tolerated; however, the resident was not always compliant. Interview with Registered Nurse (RN) #2, on 01/10/19 at 10:06 AM, revealed Resident #15 is to wear pressure relieving (bunny) boot to left foot as tolerated. RN #2 stated the resident should wear boot when out of bed and left foot elevated when in bed to relieve pressure. RN #2 revealed the resident is monitored by staff during rounds and when providing care; and it is the responsibility of all staff to ensure the resident is following the interventions Interview with Director of Nursing, on 01/10/19 at 7:20 PM, revealed Resident #15 was referred to wound care related to pressure wound to left heel. The DON stated the resident was under care of a Vascular Surgeon related to history of [MEDICAL CONDITION] which indicated wound to left heel was vascular; however, the DON revealed Resident #15's wound to the left heel was acquired at the facility and identified as an unstageable pressure ulcer. The DON stated she expected staff to implement interventions related Resident #15's wound care.

Based on interview, record review, and review of the facility's policy and procedures, it was determined the facility failed to ensure one (1) of twenty-four (24) sampled residents, received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan that will meet each resident's physical, mental, and psychosocial well-being (Resident #18). The facility failed to recognize and assess risk factors related to Resident #18's physical well-being resulting in a decline of the resident's health. The resident was hospitalized twice related to multiple infections, on 09/21/18 with [MEDICAL CONDITION], Right Lower Lobe (RLL) Pneumonia,[MEDICAL CONDITION], and Lactic Acidosis; and on 10/04/18 with Right -Sided Pneumonia, and Mucous Plug of [MEDICAL CONDITION]. However, there was no care plan to address the resident's risk for respiratory infections or the resident's asking for and obtaining food and liquid when the resident was assessed as not being able to eat or drink by mouth (NPO). The findings include: Review of the facility's policy, Standard Precautions, dated (MONTH) 2014, revealed Standard Precautions are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized source of infection in healthcare facilities. Standard Precautions apply to blood, all body fluids, secretions, and excretions except sweat, regardless or not they contain visible body fluids, non-intact skin, and mucous membranes. Standard Precautions are used for the care of all residents. Record review revealed the facility admitted Resident #18 on 08/01/18 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment, dated 08/08/18, revealed the facility assessed Resident #18's cognition as intact with a Brief Interview of Mental Status (BIMS) score of fourteen (14) which indicated the resident was interviewable. Further review revealed the resident was NPO (nothing by mouth). Review of Resident #18's medical record revealed the resident was hospitalized twice related to multiple infections, on 09/21/18 with [MEDICAL CONDITION], Right Lower Lobe (RLL) Pneumonia,[MEDICAL CONDITION], and Lactic Acidosis; and on 10/04/18 with Right-Sided Pneumonia, and Mucous Plug of [MEDICAL CONDITION]. Review of Resident #18's Comprehensive Care Plan, last revised 11/05/18, revealed the facility failed to ensure the resident had a person-centered care plan to address the resident's history of respiratory and urinary tract infections to ensure Resident #18 would receive care and services to minimize potential of re-hospitalization s. Further review revealed the care plan also did not address the resident asking for or obtaining food and liquids. Interview with MDS Coordinator #2, on 01/10/19 at 4:10 PM, revealed Resident #18 is non-compliant with her nothing by mouth (NPO) status which increased the potential of aspiration pneumonia. She stated Resident #18 is aware that he/she is only allowed ice chips; however, staff feels the resident is consuming food and/or liquids without staff knowledge. Interview with the Administrator and Director of Nursing (DON), on 01/10/19 at 7:20 PM, revealed the residents' care is provided based on the care needs. They stated staff was expected to assess residents on an ongoing basis to identify, and ensure treatment and care needs were met to maintain the residents' well-being as tolerated.

Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to ensure one (1) of twenty-four (24) sampled residents has the opportunity to exercise his or her autonomy regarding those things that are important in his or her life. Staff failed to provide Resident #49 the opportunity to choose which clothes he/she wanted to wear on a daily basis. The findings Include: Review of the facility policy, Residents Rights, not dated, revealed the discussion of Residents Rights will be included in the orientation of the new employees. The Administrator assumes the responsibility for the implementation of the Residents Rights. The facility also will ensure that their employees are trained on a regular basis regarding Resident Rights. Record review, revealed the facility admitted Resident #49 on 02/19/17 with [DIAGNOSES REDACTED]. Review of Annual Minimum Data Set (MDS) assessment, dated 12/07/18, revealed the facility assessed Resident #49's cognition as intact with a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated the resident was interviewable. Interview with Resident #49, on 01/08/19 at approximately 10:30 AM, revealed staff never allow him/her to pick out clothes. Resident #49 stated he/she is use to looking nice and likes clothes to match but staff just put anything on him/her. Resident #49 revealed he/she asked staff on many occasions to let him/her pick out outfits to wear but staff never allow him/her and they pick his/her clothes. Interview with Resident #49 on 01/10/19 at approximately 11:00 AM, revealed he/she asked staff to allow him/her to pick out clothes today but staff ignored the requests and picked the outfit out that he/she was wearing. Resident #49 stated she would be happy if they would just allow him/her to pick which clothes to wear at least two days a week. Interview with State Registered Nurse Aide (SRNA) #4 on 01/10/19 at approximately 11:30 AM revealed SRNA #3 got Resident #49 dressed today. SRNA #4 stated Resident #49 has requested to wear a dress often but there were not any dresses in Residents #49's closet, and she shows the resident there are not any dresses in there. She revealed she assisted residents like Resident #49 to pick out their clothes if they want to and communicate they want to. SRNA #4 stated she does not always ask the residents if they want to pick out their clothes but if a resident tells her they want to then she does. SRNA #4 stated she has received training on Resident Rights and allowing residents the opportunity to make decisions about their care. Interview with SRNA #2 on 01/10/19 at approximately 11:57 PM, revealed Resident #48 wanted to wear a dress today but she told Resident #49 there were no dresses for him/her to wear. SRNA #2 stated she informed Resident #49 which items of clothing were in his/her closet and Resident #49 picked out the outfit he/she was wearing today. SRNA #2 stated she assisted SRNA #3 with dressing the resident. SRNA #2 stated she has received training on Resident Rights and allowing residents the opportunity to make decisions about their care. Interview with SRNA #3 on 01/10/19 at approximately 12:17 PM revealed SRNA #4 dressed Resident #49 today. SRNA #3 stated the resident gets confused about what items are in his/her closet and does ask on occasion to wear a dress but the resident does not have any dresses. SRNA #3 revealed she has not informed Resident #49's family of his/her request to wear a dress and was not aware if the family has been informed by another staff of resident's request. SRNA #3 stated sometimes she will ask residents what they want to wear and she will get something different if a resident states they want to wear something other than the outfit that is offered by staff. SRNA #3 stated she has received training on Resident Rights and allowing residents the opportunity to make decisions about their care. Interview with the Administrator on 01/10/19 at 6:44 PM revealed all staff are trained in Residents Rights and staff are to ensure they allow resident's the opportunity to make choices in their clothing attire if they want to. The Administrator stated she does not care if a resident wants to wear pajamas all day, the staff should honor their choice. The Administrator revealed staff should allow residents that are able to have input the opportunity to make decisions regarding their choices about what they want to wear.

Based on observation, interview, record review, and review of the facility's policies and procedures, it was determined the facility failed to ensure that the comprehensive care plan is reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs for one (1) of twenty-four (24) sampled residents (Residents #38). Review of Resident #38's Comprehensive Care Plan revealed the facility failed to review and revise the care plan to address the resident's decline in bowel and bladder continence and put interventions in place to restore Resident #38's bowel and bladder continence to the extent possible. The findings include: Review of the facility's policy, Resident Care Plan, last revised 11/13/17, revealed it is the policy of the facility to provide a written resident-centered care plan based upon physician's orders [REDACTED]. Any new problem or need of the resident, which is identified between his/her scheduled care plan review, will be addressed on the care plan by the appropriate disciplines and brought to the next scheduled care plan meeting to inform the Interdisciplinary Care Plan (ICP) team of its addition. Record review revealed the facility admitted Resident #38, on 05/06/16, with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) assessment, dated 11/30/18, revealed the facility assessed Resident #38's cognition was intact with a BIMS score of thirteen (13) which indicated the resident was interviewable. Further review revealed the resident was assessed to be frequently incontinent of urine; and occasionally incontinent of bowel. Review of Resident #38's Comprehensive Care Plan, Requires Assistance/Potential to Restore or Maintain Maximum Function of Self-Sufficiency for the Physical Process of Toileting, last revised 01/26/18, revealed there was no interventions to address prompting the resident to void or any interventions to address the residents decline in continence. Interview with Resident #38, on 01/09/19 at 12:10 PM, revealed the resident was aware of his/her toileting needs, stating sometimes I just wait too late. Interview with MDS Coordinator #2, on 01/10/19 at 2:12 PM, revealed Resident #38 was trialed on a three (3) day toileting pattern scheduled on 03/17/17 through 03/20/17 when it was identified the resident had started having urine and bowel incontinence. She stated there was no documented evidence any interventions were put in place to improve Resident #38's noted decline in bowel and bladder continence. Further interview with MDS Coordinator #2, on 01/10/19 at 3:01 PM, revealed Resident #38 had a bowel and bladder assessment after prompted by the Care Area Assessment (CAA) with the Annual MDS on 11/30/18. She stated the facility does not use a bowel and bladder assessment tool, but the resident's toileting habits were assessed by interviewing direct care staff and reviewing the resident elimination pattern during the seven (7) day look back period. Further interview revealed her and the Registered Nurse (RN)/MDS Coordinator were responsible to implement intervention to assist Resident #38 to not have incontinent episodes. Interview with Administrator and Director of Nursing (DON), on 01/10/19 at 7:20 PM, revealed they expected residents continent of bowel and bladder that become incontinent to be assessed for appropriate interventions to decrease incontinent episodes.

Based on observation, interview, record review, and facility policy review it was determined the facility failed to ensure residents who were unable to carry out activities of daily living, received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for three (3) of twenty-four (24) sampled residents (Residents #45, #8 and #5). The facility failed to ensure Resident #45 received adequate oral hygiene to prevent dry mouth and lips, and severe foul mouth odor, failed to provide nail care to Resident #5 due to dirty, long nails; and poor body hygiene to Resident #8 related to a dead skin build up on left foot. The findings include: Review of the facility policy titled, Oral Hygiene, dated (MONTH) 2013, revealed the objective was to cleanse the mouth for personal hygiene, to lessen the occurrence of mouth infections, and to stimulate the gums. Further review revealed staff should explain procedure to the resident, place resident on his/her side if not able to be in a sitting position, place towel under chin, put small amount of tooth paste on tooth brush, brush downward on upper teeth and upward on lower teeth from gum line to the crown. Record review revealed the facility admitted Resident #45 on 02/14/18 with [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set, dated dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of nine-nine (99) which indicated the resident's cognition was severely impaired and the resident was not interviewable. Further review of this MDS revealed the resident was totally dependent with one person for hygiene (includes brushing teeth), and totally dependent with assist of one for eating (has a feeding tube). Review of the Comprehensive Care Plan for Resident # 45, dated 02/22/18, revealed an intervention for oral care to be done every shift and PRN (as needed); however, review of the (MONTH) and (MONTH) (YEAR); and (MONTH) 2019 Treatment Administration Records (TAR's) revealed the TAR was never initialed for any shift as being done PRN (as needed) and not initialed as being done on 11/14/18 through 11/22/18, 11/25/18, and 11/26/18, (eleven {11} shifts) on the 10:00 PM -6:00 AM shift. Observation of Resident #45 on 01/08/19 at 9:41 AM revealed the resident to be lying in bed with dry lips and mouth. The resident's mouth was open and a strong foul odor was coming from the resident's mouth and there was brown material on several teeth with some teeth missing and some teeth chipped. Observations on 01/09/19 at 9:30 AM, 9:47 AM, 9:52 AM, 10:35 AM, 11:54 AM and 1:07 PM revealed the resident to have dry lips, dry mouth, and foul odor coming from mouth. Observation on 01/09/19 at 4:10 PM revealed a foul odor coming from mouth but lips and mouth were not quite as dry. During these observations there was never any staff seen providing oral care. Interview with Certified Nurse Aide (CNA) #7 on 01/ 09/19 at 1:20 PM, revealed staff cleansed the resident's mouth three (3) times a day. When she was asked by surveyor if that was per the Care Plan she stated, That is what the nurse tells us, to clean mouth three times a day and more often when we have time. She revealed she cleaned the resident's mouth at 9:30 or 10:00 AM; however, from 8:47 AM until 10:35 AM on 01/09/19 this surveyor observed no CNA enter the resident's room to do oral care. Interview with CNA #11 on 01/10/19 at 4:50 PM revealed she did not know what the care plan said about oral care and did not know how often they were supposed to clean the resident's mouth. Interview with the Director of Nursing (DON) on 01/10/19 at 6:44 PM revealed she expected staff to provide good oral care to prevent dryness of mouth, lips and foul mouth odor and should provide oral care per the Care Plan and as needed, not just three times a day. 2. Review of the facility policy titled, Care of Nails, dated (MONTH) 2013, revealed the objective is to provide cleanliness and prevent infection. The procedure is to trim nails and clean as indicated. Record review revealed the facility admitted Resident #5 on 09/08/17 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 10/19/18 revealed the facility assessed Resident #5's cognition as moderately impaired with a BIMS score of eight (8) which indicated the resident was interviewable. Review of Resident #5's Comprehensive Care Plan for requires assistance/potential to restore or maintain maximum function of self-sufficiency for Bathing/Dressing/Hygiene related to dementia and weakness, dated 09/11/17 revealed a goal to be neat, clean, odor free, and appropriately dressed thru next review. Further review revealed an intervention that resident prefers long fingernails and to ensure nails are clean and filed. Observation of Resident #5 on 01/08/19 at 3:48 PM revealed the resident sitting in the hallway. The resident's nails were observed to be long and irregular with some broken and angled. Further observation revealed when the resident turned his/her hands over, his/her nails were extremely dirty with a large amount of unidentifiable particles under the nails. The resident stated his/her nails were done last week. Further observations on 01/09/19 at 8:41 AM and on 01/10/19 at 10:35 AM found his/her nails dirty with no change. Interview with CNA #7 on 01/10/19 at 2:10 PM revealed Resident #5 prefers to have nails long and sometime she has to go back to the resident if he/she is in a mood to provide nail care. She stated sometimes the resident is not happy but if she returns later he/she will let me do nail care. She further stated she she did not know why his/her nails were dirty. Interview on 01/10/19 at 10:35 AM with the Wound Care Nurse (WCN) revealed she expected the Certified Nurse Aides (CNA's) to clean skin and nails during bathing and hygiene. 3. Review of the facility policy, Bath, Shower revealed the objective is to cleanse and refresh the resident. The procedure includes to help resident with bath as needed. Help the resident to wash and make sure he/she is well dried. Apply lotions and powder as desired. Record review revealed the facility admitted Resident #8 on 10/03/17 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 10/23/18 revealed the facility assessed Resident #8's cognition as intact with a BIMS score of fifteen (15) which indicated the resident was interviewable. Review of the Comprehensive Care Plan for Total care with Bathing/Dressing/Hygiene related to pain, weakness, bilateral femur fractures with goal to be neat, clean, odor free, and appropriately dressed thru next review dated 10/10/15, revealed interventions for total care with bathing, and dressing; and, total care by one staff for hygiene. Review of Resident #8 skin assessment dated [DATE] revealed no concerns and no notation of scaling skin to left foot. Observation on 01/09/19 at 11:15 AM of a Skin Assessment for Resident #8 performed by the Wound Care Nurse and CNA #7 revealed a foam boot was removed from the resident's left foot and there was a build up of dead skin on lateral side of foot and dry skin and particles between toes The dead skin was flaked off by WCN. Interview on 01/10/19 at 2:10 PM with CNA #7 revealed she told the nurse about the feet when it was seen on there. She stated the dead skin has been on his/her foot for ages and she does not really remember the exact time but it had been months. She also revealed she was fearful to scrub too hard in case she hurt the resident. Interview on 01/09/19 at 2:57 PM with the WCN revealed she thought the dead skin on the foot was from the foot not being washed properly and she revealed the resident's feet needed to be scrubbed and lotion applied to remove the dead skin. She stated obviously, the dead scaling skin had been on there for some time. Observation on 01/10/19 at 10:36 AM of Resident #8's feet and ankles after being cleaned by the WCN revealed clean feet without any dry skin ridges, and no dry skin and particles between toes. Interview on 01/10/19 at 10:50 AM with Resident #8's spouse revealed, He/She is awfully happy about his/her feet. I didn't realize that was dead skin, I thought it was because of his/her diabetes. It sure is clean and pretty now, that was nasty! Interview with the Assistant Director of Nursing (ADON) on 01/10/19 at 3:33 PM revealed the dead, dry scaly skin should be removed during bathing.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to provide adequate supervision to prevent accidents for one (1) of three (3) sampled residents (Resident #1). The facility assessed and care planned for Resident #1 required extensive physical assistance of two (2) with bed mobility, however, on 09/30/17 State Registered Nursing Assistant (SRNA) #1 failed to provide adequate supervision when she assisted Resident #1 from the bed pan and repositioned the resident in bed without the assistance of another staff member. Resident #1 rolled from the bed and sustained femur fractures to both his/her right and left leg. The findings include: Review of the Nursing Policy Manual , last revised 08/22/14, revealed a Safe Resident Handling and Movement Policy. The policy stated the facility wants to ensure that its residents are cared for safely, while maintaining a safe work environment for employees. Staff will follow the movement and handling safety interventions/procedures for each resident as individually determined through the admission/re-entry admission process and the RAI process. Further review of the policy revealed all employees are required to follow the movement and handling interventions and procedures for each individual resident as specified on their Resident Care Guide in the resident's room. Record review revealed the facility readmitted Resident #1 on 10/03/17 with [DIAGNOSES REDACTED].#1's cognition as intact with a Brief Interview Mental Status (BIMS) score of fifteen (15) indicating the resident was interviewable. Further review of the MDS revealed Resident #1 was assessed as total dependence with two plus persons for physical assistance with bed mobility. Review of the Risk for Falls Comprehensive Care Plan, dated 09/27/17, and Resident Care Guide, dated 10/10/17, revealed Resident #1 required two people for physical assistance for bed mobility. Review of the Nursing Note dated 09/30/17 at 6:29 PM, revealed Licensed Practical Nurse (LPN) #1 was called to Resident #1's room and noted Resident #1 to be on his/her left side in the floor between resident beds. Resident #1 complained of pain to his/her left hip down to the left foot and the physician was notified. Resident #1 was sent out of the facility by ambulance to the emergency room for further evaluation Review of Resident #1's hospital record revealed X-rays, dated 09/30/17, which identified Resident #1 sustained a severely comminuted displaced fractures of the distal femur involving the distal shaft and metastases extending into the right lateral femoral condyle and left femoral intercondylar notch (both legs). Further review of the hospital record revealed with surgery staff evaluated the resident and determined the resident was not a suitable operative candidate given his/her multiple medical conditions. Review of the Facility Incident Report, dated 10/02/17, revealed Resident #1 sustained a fall with injury due to SRNA #1's failure to follow the care plan guide while providing care to Resident #1. The fall resulted in Resident #1 sustaining fractured femurs to both his/her right and left leg. Interview with Resident #1, on 10/11/17 at 830 AM, revealed he/she could not remember the events of 09/30/17. Resident #1 further stated two staff members always assist him/her while in the bed and out of the bed with transfers. Interviews with SRNA #1, on 10/10/17 at 3:50 PM, revealed on 09/30/17 she assisted Resident #1 off the bed pan without assistance and when Resident #1 moved his/her left leg over the right leg, gravity took over and the resident rolled off the bed into the floor. She stated she knew Resident #1 was care planned for two assist with bed mobility but had done this before without assistance. Interview with Licensed Practical Nurse (LPN) #1 on 10/10/17 at 4:10 PM, revealed SRNA #1 approached her at the nurses station and stated Resident #1 was in the floor. She stated upon entering Resident #1's room she noted the resident to be on his/her left side in the floor between resident beds. She stated other staff came to help while another nurse on the floor notified the physician and received orders to send Resident #1 out for further evaluation due to complaints of right hip. She further revealed family was present at the facility and notified as well. She further stated it was after the resident was sent out that she began to inservice staff on following resident care plans. Interview with the Director of Nursing (DON) on 10/12/17 at 1:30 PM, revealed she expected the staff to follow the care plans. She stated the care plan guides for each resident are located inside the resident's closets. She further stated SRNA #1 chose not to follow the care plan for Resident #1 resulting in a fall with injury. Interview with the Administrator on 10/12/17 at 1:50 PM, revealed she expected staff to follow the resident care plans for the resident and staffs safety. **The facility implemented the following actions to correct the deficient practice: 1. Review of the facility investigation, dated 10/03/17 revealed SRNA failed to follow Resident #1's plan of care as it indicated the resident required assistance of two for bed mobility. As a result, SRNA #1 was terminated on 10/01/17. Further review of the facility investigation revealed LPN #1 was given a disciplinary warning notice dated 10/03/17, with suspension for failure to follow Resident #1's care plan as it indicated the resident required assistance of two for bed mobility. LPN #1 was also in-serviced over the Resident Safe Handling and Movement Policy on 10/01/17. 2. All staff on duty on 09/30/17 were immediately in-serviced by LPN #1 on following resident care plans. 3. On 10/01/17, the Staff Development Coordinator began inservicing all facility staff on following Resident Care Plans and it was completed on 10/06/17, with the exception of one as needed (PRN) SRNA, whom will not be able to work until in-serviced on following resident care plans. 4. The DON and Administrator are conducting walking rounds on all shifts and checking for 100% competency with following the care plans weekly times four (4) weeks. **The State Survey Agency validated the facility's plan of action was carried out by: 1. Review of the facility, Disciplinary Warning Notice dated 10/01/17 for SRNA #1, revealed SRNA #1 was terminated for failure to obey safety rules. Review of the facility, Disciplinary Warning Notice dated 10/03/17 for Licensed Practical Nurse (LPN) #1, revealed during the fall investigation for Resident #1, LPN #1 stated she placed the resident on the bed pan without assistance from another staff member. The document further revealed Resident #1 was care planned for assistance of two (2) staff members and LPN #1 failed to obey safety rules. 2. Review of Care Guide In-Service Training Report, revealed all nursing staff on 09/30/17 were in-serviced by LPN #1. Interview with Licensed Practical Nurse (LPN) #1 on 10/10/17 at 4:10 PM, revealed she had immediately in-serviced all nursing staff on 09/30/17 on following resident care plan guides. 3. Review of Safe Resident Handling and Movement Policy In-Service Training Report, revealed all nursing staff were in-serviced from 10/01/17 through 10/06/17 with the exception of one as needed (PRN) SRNA, whom will not be able to work until in-serviced on following resident care plans. Interviews on 10/11/17 with SRNA #2 at 2:02 PM, SRNA #3 at 1:58 PM, SRNA #4 at 1:34 PM, and SRNA #5 at 1:40 PM and on 10/12/17 with SRNA #6 at 9:43 AM, SRNA #7 at 10:30 AM, SRNA #8 at 10:45 AM, and SRNA #9 at 10:58 AM, revealed they were in-serviced by the Staff Development Coordinator (SDC) on following resident care guides and she was also given a copy of the policy and a quiz to complete. She further revealed all resident care guides are located in each resident's closet. Interview with LPN #5 on 10/12/17 at 12:50 PM, revealed she had been in-serviced by the SDC in a one on one setting and received a copy of the policy and a quiz to complete. She further stated resident care guides are located in each resident's closet door. Interview with the Administrator on 10/12/17 at 1:50 PM, revealed all staff had been in-serviced on following resident care guides with the exception of one as needed (PRN) SRNA, whom will not be able to work until she is in-serviced. 4. Review the Report of Quality Improvement Action Team Meeting and documentation of audits with ten (10) percent nursing staff weekly times four weeks to ensure continued compliance with resident care plans. Further interview with the Administrator, on 10/12/17 at 1:50 PM, revealed weekly rounds were being conducted to ensure resident care guides are being followed.

