Every finding on record at Loretto Living Center at Loretto Motherhouse, Inc.

Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to follow Physician's orders for self-administration of medications for one (1) of six (6) sampled residents observed for medication administration, Resident #2. The findings include: Review of the facility's policy titled, Administration of Medication dated 02/01/2007, revealed its purpose as preparing and administering all medication to residents, accurately and effectively according to Physician's orders. Further review of the policy revealed staff administering medications were to never leave medication in a resident's room, unless an order to do so is on the chart. Review of Resident #2's medical record revealed the facility admitted Resident #2 on 10/23/2018, with diagnoses which included Hypertension (high blood pressure), Acute Pain due to Trauma, Anemia, and Chronic Fatigue. Review of Resident #2's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated he/she was cognitively intact. Review of Resident #2's Physician's Order Sheet and Progress Notes, dated 06/08/2022, revealed Resident #2's was noted to have an inability to make decisions on his/her own. Continued review revealed a recommendation for nursing staff to administer Resident #2's medications due to the resident's confusion with his/her medications. Review of Resident #2's Nurse's Note, dated 06/08/2022, revealed a new order to discontinue the resident's ability for self-administration of medications. Continued review revealed staff talked with Resident #2's power of attorney (POA) about the resident's inability for decision making. Observation and interview on 08/09/2022 at 10:00 AM, revealed Resident #2 sitting up in a recliner, finishing his/her breakfast, with two (2) white pills in a medication cup on the bedside table. Continued observation revealed Resident #2 was alone in his/her room. Interview with Resident #2 revealed he/she wanted to finish breakfast, and then would take the two (2) pills in the medication cup. Further interview revealed Resident #2 stated he/she thought the two (2) pills were vitamins. Review of Resident #2's August 2022 Medication Administration Record (MAR) revealed medications ordered at 9:00 AM included: Cymbalta 20 milligrams (mg) one (1) tablet every day (QD) started on 10/23/2018 (an anti-depressant); Benicar 40 mg QD started on 10/23/2018 (for high blood pressure); Osteobiflex one (1) tablet QD started on 10/23/2018 (a supplement); Imdur 30 mg half a tablet started on 09/11/2019 (an anti-anginal); Vitamin D 2,000 units QD started on 01/08/2020 (a supplement); Cranberry Extra CP 250 mg two (2) tablets QD started on 01/04/2022 (a supplement); Prilosec 20 mg QD started on 04/13/2022 (gastric acid reducer); Tylenol Arthritis Extended Release (ER) one (1) tablet three (3) times per day (TID) started on 09/30/2021 (pain reliever); Ditropan 5 mg tablet two (2) times per day (BID) started on 04/15/2020 (smooth muscle relaxant); Colace 100 mg BID started on 04/13/2022 (laxative); Ferrous Sulfate 325 mg BID started on 04/13/2022 (supplement); Norvasc 10 mg tablet QD started on 10/14/19 (for high blood pressure); and Coreg 12.5 mg BID started on 12/11/2019 (for high blood pressure). Continued review revealed Licensed Practical Nurse (LPN) #1 signed off as administering Resident #2's 9:00 AM medications on 08/09/2022. Interview on 08/10/2022 at 9:55 AM with LPN #1 revealed Resident #2 self-administered his/her medications previously; however, recently lost the ability to self-administer due to not taking his/her medications in a timely manner. LPN #1 further stated Resident #2 was still capable of self-administering medications, but sometimes waited too long to take the medications. Per the interview, LPN #1 stated there was no good reason she left the medications in Resident #2's room on 08/09/2022. Interview on 08/10/2022 at 3:10 PM, with the Director of Nursing (DON) revealed Resident #2 started self-administering his/her medications in April 2022. The DON further stated however, the Physician discontinued the order for Resident #2 to self-administer medications in June 2022 because Resident #2 had no longer been safe to self-administer his/her medications. A follow-up interview on 08/11/2022 at 9:00 AM, with LPN #1 revealed Resident #2 was no longer able to self-administer his/her medications, and medications should not be left in the resident's room. LPN #1 stated there was no reason for why she left the medications in Resident #2's room on 08/09/2022. LPN #1 stated staff administering medications should stand and observe a resident take their medications, but Resident #2 did not like staff standing there during medication administration. Interview on 08/11/2022 at 9:23 AM, with Resident #2's Physician revealed she discontinued Resident #2's order for self-administration in June 2022. According to the Physician, on 06/08/2022, she was rounding with the DON and found three (3) medication cups with pills in them in Resident #2's room. The Physician stated she was concerned that Resident #2 did not take all his/her medications when self-administering them, and so had discontinued the self-administration order for safety reasons. The Physician further stated nursing staff should administer all of Resident #2's medications as per the order. A follow-up interview on 08/11/2022 at 9:45 AM, with the DON revealed staff should not leave residents' medications in their rooms unless the resident had a current order for self-administration. The DON stated Resident #2's self-administration medication order was discontinued in June 2022 for safety reasons, and it was clear the resident had not been taking all his/her medications as ordered. Further interview revealed there was no known outcome from Resident #2 not taking his/her medications in a timely manner; however, it was important for nursing staff to ensure all medications were administered as ordered. Interview on 08/11/2022 at 10:03 AM, with the Administrator revealed she expected nursing staff to not leave medications in a resident's room. The Administrator stated when the Physician found the pills in Resident #2's room, she discontinued the resident's self-administration order. Further interview revealed it was important for nursing staff to ensure residents took their medications as ordered for the residents' safety.