Based on interview, record review, review of facility incident report, and facility policy review, it was determined the facility failed to provide services according to the written plan of care for one (1) of three (3) sampled residents (Resident #1). Resident #1 was care planned for extensive physical assistance of two (2) with bed mobility, however, on 09/30/17 State Registered Nursing Assistant (SRNA) #1 was removing Resident #1 from the bed pan without the assistance of another staff and when SRNA #1 repositioned the resident to his/her right side, the resident turned over and fell off the side of the bed. Resident #1 sustained femur fractures to both the right and left leg. The findings include: Review of the Nursing Policy Manual, dated August 2012, Resident Care Plan revealed, the facility is to provide an interdisciplinary written care plan based on the physician's orders [REDACTED]. The resident care plan will be an ongoing process and will include current problems and/or needs identified from a complete assessment including Minimum Data Sets (MDS) relevant to the resident's response to aging, illness, and his/her general health status. Record review revealed the facility readmitted Resident #1 on 10/03/17 with diagnoses, which included Displaced Fracture Of Lateral Condyle Of Right Femur, Displaced Fracture Of Lateral Condyle of Left Femur, [MEDICAL CONDITION], and Other Specified Disorders Of Bone Density and Structure of Left Lower Leg Review of the Risk for Falls Comprehensive Care Plan, dated 09/27/17, and Resident Care Guide, dated 10/10/17, revealed Resident #1 required two (2) people for physical assistance for bed mobility. However, review of a facility Incident Report, dated 10/02/17, revealed Resident #1 sustained a fall with injury on 09/30/17 due to SRNA #1's providing a bedpan and assisting the resident with bed mobility without another staff's assistance. The resident rolled off the bed when the SRNA turned the resident to his/her side. Review of Resident #1's hospital record revealed X-ray results dated 09/30/17, which identified Resident #1 sustained severely comminuted displaced fractures of bilateral distal femurs involving distal shaft and metastases extending into the right lateral femoral condyle and left femoral intercondylar notch. Further review of the hospital record revealed surgery staff evaluated the resident and did not feel that the resident was a suitable operative candidate given his/her multiple medical conditions. Interview with SRNA #1 on 10/10/17 at 3:50 PM, revealed on 09/30/17 she assisted Resident #1 off the bed pan without the assistance of another staff and when Resident #1 moved his/her left leg over the right leg, gravity took over and the resident rolled off the bed into the floor. She stated she knew Resident #1 was care planned for two assist with bed mobility but had done this before without assistance. Interview with the Director of Nursing (DON) on 10/12/17 at 1:30 PM, revealed she expected the staff to follow the care plans. She stated the care plan guides for each resident are located inside the resident's closets. Interview with the Administrator on 10/12/17 at 1:50 PM, revealed she expected staff to follow the resident care plans for resident and staff safety. **The facility implemented the following actions to correct the deficient practice: 1. Review of the facility investigation, dated 10/03/17 revealed SRNA failed to follow Resident #1's plan of care as it indicated the resident required assistance of two for bed mobility. As a result, SRNA #1 was terminated on 10/01/17. Further review of the facility investigation revealed LPN #1 was given a disciplinary warning notice dated 10/03/17, with suspension for failure to follow Resident #1's care plan as it indicated the resident required assistance of two for bed mobility. LPN #1 was also in-serviced over the Resident Safe Handling and Movement Policy on 10/01/17. 2. All staff on duty on 09/30/17 were immediately in-serviced by LPN #1 on following resident care plans. 3. On 10/01/17, the Staff Development Coordinator began inservicing all facility staff on following Resident Care Plans and it was completed on 10/06/17, with the exception of one as needed (PRN) SRNA, whom will not be able to work until in-serviced on following resident care plans. 4. The DON and Administrator are conducting walking rounds on all shifts and checking for 100% competency with following the care plans weekly times four (4) weeks. **The State Survey Agency validated the facility's plan of action was carried out by: 1. Review of the facility, Disciplinary Warning Notice dated 10/01/17 for SRNA #1, revealed SRNA #1 was terminated for failure to obey safety rules. Review of the facility, Disciplinary Warning Notice dated 10/03/17 for Licensed Practical Nurse (LPN) #1, revealed during the fall investigation for Resident #1, LPN #1 stated she placed the resident on the bed pan without assistance from another staff member. The document further revealed Resident #1 was care planned for assistance of two (2) staff members and LPN #1 failed to obey safety rules. 2. Review of Care Guide In-Service Training Report, revealed all nursing staff on 09/30/17 were in-serviced by LPN #1. Interview with Licensed Practical Nurse (LPN) #1 on 10/10/17 at 4:10 PM, revealed she had immediately in-serviced all nursing staff on 09/30/17 on following resident care plan guides. 3. Review of Safe Resident Handling and Movement Policy In-Service Training Report, revealed all nursing staff were in-serviced as of 10/06/17 with the exception of one as needed (PRN) SRNA, whom will not be able to work until in-serviced on following resident care plans. Interviews on 10/11/17 with SRNA #2 at 2:02 PM, SRNA #3 at 1:58 PM, SRNA #4 at 1:34 PM, and SRNA #5 at 1:40 PM and on 10/12/17 with SRNA #6 at 9:43 AM, SRNA #7 at 10:30 AM, SRNA #8 at 10:45 AM, and SRNA #9 at 10:58 AM, revealed they were in-serviced by the Staff Development Coordinator (SDC) on following resident care guides and she was also given a copy of the policy and a quiz to complete. She further revealed all resident care guides are located in each resident's closet. Interview with LPN #5 on 10/12/17 at 12:50 PM, revealed she had been in-serviced by the SDC in a one on one setting and received a copy of the policy and a quiz to complete. She further stated resident care guides are located in each resident's closet door. Interview with the Administrator on 10/12/17 at 1:50 PM, revealed all staff had been in-serviced on following resident care guides with the exception of one as needed (PRN) SRNA, whom will not be able to work until she is in-serviced. 4. Review the Report of Quality Improvement Action Team Meeting and documentation of audits with ten (10) percent nursing staff weekly times four weeks to ensure continued compliance with resident care plans. Further interview with the Administrator, on 10/12/17 at 1:50 PM, revealed weekly rounds were being conducted to ensure resident care guides are being followed.

Based on interview, record review, hospital record review, facility policy review, and review of Lippincott's Manual of Nursing Practice, it was determined the facility failed to ensure one (1) of two (2) residents identified as having a catheter in the selected sample of six (6) residents received the appropriate care and services to prevent urinary tract infections. Resident #1 had a urinary catheter and was identified as having no urinary output from 04/03/17 at 5:47 AM through 04/04/17 at 1:30 PM (thirty-one {31} hours) and a green, mucus like discharge from the catheter insertion site; however, licensed staff failed to identify the resident had no urinary output and mucus like discharge due to not assessing the resident's catheter. On 04/04/17 at 1:04 PM, the resident was noted to have a hard and distended abdomen, uneven and labored respirations, and a blood pressure of 80/60. The resident sent to hospital and admitted to the Intensive Care Unit and diagnosed with [REDACTED]. The findings include: Interview with Director of Nursing (DON), on 04/18/17 at 3:33 PM, revealed she would expect nurses to look at input and output and check catheter if no urinary output. She stated the facility uses Lippincott for Standards of Practice 10th. Edition. Review of Lippincott's Manual of Nursing Practice, tenth (10th.) Edition, pages seven-hundred and eighty-two (782) to seven-hundred and eighty-three (783) provided by the facility, revealed in maintaining a closed drainage system, one should maintain an unobstructed urine flow in order to prevent infection, empty the drainage bag at regular intervals, and change the drainage bag if urine flow becomes obstructed. Review of facility policy for Intake & Output, dated April 2013, revealed contents of urinary drainage bag will be measured at end of each tour of duty. Record review revealed the facility admitted Resident # 1 on 02/09/17 with [DIAGNOSES REDACTED]. Review of Resident # 1's Admission Minimum Data Set (MDS) assessment, dated 02/16/17, revealed the facility assessed Resident #1's cognition as intact with a Brief Interview for Mental Status (BIMS) score of thirteen (13) which indicated the resident was interviewable. Further review of the MDS revealed the resident had a urinary catheter. Review of the Comprehensive Care Plan for altered pattern of urinary elimination with indwelling catheter due to [MEDICAL CONDITION], dated 02/13/17, revealed interventions to monitor for signs/symptoms of urinary tract infection [MEDICAL CONDITION] which include fever, change in urine color, odor or consistency, flank pain, hematuria (blood in urine), nausea, vomiting, dysuria (pain on urination); notify physician for any of these symptoms, notify physician of any abnormal findings, empty drainage bag at the end of each shift, monitor and record output, and maintain a closed drainage system with an unobstructed urine flow. Review of the Facility Intake and Output Flow Sheet revealed Resident #1 had 200 milliliters (ml.) output on 04/03/17 at 5:47 AM, zero (0) ml. on 04/03/17 at 1:59 PM and 9:23 PM, and on 04/04/17 at 5:57 AM, and 1:26 PM (over a total of thirty-one {31} hours). Review of Nursing Notes, dated 04/02/17 through 04/04/17 at 1:04 PM, revealed there was no documented evidence the nurses had assessed the resident's catheter, identified that the resident was having no urinary output and/or monitored for signs and symptoms of urinary tract infection or obstruction of catheter. Review of a Nursing Note, dated 04/04/17 at 1:04 PM, revealed Resident #1's abdomen was hard and distended, there was no output this shift with urinary catheter, had complaints of shortness of air (SOA), malaise, pale, warm to touch, wheezes in upper lobes of lungs, and respirations uneven and labored. Further review of the Nursing Notes revealed the Physician was called and the resident was transported to hospital per ambulance at 1:45 PM. Review of the Emergency Medical Services (EMS) Transfer Report, dated 04/04/17, revealed they were dispatched to the facility at 1:31 PM for Resident #1 due to fever and [MEDICAL CONDITION]. Nursing home staff reported to the EMS staff that the resident had no urinary output (UOP) but was unable to tell the EMS staff when this was discovered or when the catheter was last emptied of any urine. Resident #1 was noted to be moderately lethargic, in and out of consciousness with fever, skin hot and pale, and abdomen noted to be distended and rigid, specifically in both lower quadrants. The resident was hypotensive (low blood pressure) with a systolic palpable pressure of sixty (60) (normal: 120). Further review of the report revealed the resident was given a breathing treatment and Intravenous (IV) fluids were started in route to the hospital. Review of Hospital Records revealed Resident #1 was in the emergency room (ER) on 04/04/17 at 2:30 PM, brought in by Emergency Medical Services (EMS). Review of emergency room Nursing Notes by hospital Registered Nurse (RN) #4 and RN #5 revealed upon arrival to ER Resident #1 was noted to have no urine in urinary catheter bag nor in tubing, the resident's abdomen was hard, swollen, and tender, his/her penis was noted to be swollen and testicles were red. Review of the Hospital ER Physician Notes, dated 04/04/17 at 2:30 PM revealed the resident had abdominal pain (suprapubic) and cough, vital signs at this time were noted to be temperature of 98.9 (normal:98.6) degrees F. orally, pulse 108 (normal:60-100) beats per minute, B/P of 81/44 (normal:120/80); the resident was in mild respiratory distress, with abdominal distention (swollen), and when bladder pushed on, purulence (pus) comes out of the urethra (opening at the end of penis). Further review of the ER Nursing Notes revealed the urinary catheter was removed, bloody/purulent drainage came out of penis and once a new catheter was inserted, a large amount of bloody urine with clots was returned through the new catheter. Further review of the hospital records revealed the resident was admitted to Intensive Care on 04/04/17 through 04/06/17 and was discharged back to the Nursing Home on 04/09/17. Review of laboratory studies performed on Resident #1 on 04/04/17 at 2:30 PM revealed an elevated White Blood Cell (WBC) count, indicative of infection, with Resident # 1's WBC count being thirty-thousand (30,000) (normal: five-thousand {5,000} to ten thousand {10,000}, elevated Blood Urea Nitrogen (BUN), (test used to determine kidney function) BUN: 67 milligrams (mg.) (normal: ten to fifteen (10-15). Review of A Manual of Laboratory Diagnostic Tests, Second Edition, revealed some causes of elevated BUN levels are shock, dehydration, and infection. Review of the Urinalysis dated 04/04/17 revealed the resident had red, cloudy urine with too numerous to count white blood cells and red blood cells with four plus (4+) bacteria. Further review of hospital notes revealed Resident # 1's Creatinine (test used to estimate filtration function of the kidneys) was elevated at three (3.0) milligrams per deciliter (mg./dl.), (normal: less than 1.2 mg/dl) on 04/04/17. Review of ER Physician Notes/Comments, dated 04/04/17 revealed the physician noted there was a high probability of clinically significant/life threatening deterioration in the resident's condition which required his urgent intervention. Review of Hospitalist's History & Physical Notes for Resident # 1 dated 04/09/17 revealed the resident had been treated with broad spectrum Intravenous (IV) antibiotics during stay in hospital and was now on oral antibiotics. Further review of the History and Physical Notes revealed Resident #1's Discharge [DIAGNOSES REDACTED]. Interview with Resident #1 on 04/17/17 at 1:00 PM revealed he/she thinks he/she had a Urinary Tract Infection [MEDICAL CONDITION] in April 2017, but does not remember why he/she went out to hospital as he/she was so sick. Observation of Resident #1's catheter on 04/17/17 at 1:52 PM revealed the resident had yellow urine with some sediment in tubing. Interview with State Registered Nurse Aide (SRNA) #3 on 04/18/17 at 3:03 PM revealed she emptied Resident #1's urinary drainage bag when she came on shift at 2:00 PM on 04/03/17 and documented the resident had zero (0) output. She stated she discussed the lack of any urine with LPN #2, and went to check to see if it was possible the catheter was kinked but it was not kinked. Further interview with SRNA #3, on 04/18/17 at 3:45 PM, revealed she and SRNA #1 discussed Resident #1 not having any urinary output and she reported it to LPN #1 because the SRNAs are told to tell the nurse when a resident has no urinary output for their shift. Interview with SRNA #1 on 04/18/17 at 8:48 AM revealed she worked the 10:00 PM-6:30 AM shift on 04/03/17, and Licensed Practical Nurse #1 was the nurse on duty. SRNA #1 stated Resident #1 had no urinary output from 6:00 PM until 10:00 PM and she told LPN #1 and LPN #1 said to just keep an eye on it and let her know. SRNA #1 revealed around 5:30 AM when she went to empty Resident #1's catheter, there was still no urinary output and she told LPN #1 the resident had not had any urinary output for twelve (12) hours. SRNA #1 stated LPN #1 said I will tell day shift and get the resident sent out. She stated the resident did have some discharge from around the catheter that was greenish, like mucus on 04/03/17. She further stated she did not recall an odor but did remember the resident's testicles were red and swollen. Interview with Licensed Practical Nurse (LPN) #1, on 04/17/17 at 4:55 PM and 04/21/17 at 2:43 PM, revealed she took care of Resident #1 on the night of 04/03/17 from 10:00 PM until 6:00 AM. She stated she cleaned Resident #1's catheter at midnight due to the SRNA reporting there was gunk at the top of the resident's catheter. She revealed there was a clear discharge around the catheter and the resident's urine was amber in color with no sediment. She revealed the resident had no pain at that time. LPN #1 stated she gave the resident medication on the morning of 04/04/17 and the resident had urine in catheter tubing but none in the drainage bag but stated, I thought the SRNA had just emptied the catheter bag. She stated the resident abdomen was not distended that she could see and did not complain of pain in the bladder area. LPN #1 further stated she did not know the resident had no urinary output, she saw no blood in urine, and the discharge was clear. She stated the nurses are responsible for monitoring Intake & Output (I&O) on residents and nurses failed to check and see that the SRNA's had reported and charted there was no urinary output. Interview with SRNA #4, on 04/18/17 at 4:00 PM, revealed she received report on 04/04/17 at 6:00 AM from SRNA #1 and she told her Resident #1 had no urinary output on the 10:00 PM-6:00 AM shift. She stated I assumed she had told the midnight nurse as we are taught to do this and SRNA #1 has been an SRNA for a while. SRNA #4 stated she told RN #1 and LPN #2 on 04/04/17 at 2:00 PM that Resident #1 had no urinary output and they said midnight nurse did not tell them that the resident had no urinary output all night. Interview with RN #2, on 04/18/17 at 11:25 AM revealed on 04/04/17 after lunch she was asked by SRNA #4 to empty catheter as she was working as an aide that day, and she noticed there was no urine in bag. She stated she asked SRNA #4 if she had emptied it and she said No and that the aide on night shift had told her in report the resident did not have any urinary output so she told LPN #2. Interview with LPN #2, on 04/18/17 at 9:35 AM and 04/21/17 at 1:00 PM, revealed she did not notice nor was she aware of Resident #2 having no urinary output until 1:00 PM on 04/04/17 when she saw the resident's abdomen was distended. LPN #2 stated she worked on 04/03/17 and 04/04/17 from 6:00 AM until 2:00 PM. She stated Resident #1 did not have reddened testicles but the resident did have back pain on the morning of 04/04/17 and was medicated at 7:00 AM for pain. She stated LPN #1 did not say anything in report about no urinary output nor did the aide on dayshift say anything on 04/04/17. Interview with Registered Nurse (RN) #1, on 04/18/17 at 10:57 AM and 4:30 PM, revealed Resident #1 had flu-like symptoms on 04/04/17. She stated LPN #9 had asked her to come look at Resident #1 with her. RN #1 stated she checked catheter placement and it seemed okay at 12:45 PM on 04/04/17. RN #1 revealed Resident #1 had no drainage around catheter or penis, but did have issues with excoriation to testicles. RN #1 stated she had no report from night shift about no urinary output. RN #1 revealed the resident's bladder was slightly distended, not overly and the resident did have some tenderness when the abdomen was palpated. RN #1 stated CNA #4 had told her the CNA on night shift had said the resident did not have any urinary output. She revealed LPN #2 was able to look on computer and see that the resident had not voided. Interview with LPN #9 on 04/18/17 at 12:35 PM revealed she worked 04/03/17 and 04/04/17 and LPN #1 said nothing to her on the morning of 04/04/17 about Resident #1 having no urinary output. LPN #9 stated if there is no urinary output for one shift, then the nurse should call the doctor after assessing the resident. LPN #9 revealed staff do weekly assessments on catheters and recording of Intake and Output (I&O) Accuracy is done by the Day shift charge nurse. LPN #9 further revealed the CNAs are responsible to chart input/output and to let the nurse know if there is a problem. LPN #9 stated she had noticed some drainage in the resident's brief and the resident looked like he/she was having bladder spasms. She revealed she mentioned this to the nurse in report on 04/03/17 however, she stated she was not aware of the resident having no urinary output on 04/03/17. Interview with ER RN #4, on 04/18/17 at 1:45 PM revealed Resident #1 had 975 milliliters return of urine immediately when a new catheter was inserted in the ER. She stated when Resident #1 arrived at the ER, his/her abdomen was distended, the resident was having pain on palpitation, the catheter was not in the right place, there was a lot of bloody pus from penis, and there was no urine in drainage bag or tubing. She revealed the resident had immediate relief of abdominal distention and pain when the old catheter was taken out and a new one put in. She stated the residents testicles were red and swollen. Interview with ER RN #5, on 04/18/17 at 1:55 PM, revealed when Resident #1 arrived in ER, he/she was lethargic, had [MEDICAL CONDITION](fast heart rate), and said his/her abdomen was hurting and had been hurting since that morning and this was at 2:30 PM. RN #5 revealed in her report from EMS the nursing home facility told EMS staff the catheter had not been draining for two (2) days. RN #5 stated The catheter was clearly not in the bladder and pus came out of the penis with muddy looking foul smelling discharge. Interview with MDS Coordinator #1 and #2, on 04/21/17 at 1:25 PM, revealed nurses on the floor are responsible for monitoring intake and output and to make sure SRNA'S are doing input and output. Interview with Resident # 1's Physician, on 04/21/17 at 12:50 PM, revealed the resident could have detrimental results from going thirty-one (31) hours without urinary output. He revealed this could cause pain in the bladder, pain in the abdomen, back pressure/pain, renal injury, could lead to confusion from the buildup of toxins in the blood. Interview with the facility Medical Director on 04/18/17 at 5:38 PM revealed he was not aware of Resident #1 having no urinary output for thirty-one (31) hours. He stated he would be investigating this and he would expect nursing staff to notify the attending Physician if there was no urinary output. He further revealed he would expect the facility to have a Protocol to check catheters each shift, and if no urine for one shift, call attending Physician. Interview with the Director of Nursing (DON), on 04/18/17 at 1:30 PM revealed the nurses did not know until the day of transfer that Resident #1 had no urinary output. She stated the facility did an investigation and determined that it was a miscommunication problem between the SRNA'S and nurses. Further interview with the DON, on 04/21/17 at 1:38 PM, revealed she expected the nurses to check the catheters at the beginning of their shift to make sure the catheter is draining urine, is not kinked, and bag and tubing are not on the floor. She stated she would also expect nurses to check color of urine and monitor intakes and outputs as they are responsible. She further stated if there was no urinary output for one shift the nurse should call the physician and if the SRNA told a nurse there was no urinary output for a resident she would expect the nurse to follow up. In addition, she stated if the catheter bag was empty when the nurse observed the bag she would expect the nurse to ask the SRNA if they emptied the drainage bag, not just assume. Interview with Administrator, on 04/21/17 at 1:32 PM, revealed she expected nursing to check catheters when they go in room, assess catheter to make sure it is not kinked, is draining urine, and bag not on floor. In addition, she stated nurses are responsible for monitoring intakes and outputs and making sure the SRNA'S are doing intakes and outputs. She revealed if there is no urinary output on a resident for one shift, the nurse would call the physician. She also revealed if nurse identifies drainage bag is empty, not to assume the SRNA had emptied the catheter bag but would go ask the SRNA.

Based on interview, record review, review of hospital records and facility policy review, it was determined the facility failed provide care in accordance with one (1) of six (6) sampled residents written plan of care (Resident #1). Resident #1 had a urinary catheter and was care planned for staff to empty drainage bag at the end of shift, monitor and record output, notify physician of any abnormal findings and signs/symptoms of infection, and maintain a closed drainage system with an unobstructed urine flow. However, licensed staff failed to monitor the resident's output, monitor for signs and symptoms of infection, and assess to ensure the resident had an unobstructed drainage system when Resident #1 had no urinary output from 04/03/17-04/04/17 (approximately thrifty-one (31) hours). On 04/04/17, Resident #1 was sent to hospital due to no urinary output, shortness of air, malaise, wheezes in upper lobes of lungs, and uneven and labored respirations. Resident #1 was admitted to Intensive Care with [DIAGNOSES REDACTED]. The findings include: Review of the facility's policy on Resident Care Plan, not dated, revealed it is the policy of the facility to provide an interdisciplinary written care plan based on the physician's orders [REDACTED]. Development and implementation of the care plan will occur by participating disciplines available in the facility at a team conference under the direction of the RN Coordinator. Development of an interdisciplinary plan will occur after completion of a comprehensive assessment by each discipline. Review and/or modification of the plan will be done at least quarterly and as needed for residents under the direction of the RN Coordinator/designee. The resident care plan will be an ongoing process and will include current problems and/or needs identified from a complete assessment including Minimum Data Set (MDS) relevant to the resident's response to aging, illness, and his/her general health status. Any new problem or need of the resident which is identified between his/her scheduled care plan review will be addressed on the care plan by the concerned disciplines and brought to the next scheduled care plan meeting to inform disciplines of the addition. Record review revealed the facility admitted Resident #1 on 02/09/17 with [DIAGNOSES REDACTED]. Review of the Comprehensive Care Plan for altered pattern of urinary elimination with indwelling catheter due to [MEDICAL CONDITION], dated 02/13/17, revealed interventions to monitor urinary output, monitor for symptoms of infection, notify physician of any abnormal findings, and maintain a closed drainage system with an unobstructed urine flow. However, review of Facility Intake and Output Flow Sheets revealed it was documented Resident #1 had two-hundred milliliters (ml) of urinary output on 04/03/17 at 5:47 AM, zero (0) ml. on 04/03/17 at 1:59 PM and 9:23 PM, and on 04/04/17 at 5:57 AM, and 1:26 PM (over a total of thirty-one {31} hours) and review of Resident #1's Nursing Notes from 04/02/17 through 04/04/17 revealed there was no documented evidence the nurses monitored the resident's urinary output, the resident for abnormal findings and signs/symptoms of infection, and ensured the resident had an unobstructed urine flow. Review of a Nursing Note, dated 04/04/17 at 1:04 PM by Licensed Practical Nurse (LPN) #2, revealed the resident's abdomen was hard and distended, he/she had no urine output that shift, the resident complained of shortness of air, had malaise, was pale, warm to touch, had wheezes in upper lobes of lungs, and respirations were uneven and labored. Further review of the note revealed Resident #1's Physician was called and the resident was transported to the hospital per ambulance at 1:45 PM. Review of Hospital Records and interviews with emergency room (ER) Registered Nurse (RN) #4, on 04/18/17 at 1:45 PM and ER RN #5, on 04/18/17 at 1:55 PM revealed on arrival Resident #1 was lethargic, his/her abdomen was distended, the resident was having pain on palpitation, the catheter was not in the right place, there was purulent discharge from the urethra (opening of penis) when abdomen was pressed on, and there was no urine in drainage bag or tubing. The resident's catheter was removed with a lot of bloody/purulent drainage from the penis and once a new catheter was inserted, a large amount of bloody urine with clots was returned through the new catheter. The resident was admitted to Intensive Care on 04/04/17 through 04/06/17 and was discharged back to the Nursing Home on 04/09/17. Resident #1 was diagnosed with [REDACTED]. Interviews on 04/18/17 with State Registered Nurse Aide (SRNA #1) at 8:48 AM, SRNA #3 at 3:45 PM and SRNA #4 on at 4:00 PM revealed Resident #1 did not have any urinary output from 04/03/17 at 5:47 AM until 04/04/17 at 1:30 PM. SRNA #1 and #3 stated they reported to Licensed Practical Nurse #1 that Resident #1 had no urinary output during the day and night shift (6:00 PM-6:00 AM shift) on 04/03/17-04/04/17. They stated Licensed Practical Nurse (LPN) #1 said to monitor the resident and at 5:30 AM on 04/04/17 she said she would tell the dayshift nurse to send the resident out. SRNA # 1 stated she did notice some green, mucus-like discharge from the catheter insertion site. They stated SRNA #1 and #3 had reported to SRNA #4 on 04/04/17 at 6:00 AM that Resident #1 had not had any urinary output on the day before or night shift. SRNA #4 stated she told RN #1 and LPN #2 on 04/04/17 at 2:00 PM and they said the midnight nurse did not tell them that the resident had no urinary output all night. Interviews with LPN #1, on 04/17/17 at 4:55 PM and 04/21/17 at 2:43 PM revealed the SRNAs had not told her the resident had no urinary output on dayshift/nightshift on 04/03/17. She stated she cleaned Resident #1's catheter at midnight due to the SRNA reporting there was gunk at the top of the resident's catheter. She revealed there was a clear discharge around the catheter and the resident's urine was amber in color with no sediment. She stated the resident had no pain at that time. LPN #1 stated she gave the resident medication on the morning of 04/04/17 and the resident had urine in catheter tubing but none in the drainage bag but stated, I thought the SRNA had just emptied the catheter bag. She stated the resident abdomen was not distended that she could see and did not complain of pain in the bladder area. Interview with Registered Nurse (RN) #1, on 04/18/17 at 10:57 AM and 4:30 PM, and LPN #9 on 04/18/17 at 12:35 PM, revealed LPN #1 had not reported to them during shift change that Resident #1 had not had any urinary output. RN #1 and LPN #9 stated Resident #1 had flu-like symptoms on 04/04/17 and LPN #9 had asked RN #1 to look at Resident #1 with her. RN #1 stated the resident's bladder was slightly distended, not overly and the resident did have some tenderness when the abdomen was palpated. RN #1 stated CNA #4 told them at that time that the night shift SRNAs had told her the resident did not have any urinary output. RN #1 stated the SRNA'S are responsible for charting the intake and output and letting the nurse know if there is a problem. RN #1 revealed licensed staff are supposed to check the catheters at the beginning of each shift to ensure they are draining. Interview with Resident #1's Physician, on 04/21/17 at 12:50 PM, revealed the resident could have detrimental results from going thirty-one (31) hours without urinary output. He revealed this could cause pain in the bladder, pain in the abdomen, back pressure/pain, renal injury, and could lead to confusion from the build up of toxins in the blood. Interview with the Director of Nursing (DON) on 04/18/17 at 1:30 PM revealed the nurses did not know until the day of transfer that Resident #1 had no urinary output. She stated she expected the nurses to follow the care plan by monitoring the resident's urinary output, ensuring catheter is draining properly and to monitor for signs and symptoms of infection

Based on interview, record review, review of facilitiy incident reports and facility investigations, review of the RAI Manual, Chapter Four; and review of the facility's policy and procedures, it was determined the facility failed to ensure a comprehensive care plan was revised following falls for three (3) of eighteen (18) sampled residents (Residents #4, #5, and #9). Resident #4 was ordered and received bowel prep on 11/09/15-11/10/15. The facility failed to revise the care plan to address the use of the bowel prep to ensure staff was aware of the resident receiving the bowel prep and interventions were in place to provide staff assistance and assistive devices for toileting to ensure the safety of the resident. Resident #4 fell on [DATE] at 7:30 AM while ambulating to the bathroom unassisted and sustained a left [MEDICAL CONDITION], which required surgical intervention. On 04/06/16, Resident #5 sustained a fall with no injury. The facility determined a voiding trial needed to be completed; however, the facility failed to revise the care plan to include the voiding trial to develop a toileting plan. Resident #5 sustained another fall on 04/26/16 while attempting to use the restroom with no toileting plan in place. The resident sustained [REDACTED]. Resident #9 fell on [DATE] at 6:32 AM, which resulted in a nose fracture. The facility determined the resident needed a bed alarm to notify staff if resident was attempting to transfer and the resident refused. However, the facility failed to revise the care plan to address the resident's refusal and initiate another intervention to address the resident getting up without assistance. The findings include: Review of the RAI Manual, Chapter Four, revealed the comprehensive care plan is an interdisciplinary communication tool. It must include measurable objectives and timeframes 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. Review of the facility's policy titled, Resident Care Plan, not dated, revealed it is the policy of the facility to provide an interdisciplinary written care plan based on the physician's orders [REDACTED]. Review of the care plan will be done at least quarterly and as needed. Any new problem or need of the resident, which is identified between his /her scheduled care plan review, will be addressed on the care plan. 1. Record review revealed the facility admitted Resident #4 on 07/24/15 with diagnoses, which included Cognitive Communication Deficit, Muscle Weakness and other Abnormalities of Gait. Review of Resident #4's Significant Change MDS assessment, dated 10/23/15, revealed the facility assessed Resident #4 as having a BIMS score of eight (8) which indicated this resident was interviewable. Review of Resident #4's Comprehensive Care Plan for Toileting, dated 10/26/15, revealed this resident required staff assistance for the physical process of toileting due to having fatigue and lethargy. Review of physician's orders [REDACTED]. Resident #4 started receiving bowel prep medications on 11/09/15 at 3:00 PM and continued receiving medication for the bowel prep through 6:45 PM. However, review of Resident #4's Comprehensive Care Plan, created on 07/25/15, 08/03/15, 08/12/15 and 08/18/15, revealed the facility failed revise the care plan to address the resident's receiving the bowel prep and no interventions to address the resident's probable need for toileting more often and the need to get to toilet sooner. Review of Nurses Notes, dated 11/10/15 at 7:30 AM, and the facility investigation, dated 11/12/15 revealed Resident #4 was found lying on back in floor with top half of body in resident's room and lower half of body in the bathroom. The resident was complaining of pain to tailbone and left hip. Review of the facility investigation, dated 11/12/15, related to Resident #4's fall on 11/10/15, revealed the root cause of the fall was due to Resident #4 had started a bowel prep in preparation for an appointment to have a colonoscopy and this resident had gotten up out of bed unassisted and attempted to go to the bathroom. Interview with MDS Coordinator, on 10/28/16 at 4:30 PM, revealed Resident #4's care plan should have been reviewed and revised related to the ordered bowel prep this resident was receiving. Interview with Director of Nursing (DON) on 10/28/16 at 5:53 PM, revealed she expected the care plan to be reviewed and revised with any resident who has an order for [REDACTED]. 2. Record review revealed the facility admitted Resident #5 on 01/16/15 with diagnoses, which included Dementia with Behaviors, [DIAGNOSES REDACTED], Repeated Falls, and Cerebral Vascular Disease. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 02/19/16, revealed the facility assessed Resident #5'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 the MDS revealed the resident was independent with ambulation. Review of a facility Incident Report, dated 04/06/16 at 8:45 PM, revealed Resident #5 was found in the floor with no injury and the resident stated he/she needed to urinate. Interventions implemented was a voiding trial, therapy referral, and a bed alarm; however, review of the Comprehensive Care Plan for Toileting, dated 01/19/15, revealed there was no revision to the care plan to obtain a voiding trial. Review of a facility Incident Report, dated 04/26/16 at 9:20 AM, revealed Resident #5 fell from wheelchair needing to use the bathroom. The facility determined the last time incontinent care/toileting was provided was at 6:00 AM (three {3} hours and twenty {20} minutes) before the fall but there was no toileting plan in place per the facility's investigation of the 04/06/16 fall. Review of a physician's orders [REDACTED]. Review of the X-Ray Report, dated 04/26/16 at 1:32 PM, revealed an interval left inferior pubic ramus fracture. Review of Resident #5's Toileting Comprehensive Care Plan, dated 04/27/16, and Resident Care Guide, dated 05/09/16, revealed an intervention to toilet the resident upon waking, after breakfast, after lunch, after supper, before bedtime and once during the night and as resident asks. Review of a facility Post Fall Investigation for Resident #5, dated 09/28/16 at 4:55 PM, revealed the resident was found lying in the floor in front of the bed towards the bathroom door. The facility determined the root cause of the fall was inappropriate toileting schedule for the resident. Review of a Fall Incident Report, dated 09/28/16 at 4:55 PM, revealed an intervention to place Resident #5 on a voiding hourly diary for seven (7) says to determine appropriate times for toileting upon the resident's return from the hospital. Review of the In-Service Training Sheet, dated 10/12/16, revealed an inservice was completed with staff related to Resident #5's toileting schedule which was determined from the voiding pattern to be: toilet resident upon waking (6:00 AM-7:00 AM), 9:00 AM-10:00 AM, 12:00 PM-1:00 PM, 4:00 PM-5:00 PM, 7:00 PM-8:00 PM, and during nightly bed checks. However, further review of Resident #5's Toileting Comprehensive Care Plan, dated 04/27/16, and Resident Care Guide, (State Registered Nurse Aide {SRNA} Care Plan), dated 10/25/16, revealed there was no revision to the care plans to include the new toileting schedule. Interviews on 10/28/16 with SRNA #6 at 2:00 PM, SRNA #1 at 2:35 PM , SRNA #3 at 3:40 PM, revealed they were not sure what the current toileting schedule was for Resident #5 but would check the Resident Care Guide for Resident #5 to determine his/her toileting schedule. Interview with SRNA #8 on 10/28/16 at 3:20 PM revealed Resident #5 was on every two (2) hour toileting and as needed prior to the fall. Interview (Post Survey) with SRNA #11 on 10/31/16 at 12:40 PM revealed she was not sure what toileting pattern Resident #5 was placed on after the fall on 09/28/16 as the information was not passed down. Interview with Licensed Practical Nurse (LPN) #1 on 10/28/16 at 2:55 PM revealed, she thought Resident #5 was on every two (2) hour toileting. Interview (Post Survey) with LPN #8 on 11/02/16 at 10:40 AM revealed Resident #5 was placed on every two (2) hour check and change after the [MEDICAL CONDITION] due to incontinence. Interview with MDS Coordinator on 10/28/16 at 4:10 PM revealed Resident #5 care plan states resident is on the same toileting program now as was care planned on 04/29/16, which was intervention for a pelvic fracture. She further revealed a seven (7) day voiding diary was the intervention placed for the fall on 09/28/16. Further interview at 5:00 PM with the MDS Coordinator revealed the new toileting program was not placed on the Comprehensive Care Plan or Resident Care Guide but she has placed it on there now. Interview with the Director of Nursing (DON) on 10/28/16 at 5:54 PM revealed, she expected the care plan to be updated and accurate to reflect the current resident's status. She revealed the interventions with the new toileting schedule should have been updated on the care plan for Resident #5. 3. Record review revealed the facility admitted Resident #9 on 02/10/04 with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment, dated 08/12/16, revealed the facility assessed Resident #9's cognition as moderately impaired with a BIMS score of twelve (12), which indicated the resident was interviewable. In addition, the facility assessed Resident #9 as able to walk in his/her room and/or corridor with oversight, encouragement, or cueing. Review of Resident #9's Post Fall Assessment, dated 07/31/16, revealed the resident had an unwitnessed fall while ambulating independently. Review of Resident #9's Comprehensive Care Plan: Risk for Falls, last revised 08/03/16, revealed an intervention for a bed alarm to remind the resident to call for assistance. However, review of a revision note, dated 08/01/16 on the care plan, revealed Resident #9 had refused to allow a bed alarm to be placed on his/her bed but there was no evidence the facility revised the care plan to address the resident's refusal of the bed alarm or any new interventions to address the resident getting up without staff knowledge. Interview with the Quality Improvement (QI) Nurse, on 10/27/16 at 4:21 PM, revealed the facility failed to revise the care plan with any further interventions for Resident #9 when the resident refused for bed alarm to be placed on his/her bed. The QI Nurse stated she expected the care plan to be revised to meet the residents need. Interview with the Director of Nursing, on 10/28/16 at 5:05 PM, revealed she expected staff to review/revise care plans and develop individualized care plan interventions based on the resident needs. Further interview revealed after a care plan is evaluated and if determined ineffective to the resident care needs, the staff should revise the care plan and resident care guide.