Based on interviews record review, and review of facility policy, it was determined the facility failed to ensure residents were free from significant medication errors for one (1) of forty-one (41) sampled residents, Resident #11. On 04/14/2022, Resident #11 was administered three (3) medications ordered for another resident. The facility transferred Resident #11 to the local hospital's emergency room (ER) when the resident experienced symptoms of a decrease in his/her blood pressure reading. The findings include: Review of the facility's policy titled, Administration of Medication effective 02/01/2007, revealed its purpose was, To prepare and administer all medication to residents accurately and effectively according to Physician's orders. Continued review revealed under General instructions staff were to give their undivided attention to the job when preparing and administering residents' medications. Review further revealed staff were to observe the five (5) rights in giving medications which were: right resident; right time; right medication; right dosage; and right method of administration. In addition, policy review further revealed staff administering medications were to properly identify the resident. Review of Resident #11's medical record revealed the facility admitted the resident on 02/22/2022, with diagnoses which included Iron Deficiency Anemia Secondary to Blood Loss, Activated Protein C Resistance, and Pulmonary Embolism. Review of the Quarterly Minimum Data Set (MDS) Assessment for Resident #11 dated 05/18/2022, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of nine (9) out of fifteen (15), which indicated moderate cognitive impairment. Review of Resident #11's April 2022 Medication Administration Record (MAR) revealed on 04/14/2022, three (3) medications ordered for the resident to be administered at 8:00 PM, were not administered as the resident was given the wrong medications. The medications included Aricept (used to treat dementia) 5 milligram (mg) 1 tablet, Protonix (used to treat erosive esophagitis) 40 mg 1 tablet, and Colace (as stool softener) 100 mg 1 daily. Review of Resident #11's Nurse's Note dated 04/16/2022, revealed it was a late entry medication error note. Per review, on 04/14/2022, Resident #11 received the wrong medications at 8:30 PM, which were Coreg (a medication used to treat high blood pressure and heart failure) 12.5 milligram (mg), Lipitor (cholesterol medication) 40 mg, and Nexium (a gastroesophageal reflux disease [GERD] medication) 40 mg were given in error. Continued review revealed the Physician was notified at 9:08 PM on 4/14/2022, and orders were received to monitor Resident #11's blood pressure and pulse. Review revealed at 9:00 PM, Resident #11's blood pressure was 100/57 and at 10:20 PM it was 94/57 with a pulse rate of eighty-seven (87). Further review revealed the Physician was notified of Resident #11's blood pressure readings and orders were received to send Resident #11 to the ER. Review of the facility's Vital Signs, Pain, Weight, and Oxygen Saturation Flow Sheet for Resident #11 revealed the resident's blood pressure reading on 04/14/2022 at 9:00 PM was 100/57 and on 04/14/2022 at 10:25 PM blood pressure was 94/57. Review of Resident #11's Comprehensive Care Plan revealed the self-care deficit care plan noted on 04/14/2022, the resident received the wrong medication, was sent to the ER due to a low blood pressure, and returned back to the facility after receiving fluids. Review of Resident #11's Nurse's Note dated 04/14/2022 at 11:10 PM, revealed a report was called to a nurse at the local hospital's ER regarding the resident. Review of Resident #11's Nurse's Note dated 04/14/2022 at 11:40 PM, revealed the ambulance arrived at the facility to transport Resident #11 to the ER related to decreased blood pressure. Further review revealed Resident #11 did not appear to be in acute distress. Review of the emergency room Report revealed on 04/15/2022, Resident #11 presented to the ER with low blood pressure due to receiving the wrong medication. Per review of the Report, Resident #11 was accidentally given Coreg 12.5 mg at 8:30 PM. Continued review revealed Resident #11 received 500 milliliters (ml) of normal saline administered by Emergency Medical Services (EMS). Further review revealed Resident #11's vital signs at 12:15 AM were: blood pressure 112/48 and pulse seventy-four (74); and at 12:49 AM, blood pressure was 119/60 and pulse was seventy-two (72). Interview on 08/09/2022 at 10:15 AM, with Resident #11 revealed the resident recalled being awakened during the night by the charge nurse and sent to the hospital due to receiving the wrong medications. Resident #11 reported not having felt sick and did not think going to the hospital had been necessary; however, knew the facility staff wanted to be certain no adverse event would occur to him/her. Interview on 08/10/2022 at 3:09 PM, with Kentucky Medication Aide (KMA) #1 revealed on the evening the medication error occurred the facility had been having a dinner. Per KMA #1, the residents had expressed wanting to receive their medications as soon as the dinner was over. KMA #1 stated this caused a change in the routine from the normal order the medications were given in. Continued interview revealed Resident #11 and another resident were coming down the hall after the dinner, and so the KMA prepared both residents' medications. Further interview revealed the KMA mistakenly gave Resident #11 the other resident's medications. KMA #1 further stated as soon as she was aware a medication error had occurred, she notified the nurse in charge. Interview on 08/10/2022 at 3:10 PM, with Registered Nurse (RN) #1 revealed he was notified by KMA #1 when the KMA realized a medication error had occurred. Per RN #1, he contacted the Physician immediately, and as one (1) of the medications Resident #11 received had been a blood pressure medication, the Physician ordered staff to monitor the resident's heart rate and blood pressure. RN #1 stated when Resident #11 had a slight drop in his/her blood pressure, he called the Physician again and received an order to send Resident #11 to the ER for fluids and monitoring. According to RN #1, Resident #11 had felt fine prior to being sent out to the ER. RN #1 further revealed after intravenous (IV) fluids were administered in the ER, Resident #11 returned to the facility and did not experience any significant problems. Interview on 08/10/2022 at 3:47 PM, with the facility's Consultant Pharmacist revealed pharmacy visits occurred monthly and medication administration observations were conducted during the monthly visits as needed. The Pharmacist stated the Director of Nursing (DON) was notified if a medication error was identified during the visits. Continued interview revealed the Pharmacist did not recall the medication error that occurred involving Resident #11. He further revealed Resident #11's response to receiving the wrong medication, specifically a blood pressure medication, would depend on the resident's age, weight, and other health conditions. Continued interview revealed the resident's blood pressure would have improved without medical intervention when receiving a low dose of blood pressure medication. Interview on 08/11/2022 at 9:30 AM, with the Director of Nursing (DON) revealed she had been on vacation during the time the medication error involving Resident #11 occurred; however, was informed of the error. The DON revealed she expected her staff to follow the proper procedures for medication administration, and follow the five (5) rights of administration. Interview on 08/11/2022 at 9:36 AM, with the Administrator revealed it was expected employees administering medications follow the five (5) rights of administration. The Administrator further stated it was also expected the employees perform the medication pass correctly, and report any errors immediately.

Based on observation, interview, record review, and review of facility policy, it was determined that the facility failed to ensure the medication error rate was less than five (5) percent. Observation of medication administration on 05/16/19 revealed thirty-two (32) medication opportunities were observed with two (2) errors, resulting in a medication error rate of 6.25 percent. The findings include: Review of the facility policy, Administration of Medication, dated 02/01/17, revealed residents would be administered medications accurately and effectively according to physician's orders. Review of Resident #41's physician orders dated (MONTH) 2019 revealed staff were to obtain the resident's blood pressure and pulse prior to administration of the medications Carvedilol and [MEDICATION NAME] (medications utilized to treat hypertension). Further review of the physician orders revealed if the resident's blood pressure and pulse were outside of parameters established by the physician, the medication was to be held and not administered to the resident. However, observation during the medication administration for Resident #41 on 05/15/19 at 8:45 AM, revealed the Medication Aide failed to obtain the resident's blood pressure and pulse until the medications Carvedilol and [MEDICATION NAME] had already been administered to the resident. Interview with the KMA on 05/16/19 at 9:23 AM, revealed she had mistakenly administered Resident #41 the medication prior to obtaining the resident's blood pressure and pulse as ordered. She further stated the blood pressure and pulse should have been obtained prior to administering the Carvedilol and [MEDICATION NAME] to determine if the medication should be held. Interview with the Assistant Director of Nursing on 05/16/19 at 11:40 AM, revealed she conducted competency evaluations for staff administering medications annually and stated there had been no concerns related to the KMA's previous competency evaluations. Interview with the Director of Nursing on 05/16/19 at 11:37 AM, revealed it was the expectation of the facility that staff administering medications would read the physician's order prior to administering medication and follow those orders.