Based on observation, interview, record review, review of hospital History and Physical, Operative Report and Discharge Summary; Nursing Policy Manual review, and facility policy review, it was determined the facility failed to provide adequate supervision and assistance devices to prevent accidents for three (3) of eighteen (18) sampled residents (Residents #4, #5, and #9). Resident #5 sustained falls on 04/06/16, 04/26/16, 05/06/16, 07/17/16, and 09/28/16. On 04/06/16, Resident #5 sustained a fall with no injury. The facility determined a voiding trial needed to be completed; however, the facility failed to conduct the voiding trial and develop a toileting plan until the resident had another fall on 04/26/16 while attempting to use the restroom and sustained a fracture of the left inferior pubic ramus. On 05/06/16, Resident #5 sustained a fall which resulted in a skin tear while ambulating back to bed after using the restroom. The facility failed to ensure the resident's bed alarm was plugged into the alarm box. On 07/17/16, Resident #5 sustained a fall when the resident was left on the toilet without supervision even though the resident's cognition was severely impaired and the resident required a chair alarm. On 09/28/16, Resident #5 sustained a fall which resulted in a hip fracture which required surgery. Staff failed to provide increased supervision after staff had identified the resident was continuously trying to get up every five (5) minutes. The facility also failed to provide adequate supervision and assistive devices for Resident #4 on 11/10/15 when Resident #4 was placed on bowel prep to prepare for a colonoscopy. Resident #4 fell while ambulating to the bathroom, which resulted in a left hip fracture and a decline in the resident's ambulation and increase in assistance needed. Additionally, Resident #9 fell on [DATE] and sustained a nose fracture. The facility determined to add a bed alarm but the resident refused. The facility failed to address the resident's refusal of the alarm or develop another intervention to address the resident's transferring without assistance. The findings include: Review of facility Nursing Policy Manual, dated August 2012, Fall Risk Protocol revealed the protocol is to implement guidelines to identify a resident's risk for falls. This protocol is to prevent the resident's fall and/or minimize injury from a fall, plan for the safety within the facility, determine that the implementation of preventative interventions has occurred for the resident, and to periodically review and evaluate the effectiveness of the preventative interventions in place for the resident. Further review revealed the Falls Risk Evaluation would be completed on the day of admission, quarterly, significant change, and on re-entry to the facility. If the resident's score is ten (10) or greater certain guidelines will be instituted. These guidelines include: the fall risk protocol, care plan for falls with goals and interventions to ensure safety, Resident Care Guide reviewed and updated periodically or as needed related to each fall risk intervention, staff to be notified by the Director of Nursing or designee of the resident's fall risk after completion and placed on the care guide. Review of the facility Nursing Policy Manual, dated August 2012, Fall Prevention/Reduction Interventions revealed interventions to assist with fall preventions to include: provide alternative call light; use gripper socks when the resident cannot wear safe shoes; give proper foot wear; know which residents need assistance during transfer and walking; use a raised toilet seat or bedside commode chair as needed; provide toileting, food, drink, and activity based on the resident's individual schedule; assign staff for small increments of time to observe or supervise residents; physician evaluation of the use of diuretics and cardiovascular drugs, review/monitor blood pressure for potential postural hypotension. 1. Record review revealed the facility admitted Resident #5 on 01/16/15 with diagnoses, which included Dementia with Behaviors, [DIAGNOSES REDACTED], Repeated Falls, and Cerebral Vascular Disease. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 02/19/16, revealed the facility assessed Resident #5'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 the MDS revealed the resident was independent with ambulation. Review of the Comprehensive Care Plan for Toileting, dated 01/19/15, revealed Resident #5 was continent of bowel and bladder and could toilet self without difficulty. Review of a facility Incident Report, dated 04/06/16 at 8:45 PM, revealed Resident #5 was found in the floor and stated he/she needed to urinate. Through facility investigation the facility determined the root cause of the fall to include leg weakness. Interventions implemented were a voiding trial, therapy referral, and a bed alarm. Review of a 04/09/16 X-ray of the left hip and left inferior pubic ramus revealed there was no fracture. Further record review revealed there was no documented evidence a voiding trial was completed until Resident #5 sustained another fall attempting to go to the restroom on 04/26/16. Review of a facility Incident Report, dated 04/26/16 at 9:20 AM, revealed Resident #5 fell from wheelchair needing to use the bathroom. The facility determined the last time incontinent care/toileting was provided was at 6:00 AM (three {3} hours and twenty {20} minutes) before the fall but there was no toileting plan in place per the facility's investigation of the 04/06/16 fall. Review of a physician's orders [REDACTED]. Review of the X-Ray Report, dated 04/26/16 at 1:32 PM, revealed an interval left inferior pubic ramus fracture of indeterminate age but an X-Ray of this area revealed no fracture on 04/09/16. Review of a Fall Risk Evaluation, dated 04/27/16, revealed the facility assessed the resident to be chair fast and total assist with transport and elimination with assistance. The resident was a high risk of falls. Review of the staff Training Report, dated 04/28/16, revealed the facility determined the resident's toileting plan was to toilet the resident upon waking, after breakfast, after lunch, after supper, before bedtime and once during the night and as resident asks. In addition, a Significant Change MDS was completed on 04/28/16 and determined the resident's cognition remained severely impaired and the resident now required extensive assistance of two (2) persons for transfers and did not ambulate in the last seven (7) days. Review of the Toileting Care Plan, dated 04/29/16, revealed the care plan was revised for (2) person assistance for entire process; take to the bathroom, transfer on/off the toilet, ensure safety, provide pericare/product, adjust clothing, wash hands, wears briefs size large. The resident was to be toileted upon waking, after breakfast, after lunch, after supper, before bedtime and once during the night and as resident asks. Review of facility Incident Report, dated 05/06/16 at 4:45 AM revealed Resident #5 fell trying to ambulate back to bed from the bathroom and sustained a skin tear to the right elbow. Further review revealed the facility determined the root cause of the fall was the bed alarm was not present at the time of the transfer to remind the resident to call for assistance or alert staff the resident was attempting to transfer. Interview (Post Survey) with Licensed Practical Nurse (LPN), on 11/02/16 at 10:40 AM revealed, Resident #5 was found on the floor on 05/06/16 and the bed alarm was not sounding because the alarm was not plugged into the alarm box. Review of the facility Incident Report, dated 07/17/16 at 5:30 PM, revealed Resident #5 was assisted to the toilet by a staff member and told to pull the call chain when ready and the staff member left to assist another resident even though the facility assessed the resident's cognition as severely impaired and staff was aware the resident would get up without assistance. Further review of the report revealed the resident was found in the floor with his/her feet in front of the sink and wheelchair directly in front of the sitting upright. The resident stated he/she hit his/her head while rubbing the back if his/her head. Through facility investigation the facility determined the root cause of the fall to include the resident was left alone and unattended in the bathroom. Review of the Care Plan, Risk for Falls by history of falls resulting in fracture pelvis, last revised 07/19/16, revealed, bed and chair alarm to notify staff of self-transfer, monitor routinely for needs, and lay down after meals. Review of the Resident Care Guide dated 07/25/16 revealed, fall prevention with bed and chair alarm to notify staff of unassisted transfers. In addition, toileting two (2) person total assistance for entire process. Restorative scheduled toileting program initiated 04/27/16 upon waking, after breakfast, after lunch, after supper, before bedtime, and once during the night and as needed as resident ask. Review of the facility Incident Report, dated 09/28/16 at 4:55 PM, revealed Resident #5 was found in the floor and the resident stated he/she needed to go to the bathroom. Through facility investigation, the facility determined the root cause of the fall to include the current toileting schedule was inappropriate for the resident even though the fall occurred around the time the resident should have been toileted per care plan. Interview (Post Survey) with State Registered Nurse Aide (SRNA) #11, on 10/31/16 at 12:40 PM, revealed Resident #5 was in the bed prior to fall on 09/28/16. She stated the resident had been trying to get out of the bed every five (5) minutes and the alarm had been going off, but at the time of the fall, the alarm did not sound. However, further review of the 09/28/16 Incident Report revealed the facility failed to identify the alarm did not sound and failed to identify staff were aware the resident was trying to get out of bed every five (5) minutes but no increased supervision was put in place. Review of the Hospital History and Physical dated 09/29/16, revealed Resident #5 was admitted for a fall with pain on 09/28/16 in which an X-Ray of left hip revealed a fracture. Review of Hospital Operative Report, dated 09/29/19, revealed a closed reduction and pinning of the left hip. Review of the Hospital Discharge Summary, dated 10/05/16, revealed [DIAGNOSES REDACTED]. Review of the Seven Day hourly Voiding Pattern, completed on 10/05/16-10/12/16, revealed the resident stayed on the same toileting plan but instead of toileting during the nigh one (1) time and when asked, now the resident would be toileted at all bed checks (every two {2} hours) throughout the night. However, further review of the Toileting Care Plan, dated 04/29/16, revealed the care plan was not updated to include the new toileting schedule. Observation on 10/28/16 at 9:55 AM, revealed Resident #5 was laying in the bed on his/her back and the resident stated he/she needed to have a bowel movement. Surveyor instructed the resident to press the call light and after three (3) attempts was able to perform. At 10:00 AM, when no staff had responded surveyor observed the call light outside of the resident's room and noted the light was not lit up. SRNA #1 came to room at surveyors request and found the call light was not plugged into the wall. SRNA #1 plugged the alarm back in and the call light then worked. Further interview (Post Survey) with SRNA #11, on 10/31/16 at 12:40 PM, revealed, Resident #5 was on every two (2) hour toileting at the time of the 09/28/16 fall. She stated the resident should have been moved to a room closer to the nurse's station. She further revealed a voiding pattern was done when the resident returned from the hospital but she was not sure what was determined as the information was not passed on but thinks the resident is on every two (2) hour checks. Interview with SRNA #6, on 10/28/16 at 2:00 PM, revealed Resident #5 has not been ambulatory since this last fall on 09/28/16 and was on a toileting schedule before the fall but was not for sure of the toileting times then and not sure of the toileting schedule at the present. She further revealed a resident with an alarm and a high fall risk should not be left in the bathroom alone. She stated that total assist for the entire process means the resident cannot be left alone in the bathroom as well. Interview with SRNA #7 on 10/28/16 at 2:15 PM, revealed there is usually inservice sheets at the desk to sign if new interventions are put into place. She stated Resident #5 was on every two (2) hour toileting and had a bed and chair alarm prior to the last fall on 09/28/16. Interview with SRNA #1, on 10/28/16 at 2:35 PM, revealed if a resident has an alarm the resident should not be left in the bathroom alone. Interview with SRNA #8, on 10/28/16 at 3:20 PM, revealed the SRNAs would pass on in report new interventions. She stated Resident #5 was on an every two (2) hour and as needed toileting. She stated if the resident has an alarm, the resident should not be left in the bathroom alone. Interview with SRNA #5, on 10/28/16 at 3:40 PM, revealed, a resident with a high fall risk and an alarm should not be left in the bathroom alone. Further interview (Post Survey) with LPN #8, on 11/02/16 at 10:40 AM, revealed, the resident was on an every two (2) hour check and change as the resident was incontinent before and after the fall. She also revealed that after the 09/28/16 fall the resident was continued on an every two (2) hour check and change. She stated the resident was always trying to get up and easily confused. Interview with LPN #1, on 10/28/16 at 2:55 PM, revealed if a resident falls the charge nurse should implement an immediate intervention, then the Quality Assurance (QA) nurse will follow up and either keep the same intervention or change it. She stated Resident #5 was on two (2) hour toileting unless the resident asked to toilet more often. She revealed the resident had a bed and chair alarm and was not allowed in the bathroom alone because of the alarm. Interview with the Staff Development Coordinator, on 10/28/16 at 4:42 PM, revealed a seven (7) day voiding bladder diary was completed when Resident #5 returned from the hospital on [DATE] after surgery from hip fracture. She stated not all staff was inserviced on the new toileting schedule as only two (2) midnight staff and three (3) afternoon staff signed the inservice training sheet dated 10/12/16. She revealed the new toileting plan was not placed on the resident's care plan and SRNA Care Guide. Interview with the MDS Coordinator on 10/28/16 at 5:00 PM revealed, the new toileting schedule was not placed on the care plan or care guide when completed on 10/12/16 but she did place on there today (10/28/16). Interview with the Assistant Director of Nursing on 10/28/16 at 5:05 PM revealed, she had discussed with the Interdisciplinary team when Resident #5 had fallen toileting and had concerns with her frequent falls with toileting. She further revealed that it was not appropriate to leave a resident in the bathroom with no assist if the resident is care planned for an alarm. She stated that the care plan and resident care guide for Resident #5 stated total assist during the entire toileting process, which meant staff should not have left him/her alone in the bathroom. Interview with the Director of Nursing (DON) on 10/28/16 at 5:54 PM revealed, she expected the new toileting schedule to be updated on the care plan. She further revealed if the care plan stated to stay with the resident the entire toileting process then the care plan should have been followed. However, she revealed if residents even if a high fall risk or an alarm requested privacy in the bathroom then she would shut the door to allow the resident privacy. 2. Record review revealed the facility admitted Resident #4 on 07/24/15 with diagnoses, which included Cognitive Communication Deficit, Muscle Weakness, and other Abnormalities of Gait. Review of Resident #4's Significant Change MDS assessment, dated 10/23/15, revealed Resident #4 was ambulatory with assistance of one (1) staff and required assistance of one (1) staff member for transfers, bed mobility and toileting. Review of Resident #4's Medication Administration Records (MARS) for November 2015, revealed Resident #4 started receiving bowel prep medications on 11/09/15 at 3:00 PM and continued receiving medication for the bowel prep through 6:45 PM. Review of the Comprehensive Care Plan, dated 10/26/15, revealed the care plan did not address the resident was receiving a bowel prep and there were no interventions put in place to ensure the resident had adequate supervision and assistive devices to ensure the resident would be able to get to the toilet timely and safely. Review of Nurses Notes, dated 11/10/15 at 7:30 AM, revealed Resident #4 was lying on back in floor with top half of body in resident's room and lower half of body in the bathroom. The nurses note further revealed this resident was complaining of pain to tailbone and left hip. Review of facility's investigation, dated 11/12/15, related to Resident #4's fall on 11/10/15, revealed the root cause of the fall was due to Resident #4 had started a bowel prep in preparation for an appointment to have a colonoscopy and this resident had gotten up out of bed unassisted and attempted to go to the bathroom. Interview with State Registered Nurse Aide (SRNA) #5 on 10/17/16 at 1:28 PM, revealed she was one of the SRNA's caring for Resident #4 on the day shift when Resident #4 fell and broke his/her hip. She stated she had not been informed by the nurses of Resident #4 being on a bowel prep or of needing to check on Resident #4 more frequently than normal. Interview with SRNA #4 on 10/27/16 at 2:20 PM, revealed she was a SRNA taking care of Resident #4 on the day and shift Resident #4 fell and did not recall any nurse informing her Resident #4 was receiving a bowel prep. Interview with LPN #1 on 10/28/16 at 2:20 PM, revealed she would expect any resident receiving bowel prep to have increased monitoring and increased observation from staff. She stated she would expect this information to be relayed to the SRNA's who would be taking care of the resident who was on bowel prep. Interview with LPN #3 on 10/28/16 at 2:28 PM, revealed she would expect a resident who is on a bowel prep to be checked on more frequently than the regular every two (2) hour checks. She stated she would expect the SRNA's to be informed of any resident who was receiving a bowel prep. Interview with Assistant Director of Nursing (ADON) on 10/28/16 at 5:05 PM, revealed she would expect a resident who is on a bowel prep to have increased supervision, especially if the resident had impaired gait, impaired balance and impaired cognition. Interview with Director of Nursing (DON) on 10/27/16 at 3:45 PM, revealed when asked if Resident #4 should have had increased assistance or increased monitoring after starting the bowel prep, the DON stated the facility had not had any other residents who have had a bowel prep. She stated after Resident #4 fell and broke her hip the facility implemented a new procedure, which was if any resident is on a bowel prep the resident must have a bedside commode in their room and once the bowel prep started, the resident will have one to one assistance until the resident leaves for their procedure. Interview with Physical Therapist #1 on 10/26/16 at 11:55 AM, revealed she felt like Resident #4's decline in ambulation and mobility was related to Resident #4's fall and hip fracture that the resident suffered on 11/10/15. She stated sometimes residents who have a traumatic fracture could not bounce back from it and improve back to their prior status. Interview with Physician #1 on 10/27/16 at 1:35 PM, revealed he felt like Resident #4's fall that resulted in a hip fracture has caused Resident #4 to have further deterioration in his/her overall condition which has caused this resident to no longer be able to ambulate and require increased staff assistance in general. 3. Record review revealed the facility admitted Resident #9 on 02/10/04 with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment, dated 08/12/16, revealed the facility assessed Resident #9's cognition as moderately impaired with a BIMS score of twelve (12), which indicated the resident was interviewable. In addition, the facility assessed Resident #9 as able to walk in his/her room and/or corridor with oversight, encouragement, or cueing. Review of Resident #9's Post Fall Assessment, dated 07/31/16, revealed the resident had an unwitnessed fall while ambulating independently, which resulted in a fracture of the nose. The facility determined the root cause of the fall was unsteady gait and muscle weakness; however, further review of the assessment revealed there was no documented evidence the facility put interventions in place to address the root cause of the fall. Review of Resident #9's Comprehensive Care Plan: Risk for Falls, last revised 08/03/16, revealed an intervention for a bed alarm to remind the resident to call for assistance. However, review of a revision note, dated 08/01/16 on the care plan, revealed Resident #9 had refused to allow a bed alarm to be placed on his/her bed and there was no evidence the facility addressed the resident's refusal of the bed alarm. Interview with State Registered Nurse Aide (SRNA) #1, on 10/28/16 at 9:30 AM, revealed Resident #9 requires frequent cueing and prompts to straighten his/her back when walking because he/she tends to lean forward when ambulating. SRNA #1 stated Resident #9's Care Guide indicates the resident should have a bed alarm to remind him/her to call for assistance to decrease potential of falling but the resident refused the bed alarm on 07/28/16. Interview with Registered Nurse (RN) #1, on 10/28/16 at 9:50 AM revealed Resident #9 refused bed alarm as an intervention after sustaining nose fracture from fall of 07/31/16. RN #1 stated the bed alarm is on Resident #9's Comprehensive Care Plan; however, the bed alarm was not individualized for Resident #9 because he/she never allowed the alarm to be put on her bed. Interview with the Quality Improvement (QI) Nurse, on 10/27/16 at 4:21 PM, revealed the facility failed to implement any further interventions for Resident #9 when the resident refused for bed alarm to be placed on his/her bed. The QI Nurse stated she expected the care plan to be revised to meet the residents need. Interview with the Director of Nursing, on 10/28/16 at 5:05 PM, revealed she expect staff to review/revise care plans and develop individualized care plan interventions based on the resident needs. Further interview revealed after a care plan is evaluated and if determined ineffective to the resident care needs, the staff should revise the care plan and resident care guide.

Based on observation, record review, interview, pharmacy contract review, and facility policy and procedure review, it was determined the facility failed to provide pharmaceutical services that ensured the availability and timely administration of drugs and biologicals to meet the needs of each resident for seven (7) residents (#3, #4, #5, #6, #7, #8 and #11) in the selected sample of eighteen (18). The facility failed to ensure the contracted pharmacy could ensure all necessary medications ordered to meet the residents' needs could be procured timely whether for routine or emergency medications. Furthermore, the facility failed to ensure the contracted pharmacy had contracted with a local pharmacy to ensure timely procurement of medications for it's residents. The facility failed to ensure staff was knowledgeable of the pharmacy and facility policies and procedures for the procurement of medications to ensure timely receipt and administration of medications. The facility failed to ensure the emergency drug kit maintained pharmaceuticals to meet the needs of residents while having the knowledge of identified difficulties in getting timely receipt of medications from the contract pharmacy. Furthermore, the facility failed to take necessary action to address identified issues with the contracted pharmacy's inability to provide medication timely to the facility. Resident #8 was admitted to an acute care hospital with a [DIAGNOSES REDACTED]. The resident returned to the facility on [DATE] with orders for Samsca (hyponatremia); however, the facility failed to ensure the resident received the medication for seven days after re-admission. An interview with the hospital physician revealed the hyponatremia would get worse without the Samsca and could be life threatening. Resident #7 was admitted to the facility from an acute care hospital after back surgery on 07/25/12. The physician ordered Percocet (narcotic pain medication); however, it was unavailable at the facility and the resident did not receive the medication for fourteen hours. The Resident complained of pain stating "I cried" and "it was terrible." Resident #5 sustained a fall with neck pain. Tramadol (narcotic pain medication) was ordered; however it was not available at the facility. There was no evidence the facility took action to procure pain medication for the resident to administer as soon as possible. The resident transferred to the hospital three hours later without receiving any pain medication. Resident #5 was diagnosed with [REDACTED]. The facility failure to provide pharmaceutical services that ensured the availability and timely administration of drugs and biologicals to meet the needs of each resident has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 08/31/12 and determined to exist and determined to exist on 07/25/12 and Substandard Quality of Care was identified at 42 CFR 483.25 Quality of Care. The Immediate Jeopardy was determined on-going. (Refer to F157, F309). Findings include: A review of the Pharmacy Contract, effective 11/01/91, revealed the contract did not indicate a specified local back up pharmacy. Review of the facility policy titled PHARMACEUTICAL SERVICES, dated 04/2007, included the following: "The facility provides appropriate methods and procedures for the dispensing and administering of drugs and biologicals. Pharmaceutical services are provided in accordance with accepted professional principals and appropriate federal, state, and local laws. A review of the Procurement of Emergency and After-Hours Medications policy, undated, revealed the nurse should call the "on-call" pharmacist, if after hours, weekends, or holidays and communicate to him/her the medication order in its entirety. The "on-call" pharmacist shall then make whatever arrangements necessary with a predetermined local pharmacy (back-up pharmacy), or if the back-up pharmacy could not supply, with any other local retail pharmacy or hospital pharmacy, for procurement of the needed medications such that administration may begin the time frames dictated by policy, if at all possible. The nurse or any other facility personnel should not contact the back-up pharmacy or any other alternate source of medications without first contacting the "on-call" pharmacist. A review of the Starting of New Medication Orders policy, revised 04/19/11, revealed administration of any medication order specified by the prescriber as "emergency" or "stat" shall be started within one hour of said order. If unavailable in the facility's Emergency Medication Kit, such medications shall be obtained from the back-up pharmacy. Administration of routine or scheduled MEDICATION ORDERS FOR [REDACTED]. Routine medication orders, if ordered prior to 5:00 PM and 4:00 PM on weekends, should be started with the next regularly scheduled dose following the next regular pharmacy delivery. An interview with the Pharmacist (local/back-up pharmacy), on 08/30/12 at 3:00 PM, revealed there was no written contract requiring them to provide medications on a 24 hour basis. An interview with the Pharmacist (contract pharmacy), on 08/31/12 at 8:25 AM, revealed after hours the facility should be contacting the pharmacist on call, not the back-up pharmacy directly. It was the contract pharmacy's responsibility to coordinate getting medications to the facility (per the back-up pharmacy). He stated the facility would have to obtain an "emergent" or "stat" medication order if needed within one hour; however, the area was "limited" on availability of 24 hour pharmacies. He revealed the facility should ask the physician for a medication available (in the emergency drug kit). He was aware of no pain medications in the emergency drug kit; however, it was the facility's responsibility to determine which medications were needed in the kit. 1. Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS assessment, dated 07/30/12, revealed the facility had assessed Resident #8 with no cognitive impairment and requiring limited assistance with activities of daily living. Resident #8 was transferred to an acute care hospital on [DATE] with acute respiratory failure and hyponatremia. Medications administered during the hospital stay included Samsca 15 mg every day. Hospital laboratory tests revealed Resident #8's serum sodium was 128 mEq (normal 132-146) on on admission and 134 mEq on 07/25/12. The hospital physician gave readmission orders [REDACTED]'s nursing facility physician. Resident #8 returned to the nursing facility on 07/25/12. Review of Resident #8's MAR, dated 07/01/12 through 07/31/12, revealed initials that were circled (meaning not given) for the dates of 07/26/12, 07/27/12, 07/28/12. While the facility obtained the lab results of the Basic metabolic profile laboratory test obtained on 07/28/12 which revealed serum sodium was 137 (normal 132-146), the facility continued to not have this physician ordered medication available to be administered. Continued review of Resident #8's July 2012 MAR indicated [REDACTED]. Review of a fax sent to Resident #8's physician on 07/31/12 revealed the following documentation: "Samsca for Resident #8 will not be available for a few days from pharmacy but they can get it. Do you want to order anything else in the meantime?". There was no documented response to the fax. Review of the August 2012 MAR indicated [REDACTED]. The MARs revealed the Samsca 15 mg to treat hyponatremia was not given for seven (7) days. An interview with Resident #8, on 08/30/12 at 6:15 PM, revealed he/she was aware that a medication was not available for a few days but did not know which medication it was. An interview was conducted with Pharmacist #3, from the primary pharmacy on 09/05/12 at 4:22 PM, which revealed the readmission orders [REDACTED]. The local pharmacy was contacted the next day. He stated there was a contract with the local pharmacy and the local pharmacy was responsible to supply the initial medications and then the primary pharmacy would send the balance; however, review of the pharmacy contract and interview with the local pharmacy revealed there was no written contract. Futher interview with Pharmacist #3 stated the Samsca 15 mg for Resident #8 was dispensed on 07/31/12. He did not know why the initial medication was not sent from the local pharmacy. An interview conducted with Pharmacist #2 from the local back up pharmacy on 09/05/12 at 4:05 PM revealed there was no record of Samsca being ordered for Resident #8. The pharmacist also was unfamiliar with the medication and looked for information about the drug. She stated the information revealed it was used as an electrolyte and renal agent to treat clinically significant Hyponatremia. The information also indicated the medication should be initiated and reinitiated in a hospital setting so sodium levels could be monitored. An interview conducted with Resident #8's facility physician, on 09/07/12 at 9:00 AM, revealed he would have expected the facility to let him know Resident #8 was not receiving the prescribed Samsca and the facility should have provided that medication. The facility normally faxed or called about laboratory results of medication issues that could affect a resident's wellbeing, and then said "faxing is NOT good", "I have never scolded a nurse for calling". The physician also said "They should loosen the purse strings and go to the local pharmacy". The physician stated Samsca was a drug he had not previously used and stated side effects could be lethargy, mental confusion, coma and seizures. An interview with Resident #8's hospital physician, on 09/07/12 at 9:15 AM, revealed he would expect the facility to provide the prescribed medication to Resident #8 and he was not aware it was not available and Resident #8 did not receive it for seven (7) days. The physician stated if the resident did not receive the Samsca his/her low sodium could get worse and could be life threatening. Resident #8 had Syndrome of Inappropriate Antidiuretic Hormone (SIADH) requiring treatment with the medication Samsca, once treatment is successful then the drug can be discontinued. An interview with the Director of Nursing (DON), Administrator and Assistant Director of Nursing (ADON) on 09/07/12 at 7:35 PM, revealed medication orders were to be sent to the primary pharmacy and that pharmacy was to relay it to the back up pharmacy and the back up pharmacy was to send a five day supply of the medications. The local pharmacy had been saying they were not receiving the orders from the primary pharmacy. Both pharmacies were being faxed orders at one time because they said they were not receiving the orders. Nurses were to call the DON or the primary pharmacy when medication orders were not filled adequately. The DON stated she had "Started a log today" to monitor. The facility could provide no evidence they followed their policies and procedures to ensure timely procurement of medications to assure appropriate and adequate administration of physician ordered medications to treat Resident #8's Syndrome of Inappropriate Antidiuretic Hormone (SIADH). As per the interviews with the hospital physician, the facility's failure to ensure the resident was administered the medication Samsca to address his/her low sodium could have caused the condition to worsen and could be life threatening. 2. (Refer to F309) Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission assessment, dated 07/25/12 at 11:52 PM, revealed the facility had assessed the resident as having low back pain, lower extremity pain due to recent back surgery. The pain history listed pain was worse during the day and the night and that the pain interfered with the resident's daily activities. Review of the admission MDS assessment, dated 08/01/12, revealed the facility had assessed the resident with no cognitive impairment, and required extensive assistance with activities of daily living. Review of Resident #7's record revealed the resident arrived at the facility on 07/25/12 at 9:00 PM. Admitting orders from the hospital included a prescription from the hospital, dated 07/25/12 and signed by the hospital physician, for Percocet 10/325 milligrams (mg) every four to six hours as needed for pain. Additional medications were: Gabapentin 300 mg twice a day (for chronic pain), Levothyroxine (for [DIAGNOSES REDACTED]) 50 micrograms (mcg) one a day, Ranitidine HCL (for gastritis) 150 mg two times a day, Calcium with Vitamin D (for calcium deficiency) 600/400 mg every day, Metformin HCL (antidiabetic) 1,000 mg twice a day, Flexeril (muscle relaxant) 10 mg three times a day, Glipizide (antidiabetic) 10 mg twice a day, Lisinopril (antihypertensive) 10 mg once a day, Atenolol (antihypertensive) 100 mg once a day, Famotidine (gastritis) 10 mg twice a day, Prozac (antidepressant) 20 mg once a day and Mevacor (antilipemic) 20 mg every day. Review of the admission Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Additionally, many of the routine medications were not administered on 07/26/12 including: Calcium with Vitamin D 600/400 mg due at 1:00 PM, Metformin HCL 1,000 mg due at 7:00 AM, Flexeril HCL 10 mg due at 8:00 AM and 12:00 PM, Glipizide 10 mg due at 7:00 AM, Lisinopril 10 mg due at 12:00 PM, Atenolol 100 mg due at 8:00 AM, Januvia 100 mg due at 4:00 PM, Famotidine 10 mg due at 7:00 AM, Prozac 20 mg due at 4:00 PM, Gabapentin 300 mg due ar 7:00 AM, Levothyroxine 50 mcg due at 7:00 AM and Ranitidine HCL 150 mg due at 7:00 AM. All of initials for these medications were circled indicating not given. The back of the MAR indicated . Observation and interview with Resident #7, on 08/30/12 at 5:15 PM, revealed when first admitted on [DATE] the facility had did not provide him/her any pain medications for "fourteen hours". The resident stated "I cried", "It was terrible" as she had been admitted to the facility after having back surgery and could hardly stand the pain in his/her back and legs. An interview with Resident #8, Resident #7's roommate on 08/30/12 at 5:15 PM revealed "Resident #7 cried off and on all night that night because he/she was hurting and that was uncalled for," on the day he/she was admitted . Resident #8 stated he/she has had to wait for medications in the past as well. An interview conducted, on 09/05/12 at 1:30 PM, with Licensed Practical Nurse (LPN) #5 revealed she worked the 10:00 PM to 6:00 AM shift starting on 05/25/12 and did the admission assessment on Resident #7. She revealed the resident had arrived at the facility on the 2:00 PM to 10:00 PM shift and had recent back surgery. She revealed staff had said in report that they had not received the resident's medications and they would be delivered in the morning. LPN #5 stated she had faxed the pharmacy. LPN #5 also stated she did not contact the DON or anyone about Resident #7's medications. She stated there had been a pharmacy issue lately and it was frustrating, "You call, you fax, you call, you fax." Additionally, LPN #5 stated it was her job to administer medications to residents and it "Did not make me feel great, I want to see them get what they need". She said the problem was obtaining medications after hours. An interview with LPN #9, on 08/31/12 at 9:00 AM, revealed she remembered Resident #7 was in a lot of pain the morning of 07/26/12 and she had reported to whoever was in charge and they told someone (not sure who). She said the Administrator, the DON and another person had gone in to talk with the resident the morning of 07/26/12 and then someone went to the local pharmacy. An interview with the DON, on 08/31/12 at 9:30 AM, revealed Resident #7 had arrived at the facility late on admission. On 07/26/12 when the DON arrived around 8:00 AM to 8:30 AM staff reported Resident #7 was hurting. The DON stated she told Resident #7 she would get the medication as soon as possible and thought the Administrator had gone to the pharmacy for the medication. Nurses were to fax the out of state pharmacy and that pharmacy was to fax the local pharmacy. An interview with Resident #7's facility physician, on 09/07/12 at 9:30 AM, revealed she would expect the facility to notify her if a resident did not have pain or any other medication available. The physician did not recall if anyone from the facility had called about Resident #7 not getting his/her medications. The physician additionally stated the facility used to keep certain medications at the facility but now generally have someone on call from the pharmacy. 3. (refer to F309) A record review revealed the facility admitted Resident #5 on 08/03/12 with [DIAGNOSES REDACTED]. A review of the initial Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident as severely cognitively impaired and required extensive assistance of two staff with bed mobility, transfer, and ambulation. A review of the Pain Management Assessment, dated 08/10/12, revealed the resident had no current complaints of pain with no pain medication. A review of the Physician's Orders, dated 08/03/12 through 08/31/12, revealed no evidence of pain medications. A review of the incident report, dated 08/18/12 at 6:30 AM, revealed Resident #5 sustained a fall from the bed with "a little bit" of neck pain. An interview with RN #2, on 08/24/12 at 1:05 PM, revealed she validated the incident and stated the resident's pain worsened throughout the morning. She notified the physician at 8:30 AM and Tramadol was ordered for pain; however, it was not available in the facility. She was not aware if pain medication was available in the emergency drug kit stating she did not check the kit. She instructed the physician to call the prescription into the local pharmacy by 12:00 PM or it would not arrive at the facility prior to closing as it was Saturday and the back-up pharmacy was only open from 9:00 AM-1:00 PM. She admitted no further attempts were made to ensure pain medication was received and administered timely to address the resident's pain. She stated she could have called the physician for a non-narcotic pain medication, but she did not have time. An interview with the physician, on 08/30/12 at 10:20 AM, revealed nursing staff typically have him call narcotics into the back-up pharmacy as they require a "hard script." He was unable to verify an exact time he called the Tramadol to the back-up pharmacy. A review of the Physician's Orders, dated 08/18/12 at 8:40 AM, revealed an order for [REDACTED]. A review of the medication list from the Emergency Drug Kit, dated 07/03/07, revealed no pain medications (narcotic or non-narcotic) were available, if needed. Further interview with RN #2 revealed the family transferred the resident to the emergency room per family car at approximately 9:30 AM, three hours after the fall. She stated the facility had not administered any pain medications to Resident #5 prior to the transfer. A review of the "Packing List", dated 08/18/12, revealed the Tramadol was filled by the local, uncontracted, backup pharmacy at 10:50 AM (over two hours after the order was received). An interview with the Pharmacist (back-up pharmacy), on 08/30/12 at 3:00 PM, revealed the pharmacy hours on Saturday were 9:00 AM to 1:00 PM. The facility would have to get the prescription to their pharmacy by 12:00 PM in order to get the medication that day. She verified if an order was received prior to 9:00 AM, they would have to wait until the pharmacy opened to get it filled. An interview with the DON, on 08/31/12 at 1:15 PM, revealed it typically takes at least an hour and a half to receive medications from the back-up pharmacy. She revealed RN #2 should have called the physician for a non-narcotic pain medication, such as Tylenol, and it could have been "borrowed" from another resident. She was aware the emergency drug kit had no pain medication available; however, she was unsure of the reason. An interview with the Administrator, on 08/31/12 at 9:35 AM, revealed the contents of the Emergency Drug Kit were already in place when she became Administrator in 2011. She was not sure how often it was reviewed for changes. Continued interview with the DON, on 08/31/12, revealed it was not acceptable for a resident to wait three hours for pain medication. There was no evidence that the facility nurse followed the facility's policies and procedures for obtaining medication after hours as evidenced by RN #2's interview revealing she instructed the physician to contact the local pharmacy instead of notifying the contract pharmacy. Furthermore, there was no evidence that the facility nurse attempted to obtain an emergent or stat order for the pain medication to ensure timely receipt and resident administration of the medication inorder to relieve the resident's pain. A review of the Discharge Summary, dated 08/20/12, revealed the resident sustained [REDACTED]. Interview with RN #2 revealed she did not realize the seriousness of the situation. 4. A record review revealed Resident #11 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED].) twice a day and Zestril/Prinvil (anti-hypertensive) 20 mg. twice a day to Resident #11. A review of the August 2012 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. and Zestril/Prinvil 20 mg. at 7:00 AM had initials with a circle around them for 08/08/12, 08/09/12, 08/10/12, 08/13/12 and 08/14/12. For 7:00 PM, there were intials with a circle on 08/10/12, 08/11/12, 08/12,12 and 08/13/12. Interviews with LPN #7, on 09/07/12 at 1:45 PM, revealed she placed her intials with a circle around them in the boxes at 7:00 AM next to the Tenormin and Zestril/Prinvil orders because the medications were not available. She revealed her and another nurse faxed and called the pharmacy several times before the medications were finally delivered to the building. Interview with LPN #12, on 09/07/12 at 2:35 PM, revealed she was not sure if it was her initials circled at 7:00 PM next to the Tenormin and Zestril/Prinvil. She stated the reason it would have been circled was because the medication was not available. She further revealed that some nurses will borrow the medication from other residents even though we're not supposed to and that is probably why there were two days the medication was intialed as administered. Interview with the DON, on 09/07/12 at 5:25 PM, revealed she would have expected the staff to call the pharmacy and make them aware they were out of the medication. She stated the failure to administer the blood pressure medication could have caused the resident's blood pressure to increase. 5. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Physician's Order dated 09/01/12 revealed that Resident #4 was ordered Tylenol Arthritis 650mg, by mouth daily at 7:00AM and 12:00PM, Equanil 200mg, by mouth three times daily, and Flomax 0.4mg, by mouth at bedtime. The Physician's Order also revealed that the facility was to ask the pharmacy to make sure that Resident #4's medications are received in a timely manner and make sure the resident is never out of medication. A review of Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. An interview with the Physician on 09/07/12 at 9:00AM revealed that he had written an order for [REDACTED]. An interview with Resident #4, on 09/06/12 at 10:30AM, revealed that he/she had missed doses of Tylenol Arthritis and Flomax for up to 4-5 days due to it not being available in the facility. The resident stated that he/she had been out of Equanil for 3 days at a time and that he/she had to wait 4 days to get Vick's Vapor Rub from the pharmacy. 6. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Physician's Orders, dated 09/01-30/12, revealed an order for [REDACTED]. 7. A record review revealed the facility admitted Resident #6 on 02/22/11 with [DIAGNOSES REDACTED]. A review of the annual MDS, dated [DATE], revealed the facility assessed the resident as moderately impaired and having pain during the assessment period. A review of the Pain care plan, created on 03/02/11, revealed to administer pain medication as per physician orders and note the effectiveness. The Physician Orders, dated 08/01-31/12, revealed an order for [REDACTED]. An interview with LPN #7, on 09/07/12 at 1:45 PM, revealed the resident was out of the medication. She indicated the process for receiving medications included to fax and call the pharmacy. Sometimes, the medication would be delivered the next day; however, it could take a few days. An interview with the Director of Nursing (DON) and Administrator, on 09/07/12 at 7:35 PM, revealed they were aware of the concern related to the timely receipt of medications. The Administrator revealed she could not prove where the system failure was, but medications were not being delivered timely. No plan of action was provided. An interview with the Facility Consultant, on 09/07/12 at 8:30 PM, revealed it varied how often she was at the facility, but tried to come at least once a month. It was not always possible to do that as she had four facilities to oversee. She was aware of a "couple" of incidents related to timely medications; however, she was unaware of a concern receiving pain medications. She would expect the facility staff to notify her of pharmacy issues. An interview with the Regional Vice President, on 09/07/12 at 8:40 PM, revealed he was at the facility at least monthly, sometimes bi-weekly. He was not aware of any pharmacy related issues prior to 08/20/12. He would expect the facility staff to notify him of these issues.