Based on observation, interview, record review, and review of the facility's policy and procedures, it was determined the facility failed to ensure an infection control program was established and maintained to provide a sanitary environment and help prevent the development and transmission of disease and infection for two (2) of fifteen (15) sampled residents (Residents #6 and #10) and one (1) unsampled resident (Resident A). Observation during incontinence care revealed State Registered Nurse Aide (SRNA) #2 failed to properly handle soiled linen to prevent the development and transmission of infection for Resident #6. In addition, observation during medication pass revealed staff dropped a medication on the medication cart and administered the medication to Resident #10. Observations of the lunch meal service on 12/07/16 revealed staff touched Resident A's bread with bare hands and served the bread to the resident. The findings include: Review of the facility policy titled, Infection Control Policy, not dated, revealed the facility would maintain an infection control program to provide a safe, sanitary, and comfortable environment. Additionally, the policy stated linens would be properly handled, stored, processed, and transported to prevent the spread of infection. Review of the facility policy titled, Standard Precautions not dated, revealed all resident care equipment soiled with blood, body fluids, secretions, and excretions would be handled in a manner that prevented skin and mucous membrane exposure, contamination of clothing, and transfer of other microorganisms to other residents and environment. Review of the facility policy titled, Handling of Linen, not dated, revealed all staff members would follow Standard Precautions in the handling of clean and soiled linens to prevent the spread of infection. Further review of the policy revealed soiled linen would be immediately bagged at the location it was used. The policy stated soiled linen would never be placed on the floor without first being bagged. Additional review of the policy revealed soiled linen would not be sorted or rinsed in the resident care area and heavily soiled linen would be rinsed out in the hopper/soiled utility room and the staff would wear personal protective equipment such as gowns, gloves, and goggles. 1. Record review revealed the facility admitted Resident #6 on 01/27/09, with [DIAGNOSES REDACTED]. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #6's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of zero (0) indicating Resident #6 was not interviewable. Additional review of the MDS revealed the facility had assessed Resident #6 to be frequently incontinent of his/her bowels and to require total assistance with toileting. Observation during incontinence care for Resident #6 on 12/06/16 at 4:33 PM, revealed SRNA #3 removed the resident's underpad and non-slip pad which was soiled with feces. SRNA #3 was then observed to place the soiled underpad and soiled non-slip pad directly on the floor. Additional observation revealed SRNA #3 carried the soiled underpad to Resident #6's bathroom and dipped the underpad in and out of the toilet water to rinse the fecal matter from the linen. Further review revealed a brown substance was noted on the toilet seat. Interview with SRNA #3 on 12/08/16 at 4:38 PM, revealed she was trained by the facility to rinse the soiled linens in the resident's toilet. SRNA #3 stated she did not know the facility's policy stated not to clean the linens in the resident's care area and stated she was not aware the policy and procedure directed her to use the hopper in the soiled utility room and to wear personal protective equipment. SRNA #3 stated she knew she should have not placed the soiled non-slip pad or the underpad which was soiled with feces directly on the floor. SRNA #3 stated she should have placed the items in a bag until they could be cleaned and stated she did not have a bag handy and did not know what else to do. SRNA #3 stated she realized this was not good practice and stated the practice increased the risk for spreading infection. Interview with the Director of Nursing (DON) on 12/08/16 at 4:20 PM revealed she expected all staff to provide care per the facility's policy and procedure and in a sanitary manner. Further interview revealed the DON stated she was not aware the policy directed the staff to clean the soiled linen in the hopper/soiled utility room. The DON stated rinsing the linens in the toilet had been the practice at the facility. 2. Observation during the medication pass on 12/07/16 at 1:38 PM, revealed Kentucky Medication Aide (KMA) #1 prepared medication for Resident #10. Further observation revealed KMA #1 dropped a medication pill, Klonopin, on top of the medication cart. Further observation revealed KMA #1 placed the same pill in a medication cup with a plastic spoon and administered the medication to Resident #10. Interview with KMA #1 on 12/08/16 at 4:41 PM, revealed KMA #1 stated she knew not to administer the medication because it became contaminated when it fell on the medication cart. KMA #1 stated, I don't know what I was thinking. Further interview with KMA #1 revealed the medication should have been destroyed and a new medication prepared. Interview with the DON on 12/08/16 at 6:13 PM, revealed the KMA should have thrown away the pill and prepared a new pill for the resident. The DON stated she monitored the medication pass in the past and had not identified a concern. 3. Review of the facility policy titled Tray Pass Checklist, undated, revealed no evidence the policy addressed how staff was to open, unwrap, or handle residents' food when passing trays. Observations of the lunch meal service on 12/07/16 at 12:00 PM, revealed SRNA #1 unwrapped Resident A's bread when setting up the resident's tray and placed the bread on the resident's plate with a bare hand. Interview with SRNA #1 on 12/07/16 at 12:05 PM revealed the SRNA did not realize she had touched the resident's bread with her hand. Further interview with the SRNA revealed she should not touch the residents' food with bare hands. Interview with the Director of Nursing (DON) on 12/08/16 at 10:10 AM, revealed the facility policy did not address handling of food; however, it was facility practice to not touch residents' food with bare hands when setting up a resident's tray. Further interview with the DON revealed she periodically monitored tray pass and had not identified any concerns with staff touching residents' food with bare hands.

Based on observation, interview, record review, and review of the facility policies, it was determined the facility failed to implement care plan interventions related to pain management for one (1) of fifteen (15) sampled residents (Resident #3). Facility staff failed to provide care plan interventions during wound care for Resident #3 regarding pain management. The findings include: Review of the facility policy, Resident Assessment and Care Plan Policy and Procedure, with a revision date of 11/11/14, revealed that the care plan development process included selecting interventions and planning care to identify and implement interventions and treatment to address the resident's physical, functional, and psychosocial needs, concerns, problems, and risks. It further directs Interdisciplinary Team Staff completing the MDS (Minimum Data Set) and CAA (Care Area Assessment) process are responsible for care planning problems, goals and interventions for their assigned areas. Review of the medical record revealed the facility admitted Resident #3 on 09/21/07 with [DIAGNOSES REDACTED]. Review of the Significant Change Comprehensive assessment dated [DATE], revealed the facility assessed Resident #3 to not be interviewable. According to the Minimum Data Set (MDS), the facility assessed Resident #3 to have no skin breakdown; however, the resident was assessed to be at risk for the development of pressure ulcers. In addition, the MDS revealed Resident #3 received scheduled pain medication and as needed (PRN) medication for pain management. Further medical record review revealed Resident #3 was placed on palliative care related to [DIAGNOSES REDACTED]. Review of the Weekly Skin Assessment Record revealed the resident was also noted to have developed a Stage I pressure ulcer on 10/06/15. Review of the Comprehensive Care Plan dated 09/03/15 revealed the facility had developed a care plan to address the provision of palliative care including interventions to assess for signs and symptoms of pain through observation and verbal report and to administer pain medications as ordered by the physician. Review of the Medical Record revealed the physician had prescribed [MEDICATION NAME] (narcotic pain mediation) twice daily and [MEDICATION NAME] (narcotic pain medication) every six hours routinely for pain. In addition, the physician had also prescribed [MEDICATION NAME] every four hours as needed for pain and [MEDICATION NAME] every six hours as needed for pain. Review of the Medication Administration Record [REDACTED]. Observation of wound care on 11/12/15 at 9:50 AM revealed Resident #3 had a Stage II pressure ulcer to the right heel. Further observation revealed Licensed Practical Nurse (LPN) #1 attempted to remove the soiled dressing from the right heel; however, the dressing had adhered to the wound due to drainage. LPN #1 proceeded to soak the wound with normal saline and gauze and to pull the dressing from the resident's right heel. Resident #3 was observed to moan and to make facial grimaces during this procedure. The surveyor asked Resident #3 if this caused pain and the resident replied, Yes. LPN #1 continued to pull at the soiled dressing in an attempt to remove the dressing from the resident's foot. However, there was no evidence the LPN identified or assessed Resident #3 for evidence of pain prior to or during the dressing change. Review of the Medication Administration Record [REDACTED]. Interview with LPN #1 on 11/12/15 at 4:30 PM revealed she was unaware of a policy regarding the assessment of pain. When asked how she assessed pain prior to wound care, LPN #1 stated she usually attempted to plan wound care within an hour of Resident #3 receiving his/her regular morning dose of pain medication. LPN #1 further stated she should have stopped and asked the medication nurse about pain medication for Resident #3 before continuing wound care. During interview with the Director of Nursing (DON) on 11/13/15 at 6:25 PM, she stated pain assessments are done weekly during medication pass and during MDS assessment. The pain management care plan is developed accordingly. She further stated staff had not reported any problems regarding these assessments. The DON stated she was not aware if anyone monitors the MAR indicated [REDACTED].