Based on interview, record review, review of the facility's policy/procedure and Plan of Correction (PoC), it was determined the facility's Quality Assessment and Assurance Program failed to follow their PoC related to the implementation of an appropriate action plan related to the timeliness of laboratory (lab) services for one resident (#32), in the selected sample of eleven residents. Resident #32 received an order for [REDACTED]. The missed lab was discussed in the QI Committee meeting, on 12/19/12; however there was no plan of action implemented. Refer to (F502) Findings include: A review of the Quality Improvement policy/procedure, dated 01/11, revealed through the Quality Improvement Program, the facility would recognize concerns in resident care and develop a plan of action for the resolution of those concerns. Train staff members on the plan, put the plan into effect and evaluate the plan to ensure that the concerns were resolved and do not reoccur. A review of the facility's PoC, dated 11/20/12, revealed the Administrative Assistant would complete a Daily Lab Audit form (5 times weekly) with tracking of labs drawn, results received and appropriate follow up to include physician notification. Any lab results received after hours or on the weekends would be addressed by the nurse assigned to the specific resident. The Lab Audit QI tool would be used to review the Daily Lab Audit form weekly. The Lab Audit QI tool reviewed the number of labs ordered, the number of labs received, timeliness of physician notification, if the physician replied, if there was a new order, and corrective action needed. Results of the Lab Audit QI tool would identify corrective action needed which the DON would be responsible for validating completion of the corrective action. The results of the Daily Lab Audit forms and Lab Audit QI tool would be reviewed weekly in a QI committee meeting with the Administrator and the DON. The compiled results of these audits would be assessed for any trends by the QI committee and actions taken based on these assessments. Review of Resident #32's Physician orders [REDACTED]. Interview with the Weekend Manager and record review revealed she discovered the lab was not obtained when reviewing Resident #32's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A review of the Lab Audit QI tool, dated 12/10-16/12, revealed a lab was ordered for 12/14/12; however, the lab was not completed. The physician was notified with a new order to obtain the lab 12/15/12. It was completed; however, there was not enough blood for the sample. It was redrawn on 12/16/12 and when the physician was made aware of the results, an order was received to restart the resident's [MEDICATION NAME]. There was no corrective action identified on the Lab Audit QI tool. An interview with the DON, on 12/20/12 at 6:00 PM, revealed she thought their lab system worked, the problem was the contract lab company "did not show up" to draw the PT/INR. She revealed a QI committee meeting occurred on 12/19/12 where the staff talked about the missed PT/INR; however, no new action plan was implemented. An interview with the Facility Consultant, on 12/20/12 at 6:30 PM, revealed the weekend managers would be completing the Lab Audit form on the weekends; however, she could not provide documentation that verified the implementation of the action plan prior to 12/20/12. An interview with the Administrator, on 12/20/12 at 6:50 PM, revealed the missed lab was discussed in the QI committee meeting on 12/19/12; however, an action plan had not been implemented. An interview with the Vice President of Operations, on 12/20/12 at 7:45 PM, revealed he was aware of the concern related to the missed lab; however, he felt it was an issue with the contract lab as they did not show up to draw the PT/INR. He verified there was no corrective action in place.

Based on interview, record review, and review of the facility's Quality Improvement Program policy/procedure, it was determined the Quality Assessment and Assurance (QAA) committee failed to develop and implement appropriate plans of action to correct identified quality deficiencies related to pharmacy services. The facility failed to ensure medications were available from the contract pharmacy for eight residents (#3, #4, #5, #6, #7, #8, #9 and #11) in the selected sample of 18 residents. On 07/25/12, the facility readmitted Resident #8 after an acute care hospital stay with a [DIAGNOSES REDACTED]. The facility failed to ensure the resident received physician ordered medication [MEDICATION NAME] (treatment for [REDACTED]. The hospital physician stated the [MEDICAL CONDITION] would get worse without the [MEDICATION NAME] and could be life threatening. On 7/25/12, the facility admitted Resident #7 from an acute care hospital after back surgery. The physician ordered [MEDICATION NAME] (narcotic pain medication); however, it was unavailable at the facility and the resident did not receive the medication for fourteen hours. Staff interviews revealed there was no pain medication in the facility's emergency drug kit. The Resident complained of pain stating "I cried" and "it was terrible." On 08/18/12, Resident #5 sustained a fall with neck pain. [MEDICATION NAME] (narcotic pain medication) was ordered; however it was not available at the facility. There was no evidence the facility took action to procure pain medication for the resident to administer as soon as possible. The resident transferred to the hospital three hours later without receiving any pain medication. Resident #5 was diagnosed with [REDACTED]. Additionally, record review of Resident #3, #4, #6, #9, and #11, revealed different medications were unavailable for multiple days. Interview with members of the QAA commmittee revealed they had identified an issue with the pharmacy; however, a plan of action to correct the problem was not provided. Furthermore, Substandard Quality of Care (SQC) was identified at F312 with a related deficiency at F353 identifying the facility failed to ensure sufficient nursing staff to ensure residents received showers as scheduled and per the residents' care plan for eleven (11) residents (#1, #3, #6, #7, #9, #11, #12, #22, #23, #24 and #25) in the selected sample of 18. Administrative staff interviews revealed the facility had identified staff issues and had discussed issues in QAA; however, failed to have documented evidence of how they had addressed the staffing issue to ensure residents received baths per their care plan and shower schedules through their Quality Assurance process. The QAA committee's failure to develop and implement appropriate plans of action to correct identified quality deficiencies related to pharmacy services has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy and SQC was identified at 42 CFR 483.25 Quality of Care on 08/23/12 and determined to exist on 08/04/12. A second Immediate Jeopardy and Substandard Quality of Care was identified at 42 CFR 483.25 Quality of Care on 08/31/12 and determined to exist on 07/25/12. The Immediate Jeopardy was determined on-going. (Refer to F157, 280, 309, 323, 425, 490, 520). Additionally, SQC was identified at F312 due to the facilities failure to ensure residents received appropriate care and services to meet their grooming and hygeine needs based on the facility's failure to ensure adequate staffing was provided (Refer to F312, F353) The Findings Include: A review of the Quality Improvement Program policy, dated 01/11, revealed the pharmacy review committee met quarterly to ensure concerns noted during the pharmacist's visits were discussed and a plan of action was formulated to alleviate those concerns. Interviews with Licensed Practical Nurse (LPN) #7, on 09/07/12 at 1:45 PM, revealed medications were not available. She revealed she had to fax and call the pharmacy several times before the medications were finally delivered to the building, and it could take a few days. An interview conducted, on 09/05/12 at 1:30 PM, with LPN #5 revealed there had been a pharmacy issue lately and it was frustrating, "You call, you fax, you call, you fax." Additionally, LPN #5 stated it was her job to administer medications to residents and it "Did not make me feel great, I want to see them get what they need". She said the problem was obtaining medications after hours. An interview with a facility Physician, on 09/07/12 at 9:00 AM, revealed that he has had to write "to receive medications in a timely manner" on the physician order. An interview with the Director of Nursing (DON), on 08/31/12 at 1:15 PM, revealed it typically takes at least an hour and a half to receive medications from the back-up pharmacy. She was aware the emergency drug kit had no pain medication available; however, she was unsure of the reason. An interview with the Administrator, on 08/31/12 at 9:35 AM, revealed the contents of the Emergency Drug Kit were already in place when she became Administrator in 2011. She was not sure how often it was reviewed for changes. An interview with members of the QAA committee, including the Administrator, DON, the Assistant Director of Nursing (ADON), and the Admissions Coordinator, on 09/07/12 at 7:35 PM, revealed they had discussed pharmacy issues in the QAA meetings (as well as the daily meetings). The group indicated pharmacy had been contacted numerous times about the pharmacy process. The Admissions Coordinator indicated she implemented a system with new admissions. A resident would not be admitted if not in the facility between 2-3 PM, in order to get medications timely for the resident. She was unable to provide documentation of this new system. The Administrator revealed she could not prove where the system failure was, but medications were not being delivered timely. An interview with the Medical Director, on 09/07/12 at 5:50 PM, revealed he was not notified until today (09/07/12) of the issue related to timely receipt of medications from the pharmacy. (Refer to F312, F353) The facility failed to ensure sufficient nursing staff to ensure residents received showers as scheduled and per the residents' care plan for eleven (11) residents (#1, #3, #6, #7, #9, #11, #12, #22, #23, #24 and #25) in the selected sample of 18. Director of Nursing (DON) interview, on 08/31/12 at 9:30 AM, revealed the facility had some staffing issues and some residents might not get a shower on the day it was scheduled. The DON stated, "we have hired everything that walks in the door, and they quit due to the money". An interview with the Administrator, on 09/07/12 at 7:35 PM, revealed she was aware of staffing issues in the facility; however, was not able to provide a corrective plan that she had implemented to address staffing concerns. She stated she had informed her supervisor (governing body) and it had been discussed in the QA meetings; however, she could not provide a specific daten staffing was discussed in QA nor action taken. The facility was unable to provide documented evidence that they had followed their Quality Improvement Program policy by taking corrective action, initiated by the Quality Assurance/Quality Improvement program/committee, to correct the system failure related to pharmacy services and adequate staffing to ensure care and services were provided to residents to meet their individual needs.

Based on interview and record review, it was determined the facility failed to ensure the governing body implemented policies regarding the management and operation of the facility. The governing body failed to provide adequate oversight to ensure the management and operation of the facility was appropriate to assure all residents' needs were being met through thorough nursing assessment, timely physician notification of a resident's condition change, pharmacuetical procurement and timely medication administration. Immediate Jeopardy was identified at 42 CFR 483.10 Residents Rights F157; 42 CFR 483.20 Resident Assessment F280; 42 CFR 483.25 Quality of Care F309, F323; 42 CFR 483.60 Pharmacy Services F425; and 42 CFR 483.75 Administration F490, and F520. Substandard Quality of Care was identified at 42 CFR 483.25 Quality of Care F309, F312 and F323. On 07/25/12, the facility admitted Resident #7, after having back surgery and assessed for intense pain; however, failed to ensure timely receipt and administration of medications to Resident #7 who experienced severe intense pain, having no pain medication for 14 hours after admission. Resident #7 stated "I cried, it was terrible." On 08/18/12, the facility failed to address the needs of Resident #5's complaints of pain after a fall through assessment, timely notification of the physician, procurement and administration of pain medication. Resident #5 was diagnosed with [REDACTED].#2 was thoroughly assessed for the continued use and later re-initiation (on 08/21/12) of the low air loss/alternating mattress and side rails after experiencing a fall from the bed with entrapment of the resident's left arm causing injury. The facility failed to ensure staff was knowledgeable of the appropriate use/inflation of the low air loss/alternating mattress and the risks/benefits associated with its use per each resident's assessed needs. Substandard Quality of Care was identified at F312 for the facility's failure to ensure appropriate grooming and hygeine was afforded to the residents of the facility. Additionally, the failures of F312 resulted in the identification of the facility's failure to ensure adequate staffing was provided to meet the needs of the residents as detailed in F353. While the Governing Body visited the facility on a routine basis, there was no documented evidence these professionals identified, through their reviews and audits, these quality problems nor evidence of action taken to correct the systems failures. The facility's failure to ensure the governing body implemented policies regarding the management and operation of the facility has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy and Substandard Quality of Care was identified at 42 CFR 483.25 Quality of Care on 08/23/12 and determined to exist on 08/04/12. A second Immediate Jeopardy and Substandard Quality of Care was identified at 42 CFR 483.25 Quality of Care on 08/31/12 and determined to exist on 07/25/12. The Immediate Jeopardy was determined on-going. (Refer to F157, 280, 309, 323, 425, 490, 520). The Findings Include: (Refer to F425) While review of the pharmacy contract revealed the facility did in fact have a contract since 1991 with a pharmacy there was no evidence of a contract with a local pharmacy to address emergent or stat orders as the contract pharmacy is located out of state. An interview with the Administrator, on 09/07/12 at 7:35 PM, revealed she made corporate staff (governing body) aware of the pharmacy issues prior to the survey; however, she did not have any documentation or knowledge of a date it was discussed. An interview with the Facility Consultant (governing body), on 09/07/12 at 8:30 PM, revealed she was aware of "a couple" incidents involving medications unavailable at the facility. An interview with the Regional Vice President, on 09/07/12 at 8:40 PM, revealed he was not aware of any issues related to the pharmacy, but would expect the Administrator to relay the information. (Refer to F157, 280, 309, 323) Policy review and interview with the Director of Nursing (DON), on 08/31/12 at 1:15 PM, revealed there was no policy (or standard of practice) utilized in the facility related to assessment of a resident. The DON provided a standard of practice for an acute illness assessment; however, revealed it had not been implemented for use in the facility. The facility was unable to provide evidence that they had identified problems with nursing assessments of residents through their investigations and review of the incidents regarding Resident #2's falls and entrapment on 08/04/12 and Resident #5's complaints of pain after a fall resulting in a diagnosed C2 spinal neck fracture nor could they provide evidence that they had initiated corrective action to prevent recurrence. (Refer to F312, F353) The facility failed to ensure sufficient nursing staff to ensure residents received showers as scheduled and per the residents' care plan for eleven (11) residents (#1, #3, #6, #7, #9, #11, #12, #22, #23, #24 and #25) in the selected sample of 18. Director of Nursing (DON) interview, on 08/31/12 at 9:30 AM, revealed the facility had some staffing issues and some residents might not get a shower on the day it was scheduled. The DON stated, "we have hired everything that walks in the door, and they quit due to the money". She also said people were not dedicated. The facility was unable to provide documented evidence of how they had addressed the staffing issue to ensure residents received baths per their care plan and shower schedules. An interview with the Administrator, on 09/07/12 at 7:35 PM, revealed she was aware of staffing issues in the facility; however, was not able to provide a corrective plan that she had implemented to address staffing concerns. She stated she had informed her supervisor (governing body); however, had no documented evidence and could not remember the specific date she informed the govern body of the staffing issues the facility was having. The Facility Consultant, on 09/07/12 at 8:30 PM, revealed it varied how often she was at the facility, but tried to come at least once a month. It was not always possible to do that as she had four facilities to oversee. She was aware of a "couple" of incidents related to timely medications; however, she was unaware of a concern receiving pain medications. She would expect the facility staff to notify her of pharmacy issues. An interview with the Regional Vice President, on 09/07/12 at 8:40 PM, revealed he was at the facility at least monthly, sometimes bi-weekly. While the Governing Body visited the facility on a routine basis, there was no documented evidence these professionals identified, through their reviews and audits, these quality problems nor evidence of action taken to correct the systems failures.

Based on interview, review of credentials, and review of the Allegation of Compliance (AoC), it was determined the Immediate Jeopardy (IJ) identified during the survey, concluded on 09/07/12, had been removed. Findings include: Validation of the AoC revealed a new Administrator was appointed, on 09/11/12, licensed in the State of Kentucky, to oversee and ensure the facility ' s resources were utilized effectively and efficiently to ensure the delivery of required care and services for the residents. Oversight of the new Administrator would be conducted by the Vice President of Operations. As of 09/07/12, the facility had not submitted an acceptable Plan of Correction (PoC).

Based on interview, record review, and review of the Allegation of Compliance (AoC), it was determined the Immediate Jeopardy (IJ) identified during the survey, concluded on 09/07/12, had been removed. Findings include: Validation of the AoC revealed education was provided on the facility ' s policy for obtaining medications from the pharmacy and back-up pharmacy on 09/05/12. On 09/11/12, re-education was initiated with licensed staff and Kentucky Medication Aides (KMAs) related to ordering medication refills from the facility pharmacy. On 09/12/12, the facility added a 24 hour/7 day secondary back-up pharmacy in the event medication was unable to be obtained by the primary back-up pharmacy. Additionally, a contract for a third back-up pharmacy was initiated on 09/21/12. A list of medications available in the Emergency Drug Kit were available in the resource book at each nurse ' s station. Non-narcotic and narcotic medications were added to the list of medications. On 09/10/12, the Pharmacy Consultant audited the medication room and carts to identify medications were available for use. Audits would continue using a Quality Indicator (QI) tool four times weekly for four weeks, then twice weekly for four weeks, then monthly for two months. Review of the audits thus far revealed no concerns. Frequency of the Pharmacy Consultant visits increased to twice monthly effective 09/12/12. Audits would be conducted during the visits to identify all residents have medications available and the medications were documented appropriately. As of 09/07/12, the facility had not submitted an acceptable Plan of Correction (PoC).

Based on observation, interview, record review, and review of the Administrator's Job Description, it was determined the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The Administrator failed to ensure assessments of residents were completed to determine the safe use of devices (air mattress and side rails) prior to utilization. The Administrator failed to ensure thorough assessment of residents were completed after experiencing a change in condition and failed to ensure timely physician notification for appropriate treatment. The Administrator failed to assure the contracted pharmacy could ensure all necessary medications ordered to meet the residents' needs could be procured timely whether for routine or emergency medications. Resident #2 sustained multiple falls from the low air loss/alternating mattress, on 08/04/12, the resident fell out of bed pinning his/her left arm in the side rail resulting in injury. The facility continued the use of the low air loss/alternating mattress and side rails without completing an accurate assessment to ensure the devices were safe for the resident's continued use. On 08/18/12 at 6:30 AM, the facility identified Resident #5 fell from the bed, was aware of the resident's initial complaint of neck pain upon transfer and continued increasing complaints of pain for approximately two hours before the facility took action to notify the physician of the incident, the resident's pain and significant change after the fall. The resident was transferred by family to the emergency room and received no pain medication prior to the transfer. The resident was admitted to the hospital with [REDACTED]. The facility admitted Resident #7 on 07/25/12 after having back surgery. Due to the facility's failure to ensure timely receipt of medications, per their pharmacy contract, Resident #7 experienced severe intense pain per the facility's assessment, having no pain medication for 14 hours after admission. Resident #7 stated "I cried, it was terrible." Additionally, the facility failed to ensure adequate staffing to meet the shower needs of (11) residents (#1, #3, #6, #7, #9, #11, #12, #22, #23, #24 and #25) in the selected sample of 18. This failure to administer the facility effectively and efficiently to maintain each residents highest practicable physical, mental, and psychosocial well-being has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy and Substandard Quality of Care was identified at 42 CFR 483.25 Quality of Care on 08/23/12 and determined to exist on 08/04/12. A second Immediate Jeopardy and Substandard Quality of Care was identified at 42 CFR 483.25 Quality of Care on 08/31/12 and determined to exist on 07/25/12. The Immediate Jeopardy was determined on-going. (Refer to F157, 280, 309, 323, 425, 490, 520). Findings include: A review of the Administrator's Job Description, dated 11/21/06, revealed the primary purpose of the position was to direct the overall operation of the facility's activities in accordance with federal, state, and local standards, guidelines, and regulations, and as directed by the Vice President of Operations to assure that the highest degree of quality resident care was maintained at all times. (Refer to F309) The facility failed to ensure staff conducted a thorough assessment of a resident after experiencing a change in condition related to pain after a fall. Additionally, the facility failed to ensure timely notification and failed to provide an accurate assessment of the resident's condition to the physician to address the resident's continued and increased complaints of pain. On 08/18/12 at 6:30 AM, the facility identified Resident #5 fell from the bed, was aware of the resident's initial complaint of neck pain upon transfer and continued increasing complaints of pain for approximately two hours before the facility took action to notify the physician of the incident, the resident's pain and significant change after the fall. The resident was transferred by family to the emergency room , by family and received no pain medication prior to the transfer. The resident was admitted to the hospital with [REDACTED]. The physician stated the facility's assessment was not expressed as a serious situation. The facility admitted Resident #7 on 07/25/12 after having back surgery. Due to the facility's failure to ensure timely receipt of medications, per their pharmacy contract, Resident #7 experienced severe intense pain per the facility's assessment, having no pain medication for 14 hours after admission. Resident #7 stated "I cried, it was terrible." An interview with the DON, on 08/31/12 at 1:15 PM, revealed the physician should be notified immediately (within a few minutes after the assessment) of a possible neck injury after a fall. She expected the nurse to leave the resident in the bed as neck pain was indicative of a neck injury and should be treated as such. She also stated that three hours was not acceptable to wait for pain medication. She revealed RN #2 should have called the physician for a non-narcotic pain medication, such as Tylenol, and it could have been "borrowed" from another resident. She was aware the emergency drug kit had no pain medication available; however, she was unsure of the reason. On 08/31/12 at 9:35 AM, the Administrator stated the contents of the Emergency Drug Kit were already in place and she was not sure how often it was reviewed for changes. (Refer to F323) The facility failed to assess residents to determine the safe use of devices (air mattress and side rails) prior to utilization. The facility failed to ensure staff was trained and knowledgeable regarding low air loss/alternating mattresses and to ensure appropriate setting for each residents assessed needs. The facility failed to identify causal factors of a fall which prevented the facility from taking the necessary action to ensure the safe use of assistive devices. Resident #2 sustained two falls from the low air loss/alternating mattress on 08/02/12 with no injury and on 08/04/12 where the resident's left arm was pinned in the side rail sustaining bruising to the left wrist and upper arm with a skin tear to the left lower arm. The facility placed the resident back in bed; however, failed to identify or determine the causal factor of the fall or complete an assessment to determine whether the continued use of the low air loss/alternating mattress with bilateral half side rails was safe for use by Resident #2. While the mattress was discontinued on 08/06/12, the facility placed the resident back on the low air loss/alternating mattress with bilateral half side rails again on 08/21/12 at which time the facility failed to assess the resident for the safe use of the assistive devices until 08/22/12, the day after the devices were utilized for Resident #2. The facililty failed to include the history of entrapment as a risk for the resident. Interview with Resident #4, another resident utilizing the air mattress, revealed if not positioned correctly on the mattress, he/she would slide off easily. On 08/23/12 at 1:55 PM, the DON revealed staff was not trained on the operation (including the appropriate settings) of the low air loss/alternating mattresses. She was unable to give specific instructions of how to operate the mattress, or verify how she determined the settings based on an assessment of each residents needs. During a group interview including the Administrator, on 08/23/12 at 9:55 AM, administrative staff revealed it the facility had no policy regarding assessing residents for the safe use of specialty mattresses. (Refer to F425) The facility failed to ensure the contracted pharmacy could ensure all necessary medications ordered to meet the residents' needs could be procured timely whether for routine or emergency medications. Furthermore, the facility failed to ensure the contracted pharmacy had contracted with a local pharmacy to ensure timely procurement of medications for it's residents. The facility failed to ensure staff was knowledgeable of the pharmacy and facility policies and procedures for the procurement of medications to ensure timely receipt and administration of medications. The facility failed to ensure the emergency drug kit maintained pharmaceuticals to meet the needs of residents while having the knowledge of identified difficulties in getting timely receipt of medications from the contract pharmacy. Furthermore, the facility failed to take necessary action to address identified issues with the contracted pharmacy's inability to provide medication timely to the facility. Resident #8 admitted to an acute care hospital with a [DIAGNOSES REDACTED]. The resident returned to the facility on [DATE] with orders for [MEDICATION NAME] ([MEDICAL CONDITION]); however, the facility failed to ensure the resident received the medication for seven days after re-admission. An interview with the hospital physician revealed the [MEDICAL CONDITION] would get worse without the [MEDICATION NAME] and could be life threatening. Resident #7 admitted to the facility from an acute care hospital after back surgery on 07/25/12. The physician ordered [MEDICATION NAME] (narcotic pain medication); however, it was unavailable at the facility and the resident did not receive the medication for fourteen hours. The Resident complained of pain stating "I cried" and "it was terrible." An interview with the Administrator, on 09/07/12 at 7:35 PM, revealed she knew medications were not being delivered timely; however, could not provide a plan of action the facility had taken to correct the problem. She stated she could not prove the cause of the system failure. (Refer to F353) The facility failed to ensure sufficient nursing staff to ensure residents received showers as scheduled and per the residents' care plan for eleven (11) residents (#1, #3, #6, #7, #9, #11, #12, #22, #23, #24 and #25) in the selected sample of 18. An interview with the Administrator, on 09/07/12 at 7:35 PM, revealed she was aware of staffing issues in the facility; however, was not able to provide a corrective plan that she had implemented to address staffing concerns.

Based on interview, record review, and review of the facility's policy/procedure, it was determined the facility failed to ensure timely physician notification for two residents (#5, #9) in the selected sample of eighteen residents. The facility failed to immediately consult with the physician after an accident involving a resident which resulted in injury and had the potential for requiring physician intervention for one resident (#5), Resident #5 sustained a fall from the bed, on 08/18/12 at 6:30 AM. Registered Nurse (RN) #2 assessed Resident #5 after the fall. The resident was holding the back of his/her neck and complained of "a little bit" of neck pain. After the transfer to bed, the nurse failed to notify the physician immediately after the fall with a complaint of neck pain. Multiple staff which included State Registered Nurse Aide (SRNA) #1, Nurse Aide (NA) #1, and RN #2, stated the resident continued to complain of neck pain as evidenced by statements of "my neck hurts" every time the staff passed by the resident. The facility failed to re-assess the resident's condition. The facility notified the physician at 8:30 AM, two hours after the fall, detailing the resident had no injury with a little pain, failing to give the physician an accurate picture of the resident's condition, which prevented the physician from being able to order timely and effective treatment. These failures prevented Resident #5 from receiving timely treatment experiencing increased pain for more than three hours without treatment, and the family having to transport the resident to the emergency room . The resident was admitted to the hospital with [REDACTED]. Additionally, the facility failed to ensure timely physician notification of a lab result, indicating an antibiotic ordered for Resident #9, was ineffective. This failure resulted in a delay of the physician's response to order an effective treatment for [REDACTED]. The facility assessed Resident #9 as continuing to have signs and symptoms of fluctuations of blood pressure and temperature for the period of 05/25/12 through 05/29/12 without effective antibiotic treatment. The facility's failure to ensure the physician was immediately consulted after an accident involving Resident #5 that resulted in injury has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 08/31/12 and determined to exist on 08/18/12 and Substandard Quality of Care was identified at 42 CFR 483.25 Quality of Care. The Immediate Jeopardy was determined to be on-going. (Refer to F309). Findings include: A review of the "Notification of Physician for a Change in Resident's Condition" policy, dated 04/07, revealed the facility would notify the physician when a significant change in a resident's condition occurred with documentation. 1. A record review revealed the facility admitted Resident #5 on 08/03/12 with [DIAGNOSES REDACTED]. A review of the initial Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident as severely cognitively impaired and required extensive assistance of two staff with bed mobility, transfer, and ambulation. A review of the pain management assessment, dated 08/10/12, revealed the resident did not have any current reports of pain and no pain medication ordered. A review of the Fall Risk assessment, dated 08/17/12, revealed a fall score of twelve (12), which indicated he/she was at risk for falls. A review of the incident report, dated 08/18/12 at 6:30 AM, revealed Resident #5 sustained an unwitnessed fall and was assessed with [REDACTED]. According to the report, the resident touched the back left side of his/her neck and stated "it hurt a little bit." An interview with SRNA #1, on 08/24/12 at 12:20 PM, revealed she found Resident #5 in his/her room on the floor. The resident was found on his/her right side beside the bed, one foot straight out while the other was curled up underneath him/her. The resident's neck was turned to the side and he/she was looking at her when she entered the room. She indicated the resident's position was "weird." She immediately informed RN #2 of the fall. RN #2 then assessed the resident. SRNA #1 and SRNA #2 then transferred the resident to the bed and he/she immediately complained of neck pain, pointing to the back of the neck. RN #2 asked the resident if he/she could move his/her neck, and the resident was able to follow instructions. SRNA #1 dressed the resident and transferred him/her to the wheelchair for breakfast, with assistance from SRNA #2. The resident continued to complain of neck pain during the provision of care and up until the time he/she was transferred to the emergency room . An interview with SRNA #2, on 08/24/12 at 1:00 PM, revealed she assisted SRNA #1 in transferring the resident to bed. The resident indicated the back of his/her neck hurt "a little bit" at that time. She assisted SRNA #1 in dressing the resident and getting him/her up for breakfast. While providing care, the resident complained of neck pain "once or twice." An interview with NA #1, on 08/24/12 at 12:05 PM, revealed she saw the resident up in the lobby with continued complaints of neck pain. She revealed the resident's neck was "stiff" and he/she constantly repeated "my neck hurts." She made RN #2 aware of the complaints, but was unaware of what action RN #2 had taken. A review of the Progress Notes, dated 08/18/12 at 8:30 AM, revealed the physician was not not notified of the fall until two hours later. An interview with RN #2, on 08/24/12 at 1:05 PM, revealed the resident complained of "a little bit" of pain after being transferred from the floor to the bed. The resident's pain worsened throughout the morning; however, she was unable to describe the pain as she did not reassess the resident. She stated that the resident would repeat "my neck hurts" every time she passed him/her in the lobby area. She admitted the resident's physician was not notified until 8:30 AM, as she had other tasks to complete. She informed the physician about the resident's fall with a complaint of neck pain. An interview with Family #1 and Family #2, on 08/30/12 at 9:00 AM and 9:20 AM, respectively, revealed Family #1 received a call from RN #2 approximately two hours after the resident sustained [REDACTED]. He requested the facility send the resident to the emergency room , but RN #2 stated (at a later time) that the resident could go by family car as the physician refused to send the resident by ambulance. Family #1 and Family #2 indicated they arrived at the facility to take the resident to the emergency room at approximately 9:30 AM. Family #1 stated the resident was complaining of neck pain and "holding" his/her neck when they arrived. Family #2 verified the resident was "almost out of the wheelchair trying to hold his/her neck up." The resident continuously repeated "my neck hurts." Family #1 verified the resident "never" complained of pain prior to this incident. He stated that even if the resident was in pain, he/she usually would not complain. A review of the progress notes, dated 08/18/12 at 9:30 AM, revealed the resident was transferred by family car to the emergency room . Further interview with RN #2 revealed if the family was still concerned about the resident, they could transfer him/her to the emergency room per family car. RN #2 stated she did not ask to send the resident per ambulance at that time. An interview with the Primary Physician, on 08/30/12 at 10:20 AM, revealed he was informed the resident had rolled out of bed and "appeared fine." He did not recall hearing about the neck pain initially. He expected the staff to transmit to him what they had assessed related to an injury after a fall. A review of the Discharge Summary from the hospital, dated 08/20/12, revealed the resident sustained [REDACTED]. Further interview with RN #2 revealed she should have notified the physician immediately; however, she did not realize the seriousness of the situation. Further interview with the physician revealed the information expressed to him was not sufficiently given as a serious situation. An interview with the Director of Nursing (DON), on 08/31/12 at 1:15 PM, revealed the physician should be notified immediately (within a few minutes after the assessment ) of a possible neck injury after a fall. She expected the nurse to leave the resident in the bed as neck pain was indicative of a neck injury and should be treated as such. Resident #5 sustained a fall from the bed, on 08/18/12 at 6:30 AM. RN #2 assessed Resident #5 after the fall as having neck pain after transfer to the bed. The facility notified the physician at 8:30 AM, two hours after the fall, detailing the resident had no injury with a little pain, failing to give the physician an accurate picture of the resident's condition which prevented the physician from being able to order timely and effective treatment. These failures prevented Resident #5 from receiving timely treatment experiencing increasing pain for more than three hours without treatment, family having to transport the resident to the emergency room . The resident was admitted to the hospital with [REDACTED]. 2. Review of the facility's policy, MONITORING SYSTEMS, dated 01/2011, revealed reporting results was not addressed in the policy. Review of the facility's policy, DIAGNOSTIC SERVICES, dated 07/2007, included the following: "Labs, x-ray and other diagnostic reports are signed, dated and made part of the resident's chart. Appropriate forms are filled out and sent with the resident. when reports are received, they are filed in the resident's medical record. The attending physician is notified regarding the findings". A record review revealed the facility admitted Resident #9 on 03/01/10 with [DIAGNOSES REDACTED]. A review of the annual MDS assessment, dated 09/03/12, revealed the facility assessed Resident #9 as cognitively impaired, non-ambulatory, incontinent of bowel and bladder and required extensive assistance with activities of daily living. A review of a Progress Note, dated 05/13/12 at 3:52 PM, revealed "Faxed MD (Medical Doctor) about rales noted in lungs and coughing up thick yellow sputum this afternoon." A Progress Note, dated, 05/14/12 at 9:37 PM, revealed an order for [REDACTED]. A review of the Sputum Culture results, with a collection date of 05/17/12, revealed the culture and sensitivity results indicated Escherichia coli and Pseudomonas aeruginosa. The organisms were listed as resistant to [MEDICATION NAME], indicating a need for discontinuing the existing treatment of [REDACTED]. A review of the faxed lab report, dated 05/25/12, revealed the laboratory reported the results to the facility. The faxed laboratory report revealed RN #3 faxed the results to the medical doctor's office on 05/25/12 at 2:43 PM. The "Call Placed" section was blank. The "Orders Received" section indicated a date of 05/29/12 and was initialed by RN #3. The faxed document had a date of 05/29/12 at 1:52 PM. New orders were written on the faxed document for "[MEDICATION NAME] one gram by intramuscular injection every twenty-four hours for five doses and mix with [MEDICATION NAME]," and "Cipro 500 mg by mouth twice a day for ten days," and was signed by RN #3. A physician's orders [REDACTED]." The order was signed by RN #3. Review of a Progress Note, dated 05/25/12 at 2:03 PM revealed "BLOOD PRESSURE WARNING Value 116/80, +10% change from baseline value". A Progress Note, dated 05/27/12 at 2:16 PM revealed "BLOOD PRESSURE WARNING Value 118/56, -10% change from baseline. A Progress Note, dated 05/29/12 at 9:44 PM revealed TEMPERATURE WARNING Value 92.0 degrees. An interview with RN #3, on 09/06/12 at 2:20 PM, revealed she did not recall anything about the laboratory result, dated 05/25/12, which was faxed to the facility for Resident #9. RN #3 stated if a physician was not in the office she would call the results to the physician. Additionally, she stated, "If I called the physician I would have documented it and would have likely gotten orders if the Culture and Sensitivity result showed the current antibiotic was ineffective." An interview with the Assistant Director of Nursing (ADON), on 09/07/12 at 10:30 AM, revealed nurses were instructed upon hire to call the physician directly if the physician's office was closed. The Medical Director was to be notified if the resident's physician was not available. She stated she did not know if a call was made, but it should have been noted in the nurse's notes if the physician was called. An interview with the DON, on 09/05/12 at 10:15 AM, revealed the laboratory was always closed on the weekend and 05/25/12 was the start of a long holiday weekend. The DON revealed she would have called the physician and she gave no explanation why RN #3 did not notify the physician by phone. Additionally, the DON stated she saw laboratory results not being acknowledged timely as a problem and a potential for Resident #9 to decline. An interview with Resident #9's physician, on 09/06/12 at 2:45 PM, revealed she did not recall getting a phone call about Resident #9's culture and sensitivity results. She would have expected to be notified timely if the antibiotic the resident was on was ineffective and would have given an order for [REDACTED].

Based on interview, record review, and review of the Allegation of Compliance (AoC), it was determined the Immediate Jeopardy (IJ) identified during the survey, concluded on 09/07/12, had been removed. Findings include: Validation of the AoC revealed Re-assessment was initiated on 09/05/12 and completed 09/07/12 of residents who experienced a fall in the last 30 days. The re-assessment included documentation at the time of the fall. Three residents required physician notification of the event. Progress notes of all residents were reviewed daily to ensure an adequate assessment and follow up with the physician regarding any acute episode, including a fall. Identified concerns would be addressed immediately by the Administrative Nurse, up to and including reassessment of the resident and notification of the physician as appropriate. The results of the audits would be discussed in the daily morning meeting. A Quality Indicator (QI) tool was completed daily to review residents with changes in condition and timely notification of the physician with no concerns. As of 09/07/12, the facility had not submitted an acceptable Plan of Correction (PoC).

Based on interview, record review, and review of the facility's Resident Care Plan policy, it was determined the facility failed to ensure the comprehensive care plan was revised by a team of qualified persons for three residents (#2, #3, and #4) in the selected sample of eighteen residents. Resident #2 was placed on a low air loss/alternating pressure mattress with bilateral half side rails on 07/26/12. He sustained a fall from the mattress on 08/04/12, pinning his/her left arm in the side rail. The facility assessment of the resident included a bruise to the left wrist and upper arm with a skin tear to the left lower arm. The facility placed the resident back in the bed; however, the facility did not revise the care plan to identify the side rail entrapment or the potential risk for entrapment after the fall. The mattress was discontinued on 08/06/12; however, the facility initiated the use of the the low air loss/alternating mattress with bilateral half side rails on 08/21/12. Again, the care plan was not revised to indicate the previous entrapment or the potential risk of entrapment while utilizing the assistive devices. Resident #3 and #4 were also identified as having a low air loss/alternating mattress with bilateral half side rails. The comprehensive care plan for these residents did not identify potential risks while utilizing the assistive devices. As a result, facility staff was unaware of the risks associated with these devices to ensure appropriate supervision and monitoring was afforded these residents based on their assessed needs. The facility's failure to ensure each resident's comprehensive care plan was revised to ensure staff awareness of resident care needs that must be met has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 08/23/12 and determined to exist on 08/04/12 and Substandard Quality of Care was identified at 42 CFR 483.25 Quality of Care. The Immediate Jeopardy was determined on-going. (Refer to F323) The findings include: A review of the Resident Care Plan policy, revised 09/19/11, revealed the facility would provide an interdisciplinary written care plan based on the assessment of the resident needs. Any new problem or need of the resident which was identified between his/her scheduled care plan review would be addressed on the care plan. 1. A record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility identified the resident as severely cognitively impaired and required total assistance with bed mobility and transfers. A review of the Low Air Loss initial sheet, dated July 2012, revealed the facility began utilizing a low air loss/alternating mattress on 07/26/12. A review of the Risk for Falls care plan, initiated 11/29/11, revealed poor safety awareness/unaware of safety needs, unsteady gait, and history of falls. A review of the Risk for Skin Breakdown care plan, initiated 08/10/12, revealed a low air loss mattress (as of 08/21/12); however, there were no guidelines of appropriate settings of the mattress specific to the resident's needs. A fall investigation, on 08/04/12, revealed the resident was found sitting on the mat beside the right side of the bed. His/her arm was "pinned" in the rail of the bed. Bruising was noted to the resident's left leg and wrist, with a skin tear to the left arm. An interview with Licensed Practical Nurse (LPN) #6, on 08/26/12 at 9:00 PM, revealed she was the nurse working at the time of the fall, on 08/04/12. She revealed the resident's arm was twisted into the side rail, and the resident was holding the rail tightly. She revealed after the fall, the resident was put back into the bed on the low air loss/alternating mattress with bilateral half side rails. She indicated the DON was notified of the fall, but did not instruct her to take the resident off the mattress. She could not remember if she updated the resident's care plan to include the risk of entrapment. There was no documentation of a care plan revision to include the potential risk of entrapment or interventions implemented to reduce the risk while continuing to utilize the mattress and side rails after the fall on 08/04/12. A review of the physician's orders [REDACTED]. A review of the Risk for Falls care plan, dated 08/21/12, revealed half side rails bilaterally to define parameters in the bed. A review of the Risk for Skin Breakdown care plan, dated 08/21/12, revealed a low air loss mattress to the bed. Neither care plan addressed potential risks (including entrapment) for the use of the low air loss/alternating air mattress with bilateral half side rails. An observation of Resident #2's bed, on 08/23/12 at 9:00 AM, revealed the gap between the side rail and the bed frame measured one inch on both sides of the bed. When lying on the bed, the side of the mattress deflated slightly when close to the edge. An interview with the QI Nurse, on 08/23/12 at 11:55 AM, revealed she completed the resident's side rail and low air loss/alternating mattress assessment on 08/22/12; however, she did not update the resident's care plan to include potential safety risks of the assistive devices. Additionally, she did not ensure education of staff related to monitoring Resident #2 with these assistive devices and the potential risk of entrapment. An interview with the MDS coordinator, on 08/23/12 at 12:50 PM, revealed she was not aware of Resident #2's history of side rail entrapment, had she been aware she would have updated the care plan to include the risk. An interview with Registered Nurse (RN) #1, on 08/23/12 at 7:50 AM, revealed she was not aware of any resident's being entrapped by a side rail. She revealed Administrative Staff had never discussed the possible risks associated with side rails and the low air loss/alternating mattress. An interview with State Registered Nurse Aide (SRNA) #3, #6, and Nurse Aide (NA) #1 on 08/23/12 at 9:40 AM, 10:10 AM, and 08/24/12 at 12:05 PM, revealed they were not aware of the risks of using side rails with the low air loss/alternating mattress. An interview with the DON, on 08/23/12 at 1:55 PM, revealed she was aware of the resident's side rail entrapment after a fall on 08/04/12, and she made the decision to put Resident #2 back on the low air loss/alternating mattress with bilateral half side rails on 08/21/12. She asked staff to monitor the resident closely while on the low air loss/alternating air mattress with side rails, but should have updated the care plan to ensure staff were aware of the risks related to using the assistive devices. 2. A record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident as severely cognitively impaired and required extensive assistance of two staff for bed mobility and transfers. A review of the Skin Breakdown and Potential for Falls care plan, dated 05/01/12, revealed a low air loss mattress with padded side rail covers to half side rails; however, the care plans did not address the potential risks (including entrapment) while utilizing the assistive devices. No changes were made to Resident #3's care plan to ensure potential risks were identified while using these devices with new interventions to ensure the resident's safety. 3. A record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the quarterly MDS, dated [DATE], revealed the facility assessed the resident as cognitively intact and required limited assistance with bed mobility and transfers. A review of the Skin Breakdown and Risk for Falls care plan, dated 05/02/12, indicated a low air loss mattress for the resident, but did not address side rails for the resident. Review of the care plans revealed after the entrapment of Resident #2, there were no changes to Resident #4's care plan to ensure potential risks were identified while using these assistive devices with new interventions to ensure the resident's safety. An interview with Resident #4, on 08/23/12 at 10:25 AM, revealed if not positioned correctly, it was easy to roll off the low air loss/alternating mattress. The resident revealed he/she had learned how to position in the bed to avoid injury.