Based on observation, interview, record review, and facility policy review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for one (1) of fifteen (15) sampled residents (Resident #3) related to pain. Observation of wound care on 11/12/15 for Resident #3 revealed facility staff failed to provide pain management during wound care according to the facility policy and the resident's care plan. The findings include: Review of the facility policy, Pain Management, undated, revealed the purpose of the policy was to ensure the resident is monitored and treated to manage and/or alleviate pain. The policy stated daily resident pain evaluation is completed during the medication pass and the resident is asked to describe any pain as mild, moderate, or severe. The policy directed that the resident be re-evaluated one to two hours after pain medication is given to determine effectiveness and for staff to document pain severity on the Medication Administration Record [REDACTED] Review of the medical record revealed the facility admitted Resident #3 on 09/21/07 with [DIAGNOSES REDACTED]. Further review of the record revealed Resident #3 was placed on palliative care related to a [DIAGNOSES REDACTED]. Review of the Significant Change Comprehensive assessment dated [DATE], revealed the facility assessed Resident #3 to not be interviewable. According to the Minimum Data Set (MDS) assessment, the facility assessed Resident #3 to require scheduled pain medication and as needed (PRN) medication for pain management. Review of the Comprehensive Care Plan revealed the facility had developed a care plan to address the provision of palliative care including interventions to assess for signs and symptoms of pain through observation and verbal report and to administer pain medications as ordered by the physician. Review of the Medical Record revealed the physician had prescribed [MEDICATION NAME] (narcotic pain medication) twice daily and [MEDICATION NAME] (narcotic pain medication) every six hours routinely for pain. In addition, the physician had also prescribed [MEDICATION NAME] every four hours as needed for pain and [MEDICATION NAME] every six hours as needed for pain. Review of the Medication Administration Record [REDACTED]. Observation of wound care on 11/12/15 at 9:50 AM revealed Resident #3 had a Stage II pressure ulcer to the right heel. Further observation revealed Licensed Practical Nurse (LPN) #1 attempted to remove the soiled dressing from the right heel; however, the dressing had adhered to the wound due to drainage. LPN #1 proceeded to soak the wound with normal saline and gauze and to pull the dressing from the resident's right heel. Resident #3 was observed to moan and to make facial grimaces during this procedure. The surveyor asked Resident #3 if this caused pain and the resident replied, Yes. LPN #1 continued to pull at the soiled dressing in an attempt to remove the dressing from the resident's foot. However, there was no evidence the LPN identified or assessed Resident #3 for evidence of pain prior to or during the dressing change. Review of the Medication Administration Record [REDACTED]. Interview with LPN #1 on 11/12/15 at 4:30 PM revealed she was unaware of a policy regarding the assessment of pain. When asked how she assessed pain prior to wound care, LPN #1 stated she usually attempted to plan wound care within an hour of Resident #3 receiving his/her regular morning dose of pain medication. LPN #1 further stated she should have stopped during wound care and asked the medication nurse about pain medication for Resident #3 before continuing the wound care. During interview with the Director of Nursing (DON) on 11/13/15 at 6:25 PM, she stated pain assessments are completed weekly with hydration assessment, during medication pass and during MDS assessment, and the pain management care plan is developed accordingly. She further stated staff had not reported any problems regarding these assessments, and that she was not aware if anyone monitors the MAR indicated [REDACTED].

Based on observation, interview, record review, and facility policy review, the facility failed to maintain an effective infection control program to prevent the development and transmission of disease/infection for one (1) of fifteen (15) sampled residents (Resident #3). Observation of wound care for Resident #3 on 11/12/15 revealed LPN #1 failed to change gloves and perform handwashing after removing a soiled dressing and prior to applying a clean dressing to the resident's wound. The findings include: Review of the facility policy Standard Precautions, undated, revealed use of disposable gloves is indicated for procedures where blood, body fluids, secretions, excretions and/or non-intact skin are handled and that handwashing/hand antisepsis is necessary when gloves are removed. Review of the medical record revealed the facility admitted Resident #3 on 09/21/07 with [DIAGNOSES REDACTED]. Review of the Significant Change Comprehensive assessment dated [DATE], revealed the facility assessed Resident #3 to not be interviewable. In addition, the facility assessed Resident #3 to have no skin breakdown; however, the resident was assessed to be at risk for the development of pressure ulcers. Review of the Weekly Pressure Ulcer Record, dated 10/11/15, indicated a Stage I pressure ulcer to Resident #3's right heel which had developed on 10/06/15. The pressure sore was to receive treatment and dressing changes daily and had progressed to a Stage II pressure ulcer on 10/24/15. Observation of wound care on 11/12/15 at 9:50 AM revealed Resident #3 had a Stage II pressure ulcer to the right heel. Further observation revealed Licensed Practical Nurse (LPN) #1 attempted to remove the soiled dressing from the right heel; however, the dressing had adhered to the wound due to drainage. LPN #1 proceeded to soak the soiled gauze attached to the wound with normal saline and to pull the dressing from the resident's right heel. LPN #1 discharged the soiled dressing and with the same soiled gloved proceeded to clean the wound. While wearing the same soiled gloves LPN #1 was observed to apply a Calcium Alginate dressing. LPN#1 did not remove her gloves or wash her hands until she had applied the clean dressing. Interview with LPN #1 following dressing change on 11/12/15 revealed she had been trained to change gloves between dirty and clean dressing changes. Interview conducted on 11/13/15 with the Director of Nursing (DON) revealed that she had not done direct observation of wound care. She also stated gloves should be removed and hands washed after removing a soiled dressing and before applying a clean dressing.

Based on interview, record review, and review of the facility's policy and procedures it was determined the facility failed to ensure services were provided in accordance with each resident's written plan of care for two (2) of three (3) sampled residents (Resident #1 and Resident #2). The facility developed a care plan with interventions for a gait belt to prevent falls for Resident #1; however, on 08/23/15, a State Registered Nursing Assistant (SRNA) was assisting Resident #1 with ambulating in the hallway without the assistance of a gait belt. Resident #1 sustained a non-injury fall to the floor on 08/23/15. Additionally, the facility developed a care plan with interventions for a gait belt to prevent falls for Resident #2; however, on 09/04/15, SRNA #4 was assisting Resident #2 with transferring from a bedside commode to a whirlpool chair without the assistance of a gait belt. During the transfer on 09/04/15, Resident #2 became weak, was lowered to the floor, and sustained a skin tear. The findings include: Review of the facility policy and procedure titled Resident Assessment and Care Plan, revised on 11/11/14, revealed the facility would assess the strengths and needs of each resident and develop an individualized care plan. Further review revealed the care plan was an interdisciplinary tool to describe the services needed to attain or maintain each resident's highest practicable physical, mental, and psychosocial well-being. Additional review revealed interventions would be implemented to address the individual's physical and functional needs, concerns, problems, and risks. 1. Record review revealed the facility admitted Resident #1 on 03/06/12, with [DIAGNOSES REDACTED]. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #1's cognition as intact with a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was interviewable. Further review revealed the facility assessed Resident #1 to require extensive assistance with transfer and ambulation. Review of a Comprehensive Care Plan dated 03/06/12 and revised on 10/28/14, revealed Resident #1 was at risk for falls due to an unsteady gait. Further review of the care plan revealed interventions to prevent falls included providing Resident #1 with the assistance of one (1) or two (2) staff persons and a gait belt at all times with transfers and ambulation. Review of a facility Fall Scene Investigation Report, dated 08/23/15, revealed Resident #1 sustained a non-injury fall on 08/23/15. Further review revealed SRNA #1 was assisting Resident #1 with ambulating in the hallway and Resident #1 lost his/her balance and fell to the floor. Additional review of the Fall Scene Investigation Report revealed the gait belt was not in use at the time of the fall. Interview with Resident #1 on 09/09/15 at 10:45 AM revealed he/she was ambulating with the staff in the hallway on 08/23/15. Resident #1 stated his/her leg twisted and he/she lost his/her balance and fell . Resident #1 stated he/she did not have an injury from the fall. Further interview revealed Resident #1 stated he/she could not remember if a gait belt was used. Interview with SRNA #1 on 09/09/15 at 1:10 PM revealed she was assisting Resident #1 to ambulate in the hallway on 08/23/15. SRNA #1 stated Resident #1 became weak and fell to the floor. SRNA #1 stated she did not use the gait belt per Resident #1's care plan and per the facility's policy and procedure. Further interview with SRNA #1 revealed she had been trained on the facility's gait belt policy; however, Resident #1 did not like it and she just did not use it. 2. Record review revealed the facility admitted Resident #2 on 06/24/13 with [DIAGNOSES REDACTED]. Review of a quarterly MDS assessment dated [DATE] revealed the facility assessed Resident #2's cognition as moderately impaired with a BIMS score of 9, indicating Resident #2 was interviewable. Further review revealed the facility assessed Resident #2 to require extensive assistance with transfer and ambulation. Review of a Comprehensive Care Plan dated 06/24/13 and revised on 08/21/15, revealed Resident #2 was at risk for falls due to an unsteady gait. Further review revealed interventions to prevent falls included staff using a gait belt with transfers and ambulation. Review of a facility Fall Scene Investigation Report dated 09/04/15 revealed Resident #2 sustained a fall on 09/04/15. Additional review revealed SRNA #4 was assisting Resident #2 with transferring from a bedside commode to a whirlpool chair and the resident became weak and was lowered to the floor. Further review revealed a gait belt was not used at the time of the fall. Interview with SRNA #4 on 09/09/15 at 6:30 PM, revealed she was assisting Resident #2 with transferring from the bedside commode to the whirlpool chair on 09/04/15. SRNA #4 stated Resident #2 became weak and she lowered him/her to the floor. The SRNA stated Resident #2 sustained a skin tear. SRNA #4 stated she did not use a gait belt during the transfer. SRNA #4 stated she had been trained by the facility to use the gait belt with all residents requiring extensive hands-on assistance and was aware of the facility's policy and procedure. SRNA #4 stated she did not know why she did not use the gait belt. Interview with the Director of Nursing (DON) on 09/09/15 at 4:25 PM, revealed it was her expectation for staff to follow all policies and procedures and SRNA #1 and SRNA #4 should have used the gait belt. Additionally she stated it was her expectation that all staff followed the residents' care plans.