Based on interview, record review, and review of the Allegation of Compliance (AoC), it was determined the Immediate Jeopardy (IJ) identified during the survey, concluded on 09/07/12, had been removed. Findings include: Validation of the AoC revealed the Low Air Loss Mattress had been removed for Resident #2, #3, and #4. The Resident Care Guide and Care Plan reflected these changes with no concern. Validation of the AoC revealed the Low Air Loss Mattress was removed for Resident #2, #3, and #4. The Resident Care Guide and Care Plan reflected these changes. There were no residents on a Low Air Loss Mattress; however, if a resident utilized the mattress, the care plan would be updated to include instructions on the use of the mattress and checks for safety and effectiveness. All residents were re-assessed for side rail needs, requests, and safety on 08/23/12, 08/24/12, and 08/29/12. Residents identified at risk for entrapment with half side rail use had rails locked down to prevent rising. The care plan reflected these changes. An audit, using a Quality Indicator (QI) tool, would be completed weekly to ensure the care plan reflects each residents side rail usage, if applicable. As of 09/07/12, the facility had not submitted an acceptable Plan of Correction (PoC).

Based on interview and record review, it was determined the facility failed to ensure each resident received the necessary care and services to maintain the highest practicable physical, mental, and psychosocial well being for three residents (#5, #7, #11), in the selected sample of eighteen residents. The facility failed to ensure staff conducted a thorough assessment of a resident after experiencing a change in condition related to pain after a fall. Additionally, the facility failed to ensure timely notification and failed to provide an accurate assessment of the resident's condition to the physician to address the resident's continued and increased complaints of pain. On 08/18/12 at 6:30 AM, the facility found Resident #5 on the floor sustaining a fall from the bed. While the facility assessed the resident while on the floor identifying no injuries, upon transfer assistance to the bed, Resident #5 complained of neck pain. The facility did not re-assess, initiate standards of practice to stabilize the resident due to potential neck injury, and did not notify the physician of the condition change. The staff continued to dress and transfer the resident to the wheelchair and transported the resident to the dining room for breakfast. The resident continued to express increased complaints of pain to multiple staff including the facility Registered Nurse (RN). The facility failed to re-assess the resident due to increased pain. The facility did not notify the physician for approximately two hours, the facility did not detail an accurate description of the resident condition stating the resident had no injury with a little pain. The physician ordered pain medication; however, the medication was not available. The back-up pharmacy was not open. The facility's emergency drug kit contained no pain medications. The facility made no further attempts to pain medication was given to the resident timely. Additionally, the resident's family requested the facility send the resident to the emergency room . The physician indicated he was agreeable for the family to take the resident by family car; however, did not order an ambulance at the time. The resident's family arrived at the facility to find the resident with continued neck pain. The resident was transferred by family to the emergency room at approximately 9:30 AM, three hours after the fall. Resident #5 did not receive any pain medication prior to the transfer. The resident was admitted to the hospital with [REDACTED]. The physician stated the facility's assessment was not expressed as a serious situation. Additionally, the facility failed to ensure pain medication was available and administered timely to a new admission. The facility admitted Resident #7 on 07/25/12 after having back surgery. Due to the facility's failure to ensure timely receipt of medications, per their pharmacy contract, Resident #7 experienced severe intense pain per the facility's assessment, having no pain medication for 14 hours after admission. Resident #7 stated "I cried, it was terrible." Furthermore, the facility staff failed to monitor Resident #11's blood pressure when the resident's blood pressure medications were unavailable for 6 days. The facility's failure to ensure each resident received necessary care and services related to conducting a thorough assessment of a resident after complaining of neck pain and ensuring timely receipt of pain medication for a resident experiencing intense pain for fourteen hours has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 08/31/12 and determined to exist and determined to exist on 07/25/12 and Substandard Quality of Care was identified at 42 CFR 483.25 Quality of Care. The Immediate Jeopardy was determined on-going. (Refer to F157, F425). Findings include: Interview with the Director of Nursing (DON), on 08/31/12 at 1:15 PM, revealed there was no policy (or standard of practice) utilized in the facility related to assessment of a resident. 1. A record review revealed the facility admitted Resident #5 on 08/03/12 with [DIAGNOSES REDACTED]. A review of the initial Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident as severely cognitively impaired and required extensive assistance of two staff with bed mobility, transfer, and ambulation. A review of the Fall Risk assessment, dated 08/17/12, revealed a fall score of (12) which indicated he/she was at risk for falls. A review of the Pain Management Assessment, dated 08/10/12, revealed the resident had no current complaints of pain with no pain medication. A review of the physician's orders [REDACTED]. A review of the incident report, dated 08/18/12 at 6:30 AM, and an interview with State Registered Nurse Aide (SRNA) #1, on 08/24/12 at 12:20 PM, revealed she initially heard a "cry for help" while providing care for another resident. She indicated at 6:30 AM, she found Resident #5 in his/her room on the floor. The resident was found on his/her right side beside the bed, one foot straight out while the other curled up under him/her. The resident's neck was turned to the side and he/she was looking at her when she entered the room. She indicated the resident's position was "weird." She immediately informed RN #2 of the fall. An interview with RN #2, on 08/24/12 at 1:05 PM, revealed she immediately assessed the resident. She indicated the resident was on his/her back when she entered the room. SRNA #1 and SRNA #2 assisted the resident up out of the floor to the bed. Afterwards, the resident complained of neck pain. She stated the resident was able to move his/her neck in all directions. She allowed staff to get the resident up for breakfast. Interviews with SRNA #1 and SRNA #2, on 08/24/12 at 12:20 PM and 1:00 PM, respectively, revealed they transferred the resident to the bed when he/she immediately complained of neck pain, pointing to the back of the neck. The SRNAs revealed they dressed the resident and transferred him/her to the wheelchair for breakfast. SRNA #1 stated the resident continued to complain of neck pain while she was providing care. SRNA #2 stated while providing care, the resident complained of neck pain "once or twice." SRNA #1 revealed Resident #5 ate breakfast in the dining room, but continuously complained of neck pain. An interview with Nurse Aide (NA) #1, on 08/24/12 at 12:05 PM, revealed she saw the resident up in the lobby with continued complaints of neck pain. She revealed the resident's neck was "stiff" and he/she constantly repeated "my neck hurts." She made RN #2 aware of the complaints, but was unaware of what action RN #2 had taken. An interview with RN #2, on 08/24/12 at 1:05 PM, revealed the resident was up in the lobby area and ate breakfast in the dining room. The resident's pain worsened throughout the morning; however, she was unable to describe the pain as she did not reassess the resident. She stated that the resident would repeat "my neck hurts" every time she passed him/her in the lobby area. She admitted the resident's physician was not notified until 8:30 AM as she had other tasks to complete. She stated she should have notified the physician immediately; however, she did not realize the seriousness of the situation. [MEDICATION NAME] was ordered for pain, but it was not available in the facility. She instructed the physician to call the prescription into the pharmacy by 12:00 PM or it would not arrive at the facility prior to closing. She admitted no further attempts were made to ensure pain medication was received timely. She was not aware if pain medication was available in the emergency drug kit and verified she did not check the kit. She stated she could have called the physician for a non-narcotic pain medication, but she did not have time. An interview with the physician, on 08/30/12 at 10:20 AM, revealed he was informed the resident had rolled out of bed and "appeared fine." The physician revealed he did not order ambulance services for the resident because he expected staff to transmit to him what they had assessed related to injury after a fall. He revealed the information expressed to him was not sufficiently given as a serious situation. A review of the Progress Notes, dated 08/18/12 at 8:30 AM, revealed the physician was notified of the fall (two hours later). The note revealed the physician ordered pain medication, but no other orders at that time. A review of the physician's orders [REDACTED]. A review of the medication list from the Emergency Drug Kit, dated 07/03/07, revealed no pain medications (narcotic or non-narcotic) were available, if needed. An interview with Family #1 and Family #2, on 08/30/12 at 9:00 AM and 9:20 AM, respectively, revealed they arrived at the facility to take the resident to the emergency room at approximately 9:30 AM. Family #1 stated the resident was complaining of neck pain and "holding" his/her neck when they arrived. Family #2 verified the resident was "almost out of the wheelchair trying to hold his/her neck up." The resident continuously repeated "my neck hurts." Interview with RN #2, on 08/24/12 at 1:05 PM, revealed the family had requested to transfer the resident to the emergency room . Further interview with RN #2 revealed the family transferred the resident to the emergency room per family car at approximately 9:30 AM, three hours after the fall. She stated the facility had not administered any pain medications to Resident #5 prior to the transfer. A review of the "Packing List", dated 08/18/12, revealed the [MEDICATION NAME] was filled at 10:50 AM (over two hours after the order was received). A review of the Discharge Summary, dated 08/20/12, revealed the resident sustained [REDACTED]. Interview with RN #2 revealed she did not realize the seriousness of the situation. An interview with the DON, on 08/31/12 at 1:15 PM, revealed the physician should be notified immediately (within a few minutes after the assessment) of a possible neck injury after a fall. She expected the nurse to leave the resident in the bed as neck pain was indicative of a neck injury and should be treated as such. The DON provided a standard of practice for an acute illness assessment; however, it had not been utilized in the facility. She also stated that three hours was not acceptable to wait for pain medication. It typically takes at least an hour and a half to receive medications from the back-up pharmacy. She revealed RN #2 should have called the physician for a non-narcotic pain medication, such as Tylenol, and it could have been "borrowed" from another resident. She was aware the emergency drug kit had no pain medication available; however, she was unsure of the reason. 2. A record review revealed the facility admitted Resident #7 on 07/25/12 with [DIAGNOSES REDACTED]. Review of an admission assessment, dated 07/25/12 at 11:52 PM, revealed the resident had back pain, lower extremity pain that was due to recent back surgery. Pain was worse during the day and the night and interfered with Resident #7's activities of daily living. Review of the admission MDS assessment, dated 08/01/12, revealed the facility had assessed the resident with no cognitive impairment, and required extensive assistance with activities of daily living. The pain frequency was assessed as frequent pain that had made it hard to sleep at night and had limited day to day activities and was determined to be severe in intensity. Observation and interview, on 08/30/12 at 5:15 PM, revealed Resident #7 was seated on the side of his/her bed and stated he/she was admitted to the facility after having back surgery. He/she stated he/she could hardly stand at the time and had pain in his/her back and legs. The resident stated "I cried", "It was terrible". Review of Resident #7's record revealed the resident arrived at the facility on 07/25/12 at 9:00 PM. Admitting orders from the hospital included a prescription from the hospital, dated 07/25/12 and signed by the hospital physician, for [MEDICATION NAME] 10/325 milligrams (mg) every four to six hours as needed for pain. Additional medications were: [MEDICATION NAME] 300 mg twice a day (for chronic pain), [MEDICATION NAME] (for [MEDICAL CONDITION]) 50 micrograms (mcg) one a day,[MEDICATION NAME] HCL (for gastritis) 150 mg two times a day, Calcium with Vitamin D (for calcium deficiency) 600/400 mg every day, [MEDICATION NAME] HCL (antidiabetic) 1,000 mg twice a day, [MEDICATION NAME] (muscle relaxant) 10 mg three times a day, [MEDICATION NAME] (antidiabetic) 10 mg twice a day, [MEDICATION NAME] (antihypertensive) 10 mg once a day, [MEDICATION NAME] (antihypertensive) 100 mg once a day, [MEDICATION NAME] (gastritis) 10 mg twice a day, [MEDICATION NAME] (antidepressant) 20 mg once a day and [MEDICATION NAME] (antilipemic) 20 mg every day. Review of the admission Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Additionally, many of the routine medications were not administered on 07/26/12 including [MEDICATION NAME] HCL 10 mg due at 8:00 AM. All of the initials for these medications were circled indicating they were not given. The back of the MAR indicated . There was no evidence an interm care plan for pain was implemented on 07/25/12. Review of the resident's care plan for pain, dated 07/26/12, the day the medications were received, revealed interventions to include: Acknowledge presence of pain and discomfort. Listen to resident's concerns. Administer pain medication as per MD orders and note the effectiveness. Encourage resident and/or family to request pain medication before pain becomes severe. Monitor for sign/symptoms of non-verbal pain such as changes in breathing, grunting, moans, yelling out mood/behavior changes; sad expression, crying, clenched teeth, grimacing, tenseness, rigidity of body/limbs. An interview with Resident #7's roommate, on 08/30/12 at 5:15 PM, revealed he/she recalled the night Resident #7 was admitted . The roommate said "Resident #7 cried off and on all night that night because he/she was hurting and that was uncalled for". Resident #8 stated he/she has had to wait for medications in the past as well. On 09/05/12 at 1:30 PM, an interview with Licensed Practical Nurse (LPN) #5, revealed she worked the 10:00 PM to 6:00 AM shift starting on 07/25/12 and did the admission assessment on Resident #7. She revealed the resident had arrived at the facility on the 2:00 PM to 10:00 PM shift and had recent back surgery. She revealed staff had said in report that they had not received the resident's medications and they would be delivered in the morning. LPN #5 stated she had faxed the pharmacy. LPN #5 also stated she did not contact the DON or anyone about Resident #7's medications. She stated there had been a pharmacy issue lately and it was frustrating, "You call, you fax, you call, you fax." Additionally, LPN #5 stated it was her job to administer medications to residents and it "Did NOT make me feel great, I want to see them get what they need". She said the problem was obtaining medications after hours. An interview with LPN #9, on 08/31/12 at 9:00 AM, revealed she remembered Resident #7 was in a lot of pain the morning of 07/26/12 and she had reported to whoever was in charge. The Administrator, the DON and another person had gone to talk with the resident the morning of 07/26/12 and then someone went to the local pharmacy to obtain the medications. Resident #7 had arrived for admission at the facility late on 07/26/12 according to an interview with the DON conducted on 08/31/12 at 9:00 AM. On 07/26/12 when the DON arrived at the facility around 8:00 AM to 8:30 AM, staff reported Resident #7 was hurting. The DON stated she told Resident #7 she would get the medication as soon as possible and thought the Administrator had gone to the pharmacy for the medication. Nurses were to fax the out of state pharmacy and that pharmacy was to fax the local pharmacy. An interview with Resident #7's facility physician, on 09/07/12 at 9:30 AM, revealed she would expect the facility to notify her if a resident did not have pain or any other medication available. The physician did not recall if anyone from the facility had called about Resident #7 not getting his/her medications. Resident #7 stated in an interview on 08/30/12 at 5:15 that "I had to wait fourteen hours for pain medication, I cried, it was terrible". 3. A review of the facility's vital sign policy and procedure, dated 04/2007, revealed vital signs should be taken per policy and/or as needed. The purpose will be a diagnostic aid to determine any change in a resident's condition. A record review revealed the facility admitted Resident #11 on 06/15/10 with [DIAGNOSES REDACTED].#11's cognition as cognitively impaired and had a [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED].#11 [MEDICATION NAME] (anti-hypertensive) 25 milligrams (mg.) twice a day and [MEDICATION NAME]/[MEDICATION NAME] (anti-hypertensive) 20 mg. twice a day. In addition, there was an order to obtain weekly blood pressures on Mondays. A review of the August 2012 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. and [MEDICATION NAME]/[MEDICATION NAME] 20 mg. on 08/08/12 at 7:00 AM, on 08/09/12 at 7:00 AM, on 08/10/12 at 7:00 AM and 7:00 PM, on 08/11/12 at 7:00 AM and 7:00 PM, on 08/12/12 at 7:00 AM and 7:00 PM. on 08/13/12 at 7:00 AM and 7:00 PM and on 08/14/12 at 7:00 AM and 7:00 PM. In addition, the box for Monday (08/13/12) next to obtain weekly blood pressures on Mondays was blank. A review of Resident #11's vital sign summary, dated 08/08/12-08/14/12, revealed there were no blood pressures taken during this time. Interview with LPN #7, on 09/07/12 at 1:45 PM, revealed she placed her initials with a circle around them in the boxes at 7:00 AM next to the [MEDICATION NAME] and [MEDICATION NAME]/[MEDICATION NAME] orders because the medications were not available. She revealed she and another nurse faxed and called the pharmacy several times before the medications were finally delivered to the building. She stated the blood pressure should have been monitored during that time so staff would have been aware if the resident's blood pressure increased. She stated the resident had another blood pressure medication ordered that could have been given if the resident's blood pressure had increased. She couldn't explain why the blood pressure was not monitored or why the blood pressure was not taken on 08/13/12, as ordered. Interviews with LPN #1 and LPN #8, on 09/07/12 at 5:10 PM, revealed Resident #11's blood pressure should have been monitored daily while the resident was not receiving blood pressure medications. They were unable to provide an explanation as to why Resident #11's blood pressure was not monitored. Interview with LPN #12, on 09/07/12 at 2:35 PM, revealed she was not sure if it was her initials circled at 7:00 PM next to the [MEDICATION NAME] and [MEDICATION NAME]/[MEDICATION NAME]. She stated the reason it would have been circled was because the medication was not available. When asked why there were two days the medication was initialed as given she stated that some of the nurses will borrow the medication from other residents even though we're not supposed to. Interview with the DON, on 09/07/12 at 5:25 PM, revealed she would have expected the staff to call the pharmacy and make them aware they were out of the medication. She stated the staff should have monitored the resident's blood pressure daily during the time the medication was not available to ensure the resident's blood pressure did not increase.