Based on interview, record review, and review of the facility's policy and procedures it was determined the facility failed to ensure staff utilized assistive devices to prevent accidents when assisting two (2) of three (3) sampled residents (Resident #1 and Resident #2). Resident #1 and Resident #2 had care plan interventions for a gait belt to be utilized to prevent falls. On 08/23/15, State Registered Nursing Assistant (SRNA) #1 was assisting Resident #1 with ambulating in the hallway without the assistance of a gait belt. Resident #1 sustained a non-injury fall to the floor on 08/23/15. On 09/04/15, SRNA #4 was assisting Resident #2 with transferring from a bedside commode to a whirlpool chair without the assistance of a gait belt. Resident #2 became weak, was lowered to the floor, and sustained a skin tear. The findings include: Review of the facility's policy and procedure titled Gait Belts for Transfer, not dated, revealed gait belts were provided to assist staff to safely transfer or ambulate residents. Further review revealed the use of the gait belt was mandatory if a resident needed hands-on assistance. 1. Record review revealed the facility admitted Resident #1 on 03/06/12, with [DIAGNOSES REDACTED]. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed Resident #1's cognition as intact with a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was interviewable. Further review revealed the facility assessed Resident #1 to require extensive assistance with transfers and ambulation. Review of a Comprehensive Care Plan dated 03/06/12 and revised on 10/28/14, revealed Resident #1 was at risk for falls due to an unsteady gait. Further review revealed Resident #1 required the assistance of one (1) or two (2) staff persons and a gait belt at all times with transfers and ambulation to prevent falls. Review of a facility Fall Scene Investigation Report, dated 08/23/15, revealed Resident #1 sustained a non-injury fall on 08/23/15. Further review revealed SRNA #1 was assisting Resident #1 with ambulating in the hallway and Resident #1 lost his/her balance and fell to the floor. Additional review of the Fall Scene Investigation Report revealed the gait belt was not in use at the time of the fall. Interview with Resident #1 on 09/09/15 at 10:45 AM, revealed he/she was ambulating with the staff in the hallway on 08/23/15. Resident #1 stated his/her leg twisted and he/she lost his/her balance and fell . Resident #1 stated he/she did not have an injury from the fall. Further interview revealed Resident #1 stated he/she could not remember if a gait belt was used. Interview with SRNA #1 on 09/09/15 at 1:10 PM revealed she assisted Resident #1 to ambulate in the hallway on 08/23/15. SRNA #1 stated Resident #1 became weak and fell to the floor. SRNA #1 stated she did not use the gait belt per Resident #1's care plan and per the facility's policy and procedure. Further interview with SRNA #1 revealed she had been trained on the facility's gait belt policy; however, Resident #1 did not like the gait belt and she just did not use it. 2. Record review revealed the facility admitted Resident #2 on 06/24/13 with [DIAGNOSES REDACTED]. Review of a quarterly MDS assessment dated [DATE] revealed the facility assessed Resident #2's cognition as moderately impaired with a BIMS score of 9, indicating Resident #2 was interviewable. Further review revealed the facility assessed Resident #2 to require extensive assistance with transfer and ambulation. Review of a Comprehensive Care Plan dated 06/24/13 and revised on 08/21/15 revealed Resident #2 was at risk for falls due to an unsteady gait. Further review revealed staff was to use a gait belt with transfers and ambulation. Review of a facility Fall Scene Investigation Report dated 09/04/15 revealed Resident #2 sustained a fall on 09/04/15. Additional review revealed SRNA #4 was assisting Resident #2 with transferring from a bedside commode to a whirlpool chair and the resident became weak and staff lowered the resident to the floor. Further review revealed a gait belt was not used at the time of the fall. Additional review revealed Resident #2 was assessed to have a skin tear on his/her right shin which measured 3 centimeters (cm) by 2.3 cm. Further review revealed Resident #2 received first aid including steri-strips and a clear adhesive dressing. Interview with Resident #2 on 09/09/15 at 11:20 AM revealed he/she had a fall on 09/04/15. Resident #2 stated he/she was transferred from the bedside commode to the whirlpool chair and became weak. Resident #2 stated the staff assisted him/her to the floor and he/she scraped his/her leg. Resident #2 stated he/she could not remember if the staff used a gait belt. Interview with SRNA #4 on 09/09/15 at 6:30 PM, revealed she was assisting Resident #2 with transferring from the bedside commode to the whirlpool chair. SRNA #4 stated Resident #2 became weak and she lowered him/her to the floor and the resident sustained [REDACTED].#4 stated she did not use a gait belt during the transfer. SRNA #4 stated she had been trained by the facility to use the gait belt with all residents requiring extensive hands-on assistance and was aware of the facility's policy and procedure. She stated she did not know why she did not use the gait belt. Interview with the Director of Nursing (DON) on 09/09/15 at 4:25 PM, revealed it was her expectation for staff to follow all policies and procedures and SRNA #1 and SRNA #4 should have used the gait belt to prevent falls for Resident #1 and Resident #2.