Based on observation, interview, record review, and review of the Manufacturer's Guidelines for the low air loss/alternating mattress, it was determined the facility failed to ensure the resident environment remained as free of accident hazards as is possible for three residents (#2, #3, #4) in the selected sample of eighteen residents. The facility failed to assess residents to determine the safe use of devices (air mattress and side rails) prior to utilization. The facility failed to ensure staff was trained and knowledgeable regarding low air loss/alternating mattresses and to ensure appropriate setting for each residents assessed needs. The facility failed to identify causal factors of a fall which prevented the facility from taking the necessary action to ensure the safe use of assistive devices. On 07/26/12, the facility initiated the use of a low air loss/alternating pressure mattress with bilateral half side rails for Resident #2 related to pressure sores. The facility failed to assess for the safe use of these assistive devices. Resident #2 sustained a fall from the low air loss/alternating mattress on 08/02/12 with no injury. The facility placed the resident back in the bed; however, the facility failed to identify or determine the causal factor of the fall or complete an assessment to determine whether the continued use of the low air loss/alternating mattress with bilateral half side rails was safe for Resident #2. On 08/04/12, the resident fell out of bed pinning his/her left arm in the side rail. The facility assessed the resident as sustaining bruising to the left wrist and upper arm with a skin tear to the left lower arm The facility placed the resident back in bed; however, failed to identify or determine the causal factor of the fall or complete an assessment to determine whether the continued use of the low air loss/alternating mattress with bilateral half side rails was safe for use by Resident #2. The facility failed to revise the care plan to include a new intervention to prevent recurrence of the falls and entrapment after the fall on 08/04/12. While the mattress was discontinued on 08/06/12, the facility placed the resident back on the low air loss/alternating mattress with bilateral half side rails again on 08/21/12 at which time the facility failed to assess the resident for the safe use of the assistive devices until 08/22/12, the day after the devices were utilized for Resident #2. The facililty failed to include the history of entrapment as a risk for the resident. The facility failed to revise the care plan to ensure safety interventions were included related to the resident's continued use of the air loss/alternating mattress with bilateral half side rails. The facility failed to ensure the resident's mattress was inflated adequately to his/her weight and failed to ensure the correct spacing between the mattress and side rail were provided to prevent entrapment. The facility failed to ensure all staff was trained and knowledgeable of how to operate the low air loss/alternating mattress specific to the resident's needs and failed to ensure their knowledge of risks associated with these devices. The facility had identified two other residents (#3 and #4) utilizing a low air loss/alternating mattress with bilateral half side rails for which the facility failed to assess for the safe use of these devices and failed to ensure the inflation of the air mattress was adequate for each resident. Interview with Resident #4 revealed if not positioned correctly on the mattress, he/she would slide off easily. The facility's failure to ensure each resident was free of accident hazards has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 08/23/12 and determined to exist on 08/04/12 and Substandard Quality of Care was identified at 42 CFR 483.25 Quality of Care. The Immediate Jeopardy was determined on-going. (Refer to F280) The findings include: A review of the Manufacturer's Guidelines, undated, revealed it was recommended to use the mattress system with a bed frame and adequate side rails to prevent falling. The guidelines also revealed if the user set the comfort level less than the patient's actual weight, it may have the risk of bottoming out and developing a pressure ulcer. If set greater than the patient's weight, the patient may feel the mattress was too hard and not comfortable. There are four therapy modes (auto firm, alternate, static, and seat inflation). Please consult in your physician for a suitable setting. 1. A record review revealed the facility admitted Resident #2 on 11/28/11 with [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident as severely cognitively impaired requiring total assistance with bed mobility and transfers. A review of the Low Air Loss initial sheet for Resident #2, dated July 2012, revealed a low air loss/alternating mattress was utilized on 07/26/12. There was no documented evidence the facility completed an assessment to ensure the low air loss mattress was safe to utilize the device. An interview with the Quality Improvement (QI) Nurse, on 08/23/12 at 11:55 PM, revealed she was unaware it was her responsibility to assess resident's for the use of the low air loss/alternating mattress. An assessment was not completed prior to utilization of the low air loss/alternating mattress on 07/26/12. A review of a fall investigation, on 08/02/12, revealed the resident sustained [REDACTED]. There resident was found with his/her feet over the edge of the bed. No injury occurred as a result of the fall. Mats were placed to each side of the bed after the fall as an intervention and staff put the resident back in the bed. A Quality Improvement Fall Review was conducted on 08/03/12, indicating the resident had rolled over the side of the bed and was caught by the bedding. There was no mention of the low air loss/alternating air mattress in the review. There was no documented evidence the facility re-assessed Resident #2 for the continued use of the mattress to ensure it was safe after the fall on 08/02/12. A review of a fall investigation, on 08/04/12, revealed staff found Resident #2 sitting on the mat beside the right side of the bed. His/her left arm was "pinned" in the rail of the bed. Bruising was noted to the resident's left leg and wrist, with a skin tear to the left arm. An interview with Licensed Practical Nurse (LPN) #6, on 08/26/12 at 9:00 PM, revealed she was the nurse working at the time of the fall, on 08/04/12. She revealed the resident's arm was twisted into the side rail, and the resident was holding the rail tightly. She revealed after the fall, the resident was put back into the bed on the low air loss/alternating mattress with bilateral half side rails. She indicated the DON was notified of the fall, but did not instruct her to take the resident off the mattress. A bed alarm was put in place at that time to prevent further falls; however, there was no documented evidence the facility competed an assessment to ensure the safe use of the low air loss/alternating mattress with bilateral half side rails after the fall on 08/04/12. The Risk for Falls care plan, initiated 11/29/11, was not updated to address the resident's risk for entrapment while utilizing the assistive devices. A review of the physician's orders [REDACTED]. about the possibility of utilizing the low air loss/alternating air mattress again due to skin issues. The note indicated the risks and benefits were discussed and the family understood the increased risk of the resident rolling out of the bed. The note did not indicate the risk for entrapment while using the mattress with bilateral half side rails. A review of the Low Air Loss initial sheet for Resident #2, dated August 2012, revealed the facility utilized the mattress on 08/21/12; however, there was no documented evidence the facility conducted an assessment for Resident #2's safe use of the low air loss mattress with side rails until 08/22/12. A review of the Side Rail Assessment, dated 08/22/12 at 3:17 PM, revealed the facility recommended Resident #2's use of the bilateral half side rails. Risks for the side rails included the increased potential for injuries such as skin tears and bruising; however, the assessment did not indicate the potential for side rail entrapment or the resident's previous history of entrapment on 08/04/12. A review of the Specialty Mattress Screening Tool, dated 08/22/12, revealed the risks of utilizing the low air loss/alternating air mattress included falls, skin tears, and bruising; however, the facility's assessment did not address Resident #2's prior side rail entrapment or the risk for another entrapment. A review of the Risk for Falls care plan, dated 08/21/12, revealed the facility implemented half side rails bilaterally to define parameters in the bed for Resident #2. A review of the Risk for Skin Breakdown care plan, dated 08/21/12, revealed the facility implemented a low air loss mattress to the bed. There was no documented evidence either care plan addressed potential risks (including entrapment) for the resident's use of the low air loss/alternating air mattress with bilateral half side rails or further additional interventions implemented to prevent recurrence. Additionally, the care plans did not address guidelines to ensure staff was utilizing appropriate settings of the mattress specific for the resident. An interview with the QI Nurse, on 08/23/12 at 11:55 AM, revealed she did not complete the assessment for the side rails and mattress until 08/22/12 because she was not aware of the utilization of the assistive devices until the next day. She was aware of the resident's previous side rail entrapment and the risk for another entrapment; however, she did not indicate the information on the assessment. She did not update the resident's care plan to include potential safety risks of the assistive devices. Additionally, she did not ensure education of staff related to monitoring Resident #2 with these assistive devices and the potential risk of entrapment. An observation of Resident #2's bed, on 08/23/12 at 9:00 AM, revealed the gap between the side rail and the bed frame measured one inch on both sides of the bed. When lying on the bed, the side of the mattress deflated slightly when close to the edge. An interview with Resident #4, on 08/23/12 at 10:25 AM, revealed if he/she was "too close" to the edge of the mattress it was "as slick as a whistle" and you would fall off if not careful. The resident revealed he/she had learned how to position in the bed to avoid injury. A review of the Low Air Loss initial sheet, dated August 2012, revealed the pressure setting for Resident #2 was (110). Observations, on 08/22/12 at 10:20 AM and 11:20 AM, revealed the comfort setting at (350), therapy setting "auto firm." An interview with the DON, on 08/23/12 at 1:55 PM, revealed she was aware of the resident's side rail entrapment after a fall on 08/04/12, and she made the decision to put Resident #2 back on the low air loss/alternating mattress with bilateral half side rails on 08/21/12. She did not complete an assessment or ask the QI Nurse to document an assessment for the assistive devices until 08/22/12. Assessments were not "typically" completed to include risks versus benefits for residents on specialty mattresses. She indicated there was not a policy to do such assessments. She would have expected the QI Nurse to indicate a risk of side rail entrapment on the assessments. She asked staff to monitor the resident closely while on the low air loss/alternating air mattress with side rails, but should have updated the care plan to ensure staff was aware of the risks related to using the assistive devices. An interview with Registered Nurse (RN) #1, on 08/23/12 at 7:50 AM, revealed she was not aware of any residents being entrapped by a side rail. She revealed Administrative Staff had never discussed the possible risks associated with side rails and the low air loss/alternating mattress. An interview with State Registered Nurse Aide (SRNA) #3, #6, and Nurse Aide (NA) #1 on 08/23/12 at 9:40 AM, 10:10 AM, and 08/24/12 at 12:05 PM, revealed they were not aware of the risks of using side rails with the low air loss/alternating mattress. 2. A record review revealed the facility admitted Resident #3 on 06/06/11 with [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident as severely cognitively impaired and required extensive assistance of two staff for bed mobility and transfers. An interview with the DON, on 08/23/12 at 9:55 AM, revealed through record review the resident had been placed on a low air loss/alternating mattress with side rails since 06/14/11; however, the facility had not assessed the resident for the safe use of the low air loss mattress. A review of the Low Air Loss initial sheet for Resident #3, dated August 2012, revealed the pressure setting for Resident #3 was (200). Observations, on 08/21/12 at 9:45 AM, 10:35 AM, 1:55 PM, and 08/22/12 at 10:15 AM, revealed the comfort setting at (350), therapy setting at "seat inflation" or "alternate." A review of the Risk for Skin Breakdown care plan, initiated 05/01/12, revealed the facility utilized a low air loss mattress for the resident; however, there were no guidelines to ensure staff was utilizing the appropriate settings. 3. A record review revealed the facility admitted Resident #4 on 01/27/12 with [DIAGNOSES REDACTED]. A review of the quarterly MDS, dated [DATE], revealed the facility assessed the resident as cognitively intact and required limited assistance with bed mobility and transfers. An interview with the DON, on 08/23/12 at 9:55 AM, revealed through record review the resident had been placed on a low air loss/alternating mattress with side rails on 02/02/12; however, the facility had not assessed the resident for the safe use of the low air loss mattress. A review of the Low Air Loss initial sheet, dated August 2012, revealed the pressure setting for Resident #4 was (200). Observations, on 08/23/12 at 7:00 AM, revealed the comfort setting at (140), therapy setting "alternate."A review of the Risk for Skin Breakdown care plan, initiated 05/02/12, revealed the facility utilized a low air loss mattress for the resident; however, there were no guidelines to ensure staff was utilizing the appropriate settings. Interviews with LPN #1, #2, #3, and RN #1 on 08/22/12 at 6:20 PM, 6:25 PM, and 08/23/12 at 7:20 AM and 7:50 AM, respectively, revealed they had received no training over the operation of the low air loss/alternating air mattresses. LPN #1 and RN #1 verified they were not aware of the Low Air Loss initial sheet to check the mattress every shift. An interview with LPN #4, on 08/23/12 at 7:00 AM, revealed she checked the mattress settings during the day shift, as she was the treatment nurse most days. The comfort setting of the bed depended on how much the resident weighed. The Low Air Loss initial sheet indicated the comfort setting for the resident, and was supposed to be checked each shift and documented as correct. She always set the mattresses to "alternate," so the resident's weight would be shifted while on the mattress. Interviews with the DON, on 08/22/12 at 4:20 PM and 08/23/12 at 1:55 PM, revealed the treatment nurse or the licensed nurse was supposed to check the low air loss/alternating mattress every shift to ensure it was inflated, there was good positioning of the resident, and the settings were correct. She revealed the comfort setting was set by the resident's weight. She preferred staff to keep the therapy setting on "auto firm"; however, she was unable to verify how this was determined. She was unable to provide documentation of staff education related to the operation of the low air loss/alternating mattress.

Based on interview, record review, and Allegation of Compliance (AoC) review, it was determined the Immediate Jeopardy (IJ) identified during the survey, concluded on [DATE], had been removed. Findings include: Validation of the AoC revealed all residents were re-assessed for side rail needs and requests on [DATE], [DATE], and [DATE]. Residents identified for the risk of entrapment with half side rails in use were locked down to prevent raising the rails. Nursing staff were inserviced on [DATE] on side rail entrapment, risks of injury or even death due to entrapment, type of residents at higher risk, potential areas where entrapment was possible, what to do if there was a matter of safety regarding a bed, and what to do if a resident was entrapped. An inservice for nursing staff was initiated on [DATE] on the use of the Low Air Loss Mattress, control panels, settings, how to check for comfort and effectiveness of the mattress, and the CPR valve. A Specialty Mattress Screening Tool would be completed to determine if benefits outweigh the risks of using a specialty mattress. Resident #2, #3, and #4 were assessed for the Low Air Loss Mattress and determined the risks outweighed the benefits. There were no residents currently utilizing the Low Air Loss Mattress. A Quality Indicator (QI) tool was completed weekly to ensure daily observation checks that side rail assessments were current, corrections were noted and corrections were noted. Findings would be reviewed weekly by the Administrator and DON. As of [DATE], the facility had not submitted an acceptable Plan of Correction (PoC).

Based on observation, interview, record review, and review of the facility's policy/procedure, it was determined the facility failed to ensure a resident having pressure sores received necessary treatment and services to promote healing, prevent infection, and prevent new sores from developing for one resident (#2) in the sample selection of eighteen residents. The facility failed to ensure physician notification policies were followed related to a Resident's worsening pressure sore. The facility failed to ensure staff was knowledgeable of how to use the low air loss/alternating mattress and to ensure settings were maintained specific to a resident's assessed need. Resident #2 acquired a pressure sore to the left trochanter (hip) identified 08/16/12. The facility assessed the pressure sore again on 08/20/12 and 08/22/12. Observations and staff interviews identified that the facility was not maintaining the settings of the low air loss/alternating mattress as required for Resident #2. Changes in the wound were identified in color and stage with an increase in the resident's pain; however, the facility failed to notify the physician for a treatment change to promote healing. Findings include: A review of the Notification of Physician for Change in Resident's Condition policy, dated 04/2007, revealed staff was to notify the physician when a significant change in a resident's condition occurred with documentation. A record review revealed the facility admitted Resident #2 on 11/28/11 with [DIAGNOSES REDACTED]. The Norton Scale for Predicting Pressure Ulcers, dated 11/29/11, revealed the facility assessed the resident at high risk for pressure sores. A review of the initial Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident as having no pressure sores upon admission. A review of the quarterly MDS, dated [DATE], revealed the facility identified the resident as severely cognitively impaired and required total assistance of two staff with bed mobility, hygiene, and bathing. A review of the Skin Breakdown care plan, initiated 08/10/12, revealed the resident was at risk for pressure sores related to a history of skin breakdown, incontinence, and total care for all activities of daily living. A review of the Wound/Ulcer Flow Sheet, dated 08/16/12, revealed the facility identified a pressure sore (suspected deep tissue injury) to the resident's left trochanter (hip) measuring 2 centimeters (cm) in length by 4.5 cm width. Further review of the flow sheet indicated the definition of a suspected deep tissue injury as: "purple or maroon localized area or discoloration intact skin or blood-filled blister due to damage of underlying soft tissue that was painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue." There was no signs or symptoms of infection and no pain. The facility notified the physician of the suspected deep tissue injury with a new order for treatment. A review of the Physician Orders, dated 08/16/12, revealed staff was to cleanse the left hip with a cleanser and apply a foam dressing. Change the dressing daily and as needed. A review of the Wound/Ulcer Flow Sheet, dated 08/20/12, revealed the facility assessed the left hip pressure sore as a Stage II measuring 3 cm in length by 4 cm width, depth superficial. The definition of a Stage II pressure area was as follows: "Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister." The facility assessed the area as having no signs or symptoms of infection, red in color with blanchable redness around the wound, with no odor or drainage. The wound had no necrosis (dead tissue) and pain was noted with turning the resident. There was no documented evidence the physician was made aware of the wound changes. A review of the Progress Notes, dated 08/20/12 at 7:27 PM, revealed the Director of Nursing (DON) discussed benefits of a low air loss/alternating mattress with the resident's family. A review of the Skin Breakdown care plan, initiated 08/10/12, revealed a low air loss mattress was initiated 08/21/12. A review of the Manufacturer's Guidelines, undated, revealed if the user set the comfort level less than the patient's actual weight, it may have the risk of bottoming out and developing a pressure ulcer. If set greater than the patient's weight, the patient may feel the mattress was too hard and not comfortable. There are four therapy modes (auto firm, alternate, static, and seat inflation). Please consult with your physician for a suitable setting. A review of the Low Air Loss initial sheet, dated August 2012, revealed the pressure setting for Resident #2 was (110). Observations, on 08/22/12 at 10:20 AM and 11:20 AM, revealed the comfort setting at (350), therapy setting "auto firm." Interviews with LPN #1, #2, #3, and RN #1 on 08/22/12 at 6:20 PM, 6:25 PM, and 08/23/12 at 7:20 AM and 7:50 AM, respectively, revealed they had received no training over the operation of the low air loss/alternating air mattresses. An interview with LPN #4, on 08/23/12 at 7:00 AM, revealed she checked the mattress settings during the day shift, as she was the treatment nurse most days. She always set the mattresses to "alternate," so the resident's weight would be shifted while on the mattress. Interviews with the DON, on 08/22/12 at 4:20 PM and 08/23/12 at 1:55 PM, revealed the comfort setting was set by the resident's weight. She preferred staff to keep the therapy setting on "auto firm"; however, she was unable to verify how this was determined. She was unable to provide documentation of staff education related to the operation of the low air loss/alternating mattress. An observation of wound care, on 08/22/12 at 11:10 AM, revealed an open area to the resident's left hip covered completely with a brown substance. The area around the wound was dark red in color. The resident appeared in pain during the treatment, wincing and moaning when the wound was touched. Licensed Practical Nurse (LPN) #4 performed the wound care and described the wound as an unstageable pressure sore measuring 2 cm in length by 4 cm width. The sore was covered with brown slough and the area was dark red around the perimeter of the wound. She indicated the resident received a "pain pill" prior to the anticipated wound treatment. The definition of an unstageable pressure sore, according to the Wound/Ulcer Flow Sheet, revealed the following: "Full thickness tissue loss in which the base of the ulcer was covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the would bed. An interview with LPN #4, on 08/22/12 at 2:00 PM, revealed she assessed the resident as having a suspected deep tissue injury to the left hip on 08/16/12. When assessed on 08/20/12, the wound bed was visible; therefore, it was considered a Stage II. During today's assessment (08/22/12), it had obviously changed as it was now unstageable. She stated it was typical to keep a treatment in place for two weeks before notifying the physician of the wound decline. She did not notify the physician of the wound changes on 08/20/12 or 08/22/12. An interview with the DON, on 08/22/12 at 5:00 PM, revealed she would expect the nurse to notify the physician when a pressure sore showed signs of decline, as soon as it was noticed. An interview with the Advanced Practitioner Registered Nurse (APRN), on 08/22/12 at 3:15 PM and 3:25 PM, revealed she was not aware of a decline in Resident #2's pressure sore. She visualized the wound (after interview with surveyor at 3:15 PM). She indicated a treatment change was necessary and she would have expected staff to notify her of the changes in the resident's wound. However, review of the Allegation of Compliance submitted by the facility on 08/25/12 revealed the facility discontinued the use of the low air loss/alternating mattress utilized to prevent worsening of the resident's wounds on 08/23/12 and a winged pressure redistribution foam mattress was added for safety and pressure reduction despite identification that Resident #2's wound had worsened on 08/22/12.

Based on observation, interview, record review, and review of the facility's policy/procedure, it was determined the facility failed to ensure a resident having pressure sores received necessary treatment and services to promote healing, prevent infection, and prevent new sores from developing for one resident (#2) in the sample selection of eighteen residents. The facility failed to ensure physician notification policies were followed related to a Resident's worsening pressure sore. The facility failed to ensure staff was knowledgeable of how to use the low air loss/alternating mattress and to ensure settings were maintained specific to a resident's assessed need. Resident #2 acquired a pressure sore to the left trochanter (hip) identified 08/16/12. The facility assessed the pressure sore again on 08/20/12 and 08/22/12. Observations and staff interviews identified that the facility was not maintaining the settings of the low air loss/alternating mattress as required for Resident #2. Changes in the wound were identified in color and stage with an increase in the resident's pain; however, the facility failed to notify the physician for a treatment change to promote healing. Findings include: A review of the Notification of Physician for Change in Resident's Condition policy, dated 04/2007, revealed staff was to notify the physician when a significant change in a resident's condition occurred with documentation. A record review revealed the facility admitted Resident #2 on 11/28/11 with [DIAGNOSES REDACTED]. The Norton Scale for Predicting Pressure Ulcers, dated 11/29/11, revealed the facility assessed the resident at high risk for pressure sores. A review of the initial Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident as having no pressure sores upon admission. A review of the quarterly MDS, dated [DATE], revealed the facility identified the resident as severely cognitively impaired and required total assistance of two staff with bed mobility, hygiene, and bathing. A review of the Skin Breakdown care plan, initiated 08/10/12, revealed the resident was at risk for pressure sores related to a history of skin breakdown, incontinence, and total care for all activities of daily living. A review of the Wound/Ulcer Flow Sheet, dated 08/16/12, revealed the facility identified a pressure sore (suspected deep tissue injury) to the resident's left trochanter (hip) measuring 2 centimeters (cm) in length by 4.5 cm width. Further review of the flow sheet indicated the definition of a suspected deep tissue injury as: "purple or maroon localized area or discoloration intact skin or blood-filled blister due to damage of underlying soft tissue that was painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue." There was no signs or symptoms of infection and no pain. The facility notified the physician of the suspected deep tissue injury with a new order for treatment. A review of the Physician Orders, dated 08/16/12, revealed staff was to cleanse the left hip with a cleanser and apply a foam dressing. Change the dressing daily and as needed. A review of the Wound/Ulcer Flow Sheet, dated 08/20/12, revealed the facility assessed the left hip pressure sore as a Stage II measuring 3 cm in length by 4 cm width, depth superficial. The definition of a Stage II pressure area was as follows: "Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister." The facility assessed the area as having no signs or symptoms of infection, red in color with blanchable redness around the wound, with no odor or drainage. The wound had no necrosis (dead tissue) and pain was noted with turning the resident. There was no documented evidence the physician was made aware of the wound changes. A review of the Progress Notes, dated 08/20/12 at 7:27 PM, revealed the Director of Nursing (DON) discussed benefits of a low air loss/alternating mattress with the resident's family. A review of the Skin Breakdown care plan, initiated 08/10/12, revealed a low air loss mattress was initiated 08/21/12. A review of the Manufacturer's Guidelines, undated, revealed if the user set the comfort level less than the patient's actual weight, it may have the risk of bottoming out and developing a pressure ulcer. If set greater than the patient's weight, the patient may feel the mattress was too hard and not comfortable. There are four therapy modes (auto firm, alternate, static, and seat inflation). Please consult with your physician for a suitable setting. A review of the Low Air Loss initial sheet, dated August 2012, revealed the pressure setting for Resident #2 was (110). Observations, on 08/22/12 at 10:20 AM and 11:20 AM, revealed the comfort setting at (350), therapy setting "auto firm." Interviews with LPN #1, #2, #3, and RN #1 on 08/22/12 at 6:20 PM, 6:25 PM, and 08/23/12 at 7:20 AM and 7:50 AM, respectively, revealed they had received no training over the operation of the low air loss/alternating air mattresses. An interview with LPN #4, on 08/23/12 at 7:00 AM, revealed she checked the mattress settings during the day shift, as she was the treatment nurse most days. She always set the mattresses to "alternate," so the resident's weight would be shifted while on the mattress. Interviews with the DON, on 08/22/12 at 4:20 PM and 08/23/12 at 1:55 PM, revealed the comfort setting was set by the resident's weight. She preferred staff to keep the therapy setting on "auto firm"; however, she was unable to verify how this was determined. She was unable to provide documentation of staff education related to the operation of the low air loss/alternating mattress. An observation of wound care, on 08/22/12 at 11:10 AM, revealed an open area to the resident's left hip covered completely with a brown substance. The area around the wound was dark red in color. The resident appeared in pain during the treatment, wincing and moaning when the wound was touched. Licensed Practical Nurse (LPN) #4 performed the wound care and described the wound as an unstageable pressure sore measuring 2 cm in length by 4 cm width. The sore was covered with brown slough and the area was dark red around the perimeter of the wound. She indicated the resident received a "pain pill" prior to the anticipated wound treatment. The definition of an unstageable pressure sore, according to the Wound/Ulcer Flow Sheet, revealed the following: "Full thickness tissue loss in which the base of the ulcer was covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the would bed. An interview with LPN #4, on 08/22/12 at 2:00 PM, revealed she assessed the resident as having a suspected deep tissue injury to the left hip on 08/16/12. When assessed on 08/20/12, the wound bed was visible; therefore, it was considered a Stage II. During today's assessment (08/22/12), it had obviously changed as it was now unstageable. She stated it was typical to keep a treatment in place for two weeks before notifying the physician of the wound decline. She did not notify the physician of the wound changes on 08/20/12 or 08/22/12. An interview with the DON, on 08/22/12 at 5:00 PM, revealed she would expect the nurse to notify the physician when a pressure sore showed signs of decline, as soon as it was noticed. An interview with the Advanced Practitioner Registered Nurse (APRN), on 08/22/12 at 3:15 PM and 3:25 PM, revealed she was not aware of a decline in Resident #2's pressure sore. She visualized the wound (after interview with surveyor at 3:15 PM). She indicated a treatment change was necessary and she would have expected staff to notify her of the changes in the resident's wound. However, review of the Allegation of Compliance submitted by the facility on 08/25/12 revealed the facility discontinued the use of the low air loss/alternating mattress utilized to prevent worsening of the resident's wounds on 08/23/12 and a winged pressure redistribution foam mattress was added for safety and pressure reduction despite identification that Resident #2's wound had worsened on 08/22/12.