Based on interview, record review, and facility policy review, it was determined the facility failed to ensure services were provided in accordance with each resident's written plan of care for one (1) of three (3) sampled residents (Resident #1). The facility developed a care plan with interventions to prevent falls for Resident #1; however, on 06/13/15, the staff caring for Resident #1 failed to ensure the interventions were provided and the resident sustained [REDACTED]. The findings include: Review of the facility policy titled Resident Assessment and Care Plan Policy and Procedure, updated 11/11/14, revealed a resident's Comprehensive Care Plan would detail services that would be used to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The policy indicated the care plan would be reviewed and revised on an ongoing basis to reflect changes in the resident and the care that the resident was to receive. The policy also stated that a Nurse Aide Care Plan, containing interventions the nurse aide was responsible for, would be kept in the resident's room for daily review by direct care staff. Review of Resident #1's medical record revealed the facility admitted Resident #1 on 12/21/08. Review of Resident #1's Minimum Data Set Assessment (MDS) and Fall Risk Assessment both dated 03/25/15, revealed the facility assessed Resident #1 to be at high risk for falls. Review of Resident #1's Comprehensive Care Plan, undated, which was in effect on 03/13/15, revealed Resident #1 was to be transferred utilizing a mechanical lift with two staff members assisting, was to have a non-skid pad placed in any chair the resident sat in, and was to have foot pedals in place on the wheelchair utilized by Resident #1. Additionally, review of the Nurse Aide Care Plan, dated 05/27/15, revealed the care plan directed staff that Resident #1 required a mandatory lift for transfers with two staff members, to make sure foot pedals were on when the resident was in a wheelchair, and that a non- skid pad was required to be in any chair Resident #1 was sitting in. Review of a facility investigation dated 06/17/15, revealed on 06/13/15, Certified Nursing Assistant (CNA) #1 transferred Resident #1 from the wheelchair to the bedside toilet and then back from the bedside toilet to the wheelchair, both times without obtaining assistance of an additional staff member. Additionally, the investigation revealed CNA #1 failed to ensure the wheelchair that the resident was transferred into had the required non-skid pad in the seat or that the chair had attached foot pedals as required for Resident #1. As a result, Resident #1 sustained a non-injury fall from the wheelchair onto the floor on 06/13/15. Although attempted interviews with CNA #1 were unsuccessful, review of the Nurse Aide Care Plan dated 05/27/15, revealed CNA #1 had initialed the care plan to indicate she reviewed it prior to caring for Resident #1 on 06/13/15. Interview with the Administrator on 07/01/15 at 10:30 AM, revealed the facility's investigation determined that the fall sustained by Resident #1 on 06/13/15, could have likely been prevented if CNA #1 had followed the interventions listed on the resident's plan of care. The Administrator stated that CNA #1 was terminated from employment at the facility on 06/16/15. Refer to F323.

Based on interview, record review, facility policy review, and review of a facility investigation it was determined the facility failed to ensure staff utilized assistive devices when assisting one (1) of three (3) sampled residents (Resident #1) to transfer to and sit safely in a wheelchair. Resident #1 was assessed to require a mechanical lift for transfers with the assistance of two (2) staff members, placement of a non-skid pad in the chair the resident was to sit in, and have foot pedals on the wheelchair being utilized by Resident #1. However, on 06/13/15, Certified Nursing Assistant (CNA) #1 transferred Resident #1 from the bedside toilet to the wheelchair without assistance of another staff member and failed to ensure that a non-skid pad was in the chair or that the wheelchair's foot pedals were in place as required. Resident #1 sustained a non-injury fall from the wheelchair onto the floor on 06/13/15. The findings include: Review of the facility policy titled Safe Lifting, undated, revealed any resident who could not sit up on the side of the bed would be transferred utilizing a mechanical lift. Review of the policy titled Resident Safety Clinical protocol, undated, revealed if a resident had been identified to be at risk for falls, the resident's care plan would include appropriate approaches to prevent injury. Review of Resident #1's medical record revealed the facility admitted the resident on 12/21/08, with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment completed on 03/25/15, revealed the facility assessed the resident to be severely cognitively impaired and dependent on staff to provide extensive assistance with all activities of daily living, including requiring extensive assistance of two or more staff members for transferring. Review of a Fall Risk assessment dated [DATE], for Resident #1 revealed the resident was at high risk for falls. Review of Resident #1's Care Plan (undated) which was in effect on 06/13/15, revealed Resident #1 required a mechanical lift for transfers utilizing two staff members, required a non-skid pad to the chair the resident was sitting in, and staff was to make sure foot pedals were in place on Resident #1's wheelchair. Review of the facility investigation dated 06/17/15, revealed on 06/13/15, at approximately 1:15 PM, CNA #1 transferred Resident #1 utilizing a mechanical lift from the bedside toilet to a wheelchair without the assistance of another staff member. The investigation further revealed that the wheelchair Resident #1 was positioned in did not have a non-skid pad in place, and the CNA did not ensure that foot pedals were in place on the wheelchair. The investigation stated CNA #1 then went to clean the (bedside toilet) and Resident #1 kicked off a shoe, leaned over the side of the wheelchair, and fell out. The investigation stated CNA #1 explained that Resident #1 slipped out of the chair onto his/her right side. The investigation determined that if CNA #1 had been utilizing two staff members as required to facilitate transferring Resident #1, the second staff member could have monitored Resident #1, while CNA #1 cleaned the bedside toilet and possibly prevented Resident #1 from sustaining the fall. Additionally, the investigation concluded that if the non-skid pad was appropriately placed in the wheelchair as directed, Resident #1 would have been less likely to slide out of the chair. The investigation revealed Resident #1 sustained no injury as a result of the fall. Observations of Resident #1 on 07/01/15, at 10:45 AM, revealed the resident was sitting up in a rocking chair with a non-skid mat positioned under the resident. Resident #1 would make eye contact when his/her name was spoken, but made no attempt to communicate verbally. Attempted interviews with CNA #1 were unsuccessful. However, review of the facility investigation dated 06/17/15, revealed when the Administrator interviewed CNA #1, the CNA stated she was aware that two staff members were required to utilize a mechanical lift when transferring Resident #1, and that the resident required a non-skid pad and foot pedals to be utilized when transferred into the wheelchair. However, according to the investigative interview with CNA #1, she didn't consider what would happen the one time she did not follow it (the resident's plan of care). Interview with the Administrator on 07/01/15, at 10:30 AM, revealed CNA #1 had received disciplinary action in December 2013 for failing to utilize a gait belt during a resident transfer and was again counseled during her December 2014 annual evaluation to be sure and follow each resident's plan of care. Therefore, the Administrator stated CNA #1 was terminated from employment at the facility on 06/16/15 for failure to follow instructions. Refer to F282.

Based on interview, record review, and a review of the facility's policy it was determined the facility failed to provide care in accordance with the resident's plan of care for one of three sampled residents (Resident #1). Staff assisted Resident #1 to a chair at the reception desk where staff was not familiar with the resident's need for assistance when ambulating. Resident #1 rose from the chair, ambulated unassisted to a bathroom near the reception desk, and sustained a fall that resulted in bruising to the resident's head. The findings include: A review of the facility's policy titled "Resident Assessment and Care Plan Policy and Procedure," with a revision date of 11/11/14, revealed a resident's care plan was developed in accordance with the Minimum Data Set (MDS) and the Care Area Assessment (CAA). Further review of the policy revealed staff was to review residents' care plans daily at the beginning of the shift and provide assistance with mobility in accordance with the care plan. A record review for Resident #1 revealed the facility admitted the resident on 10/22/14 with [DIAGNOSES REDACTED]. Further review of the record revealed the facility assessed the resident as being at risk for falls and developed a care plan on 10/22/14 that addressed the resident's fall risk. The facility revised Resident #1's care plan on 11/09/14, after the resident sustained [REDACTED]. A review of nurse's notes revealed Resident #1 sustained a fall with injury on 12/16/14 at 11:45 AM while ambulating without assistance in a first floor bathroom. Further review revealed the resident was transferred to a hospital and returned to the facility with a [DIAGNOSES REDACTED]. An interview conducted with the facility Receptionist on 12/23/14 at 10:10 AM, revealed Resident #1 was observed sitting in a chair near the reception desk when the resident got up without the assistance of staff and ambulated to a bathroom approximately twelve steps from the reception desk. According to the Receptionist, she was not aware of the care needs of the resident and called the unit the resident resided on to inform staff the resident was walking back to the unit. Further interview revealed after the resident entered the bathroom, the Receptionist heard a noise, and when she looked in the bathroom, the resident was lying on the floor. The Receptionist stated that Licensed Practical Nurse (LPN) #1 arrived from the unit, assessed the resident, and staff called an ambulance to take the resident to the hospital. An interview conducted with LPN #1 on 12/23/14 at 12:55 PM, revealed Resident #1 exited the unit on 12/16/14 and was walking in the hallway with the Director of Nursing, and the DON had taken the resident to the front desk while the LPN was making rounds with a physician. LPN #1 stated someone then called the unit and reported that the resident had fallen in the bathroom by the reception desk. The LPN stated she assessed the resident and the resident was transferred to the hospital due to a large bruise on the right side of the head. An interview conducted with the DON on 12/23/14 at 1:10 PM revealed on 12/16/14, the DON assisted Resident #1 with ambulating to the front desk because the resident did not want to return to his/her room. Further interview revealed the DON was aware the resident required assistance of one person with ambulation and assisted the resident to a chair by the reception desk on the first floor while the DON returned a medical record to the second floor. Additional interview revealed the DON did not arrange for the resident to be supervised and did not inform staff at the reception desk that the resident was not to be up without assistance. When the DON returned from the second floor, the resident had ambulated to the bathroom unassisted and sustained a fall.

Based on interview, record review, and a review of the facility's policy it was determined the facility failed to ensure one of three sampled residents (Resident #1) received adequate supervision and assistance to prevent accidents. Resident #1, who the facility assessed as having moderately impaired cognition and requiring assistance with ambulation, was left in a chair at the reception desk where staff was not familiar with the resident's needs. Resident #1 got up from the chair, ambulated without assistance to a bathroom near the reception desk, and sustained a fall. Resident #1 sustained bruising to the resident's head as a result of the fall. The findings include: A review of the facility's fall policy titled "Resident Safety Clinical Protocol," with a revision date of 11/10/14, revealed if a resident was at risk for falls or injuries, the initial resident care plan would include appropriate approaches to prevent injury. A record review for Resident #1 revealed the facility admitted the resident on 10/22/14 with [DIAGNOSES REDACTED]. Further review of the record revealed the facility assessed the resident to be at risk for falls and developed a care plan dated 10/22/14 with interventions to address the resident's fall risk. Further review revealed the resident's care plan was revised on 11/09/14, when the resident sustained [REDACTED]. Further review of Resident #1's medical record revealed a nurse's note dated 12/16/14 at 11:45 AM. The note stated the resident sustained [REDACTED]. The resident was transferred to a hospital for evaluation/treatment and returned to the facility on [DATE] at 2:30 PM with a [DIAGNOSES REDACTED]. On 12/23/14 at 10:10 AM, an interview with the facility Receptionist revealed the Receptionist observed Resident #1 sitting in a chair near the reception desk. She stated the resident stood up without the assistance of staff and ambulated to a bathroom approximately twelve steps from the reception desk. According to the Receptionist, she was not aware of the resident's care needs and called the unit where Resident #1 resided to inform staff that the resident was walking back to the unit. Further interview revealed after the resident entered the bathroom the Receptionist heard a noise, and when she looked into the bathroom the resident was lying on the floor. The Receptionist stated that Licensed Practical Nurse (LPN) #1 arrived from the unit, assessed the resident, and staff called an ambulance to take the resident to the hospital. An interview conducted with LPN #1 on 12/23/14 at 12:55 PM, revealed Resident #1 was walking in the hallway with the Director of Nursing's (DON) assistance. She further stated the DON had taken the resident to the front desk while the LPN was making rounds with a physician. LPN #1 stated someone then called the unit and reported that Resident #1 had fallen in the bathroom by the reception desk. The LPN stated she assessed the resident and the resident was transferred to the hospital due to bruising to the resident's face. An interview with the DON on 12/23/14 at 1:10 PM revealed on 12/16/14, the DON assisted Resident #1 with ambulating to a chair at the front desk because the resident did not want to return to his/her room. The DON was aware the resident required assistance of one person with ambulation; however, the DON left the resident to go to another floor of the facility without arranging for the resident to be supervised and without informing staff at the reception desk that the resident was not to be up without assistance. When the DON returned from the second floor, the resident had ambulated to the bathroom unassisted and sustained a fall.

Based on observation, interview, record review, facility policy review, and a review of the facility's fall investigations, it was determined the facility failed to ensure staff implemented care plan interventions to prevent falls for three (3) of fifteen (15) sampled residents (Resident #4, Resident #5, and Resident #13). Resident #4 sustained falls on 01/27/14 and 05/22/14. Prior to the fall on 01/27/14, staff failed to ensure the resident was wearing regular shoes as required by the resident's care plan and on 05/22/14, staff failed to ensure Resident #4's chair alarm was on prior to the resident's fall. Resident #5 required the assistance of two (2) staff persons for activities of daily living; however, on 05/09/14, one staff person was assisting Resident #5 with a shower and the resident slid out of the shower chair in the shower room. Resident #13 required a Dycem Pad (non-slip padding) while in a chair. On 06/30/14 and 08/03/14, the facility failed to ensure the Dycem Pad was in the resident's chair and the resident slid/scooted from the chair and sustained falls. The findings include: Review of the facility policy titled "Resident Assessment and Care Plan Policy and Procedure," dated May 2012, revealed the Care Plan was an interdisciplinary communication tool and would identify interventions and treatments which would be implemented to address the individual's physical, functional, and psychosocial needs, concerns, problems, and risks. However, the policy did not address how often staff was required to review the Plan of Care. 1. Observation of Resident #4 on 10/21/14, at 4:15 PM, revealed the resident was in a low bed with a bed alarm. Review of the medical record for Resident #4 revealed the facility admitted the resident on 02/13/03, with [DIAGNOSES REDACTED]. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had been assessed to require the extensive assistance of two staff persons for transfers. The MDS also revealed the facility had assessed the resident to be severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 5. Review of the Plan of Care for Resident #4 dated 12/05/12, revealed the resident was to have a chair alarm when in the resident's bedroom and was also to wear regular shoes with all ambulation and transfers. Review of a facility investigation dated 01/27/14, at 6:15 PM, revealed while Resident #4 was being transferred from the wheelchair to a recliner by State Registered Nursing Assistant (SRNA) #2 and Licensed Practical Nurse (LPN) #4 the resident slipped and had to be lowered to the floor by the staff. According to the investigation, Resident #4 was wearing house slippers and not regular shoes as directed in the Plan of Care. Documentation revealed the resident sustained [REDACTED].#4 was wearing regular shoes. Interview conducted with SRNA #2 on 10/23/14, at 7:08 PM revealed she was required to check the Plan of Care at the beginning of her shift. The SRNA stated Resident #4 should have had on regular shoes instead of house slippers and did not recall why Resident #4 did not have regular shoes on. Interview conducted with LPN #4 on 10/23/14, at 7:20 PM, revealed she was required to check the Plan of Care at the beginning of her shift. The LPN stated she vaguely remembered the incident with Resident #4 but the resident should have had on regular shoes instead of house slippers, and she did not recall why Resident #4 did not have regular shoes on. Review of a facility investigation dated 05/22/14, at 4:45 AM, revealed Resident #4 was found sitting on the resident's bathroom floor. Documentation revealed the resident sustained [REDACTED].#4's alarm was not turned on and both SRNA #3 and SRNA #4 were provided with disciplinary action. Interview conducted with the DON on 10/23/14, at 7:30 PM, revealed both SRNA #3 and SRNA #4 had resigned, and the facility had no phone numbers to reach the SRNAs. The DON stated the alarm for Resident #4 should not have been turned off. 2. Observation of Resident #5 on 10/21/14, at 4:10 PM, revealed the resident was sitting in a recliner resting with his/her eyes closed. Review of the medical record for Resident #5 revealed the facility admitted the resident on 01/27/09, with [DIAGNOSES REDACTED]. Review of Resident #5's most recent quarterly MDS assessment dated [DATE], revealed the facility assessed the resident to have severely impaired cognition. The MDS also revealed the resident was assessed to require the total assistance of two persons for transfers. Review of the Plan of Care for Resident #5 dated 02/03/09, revealed Resident #5 required the assistance of two staff persons when providing all care. Review of a facility investigation dated 05/09/14, at 5:45 AM, revealed Resident #5 slid out of the shower chair in the shower room, and SRNA #6 was the only staff member with the resident. Documentation revealed Resident #5 sustained an abrasion to the left side of the forehead, a skin tear to the left elbow, and a skin tear to the left knee. Interview conducted with SRNA #6 on 10/23/14, at 7:25 PM, revealed she was required to check the Plan of Care at the beginning of every shift. The SRNA stated she should have had a second staff member with her when bathing Resident #5 but could not recall why another staff person was not present. 3. Observation of Resident #13 on 10/23/14, at 3:10 PM, revealed the resident was sitting in a rocking chair in the activity room listening while other residents were singing. Review of the medical record for Resident #13 revealed the facility admitted the resident on 12/02/13, with [DIAGNOSES REDACTED]. Review of the most recent quarterly MDS assessment dated [DATE], revealed the facility assessed the resident to require the extensive assistance of two persons for transfers. The MDS also revealed the facility had assessed the resident to have severely impaired cognition. Review of the Plan of Care for Resident #13 dated 12/02/13, revealed a Dycem Pad was required to be in the resident's chair. Review of a facility investigation for Resident #13 dated 06/30/14, at 7:15 PM, revealed Resident #13 slid out of a chair in the activity room and sustained two skin tears to the left elbow. Documentation revealed the Dycem Pad was not in Resident #13's chair. Interview conducted with SRNA #1 on 10/23/14, at 6:40 PM, revealed she was responsible for placing the Dycem Pad on Resident #13's chair on 06/30/14, and had not. The SRNA stated she was required to check the Plan of Care at the beginning of every shift. Review of a facility investigation for Resident #13 dated 08/03/14, at 11:05 AM, revealed the resident scooted out of the chair in the activity room. Documentation revealed the resident sustained [REDACTED]. However, the documentation revealed a Dycem Pad was not in the resident's chair at the time of the fall. Interview conducted with LPN #1 on 10/23/14, at 7:30 PM, revealed she was responsible for ensuring the Dycem Pad was on the chair for Resident #13 on 10/23/14. The LPN stated it was just an oversight and the Dycem pad should have been underneath the resident. Interview conducted with the DON on 10/23/14, at 8:00 PM, revealed all fall investigations were reported to her and she attended a falls committee meeting every week during which resident falls were discussed. The DON stated staff was required to review residents' Plans of Care at the beginning of every shift. The DON stated she made compliance rounds daily and random spot checks to ensure care was being provided as directed on the resident's Plan of Care. The DON stated she had not identified any concerns with resident care plans being followed.

Based on observation, interview, record review, facility policy review, and a review of the facility's fall investigations, it was determined the facility failed to ensure assistive devices to prevent falls were implemented for three (3) of fifteen (15) sampled residents (Resident #4, Resident #5, and Resident #13). On 01/27/14, Resident #4 slipped while being transferred by staff. The facility failed to ensure the resident was wearing regular shoes prior to transferring the resident. Resident #4 sustained another fall on 05/22/14. The facility failed to ensure the resident's chair alarm was turned on as required by the resident's Plan of Care prior to the fall. On 05/09/14, Resident #5 slid out of a shower chair in the shower room with one staff member present, instead of two (2) staff members, which was required according to the resident's Plan of Care. Resident #13 sustained falls on 06/30/14 and 08/03/14, when the resident slid from a chair. The facility failed to ensure a Dycem Pad (non-slip padding) was in the resident's chair as directed by the resident's Plan of Care prior to the falls. The findings include: Review of the facility's policy titled "Assessing Falls and Their Causes," undated, revealed an incident report with the initial investigation would be completed no later than twenty-four (24) hours after a fall occurs. The policy revealed the facility would begin to identify possible causes of the incident. 1. Observation of Resident #4 on 10/21/14, at 4:15 PM, revealed the resident was in a low bed with a bed alarm. A review of Resident #4's medical record revealed the facility admitted the resident on 02/13/03, with [DIAGNOSES REDACTED]. A review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed the resident to have severely impaired cognition and required the extensive assistance of two staff persons for transfers. A review of Resident #4's Plan of Care dated 12/05/12, revealed the resident was required to have a chair alarm when the resident was in his/her bedroom and was to wear regular shoes with all ambulation and transfers. A review of a facility investigation dated 01/27/14, at 6:15 PM, revealed State Registered Nursing Assistant (SRNA) #2 and Licensed Practical Nurse (LPN) #4 were transferring Resident #4 from the wheelchair to a recliner when the resident slipped and staff had to lower the resident to the floor. Documentation revealed Resident #4 was wearing house slippers and not regular shoes as directed in the Plan of Care. Documentation revealed the resident sustained [REDACTED]. An interview conducted with SRNA #2 on 10/23/14, at 7:08 PM, revealed she should have ensured resident #4 had on regular shoes prior to transferring the resident. An interview conducted with LPN #4 on 10/23/14, at 7:20 PM, revealed she checked the Plan of Care at the beginning of her shift. The LPN stated she vaguely remembered the incident with Resident #4. She stated the resident should have had on regular shoes, instead of house slippers, prior to transferring the resident and did not recall why Resident #4 did not have on regular shoes. A review of a facility investigation dated 05/22/14, at 4:45 AM, revealed Resident #4 was found sitting on the resident's bathroom floor. The investigation revealed the resident sustained [REDACTED].#4's alarm was not turned on and both SRNA #3 and SRNA #4 were provided with disciplinary action. Interview conducted with the DON on 10/23/14, at 7:30 PM, revealed SRNA #3 and SRNA #4 had resigned, and the facility had no phone numbers to reach the SRNAs. The DON stated the alarm for Resident #4 should not have been turned off. 2. Observation of Resident #5 on 10/21/14, at 4:10 PM, revealed the resident was sitting in a recliner with his/her eyes closed. A review of the medical record for Resident #5 revealed the facility admitted the resident on 01/27/09, with [DIAGNOSES REDACTED]. A review of the most recent quarterly MDS assessment for Resident #5 dated 08/27/14 revealed the facility assessed the resident to have severely impaired cognition and to require the total assistance of two persons for transfers. A review of the Plan of Care for Resident #5 dated 02/03/09 revealed Resident #5 required the assistance of two staff persons when providing all care. A review of a facility investigation dated 05/09/14, at 5:45 AM, revealed Resident #5 slid out of the shower chair in the shower room, and SRNA #6 was the only staff member with the resident. The investigation revealed Resident #5 sustained an abrasion to the left side of the forehead, a skin tear to the left elbow, and a skin tear to the left knee. An interview conducted with SRNA #6 on 10/23/14, at 7:25 PM, revealed she should have had a second staff member with her when bathing Resident #5 but did not. The SRNA stated she could not recall why she had not had another staff person present. 3. Observation of Resident #13 on 10/23/14, at 3:10 PM, revealed the resident was sitting in a rocking chair in the activity room while other residents were singing. A review of the medical record for Resident #13 revealed the facility admitted the resident on 12/02/13, with [DIAGNOSES REDACTED]. A review of the most recent quarterly MDS assessment dated [DATE] revealed the facility assessed the resident to require extensive assistance of two persons for transfers. The MDS also revealed the facility assessed the resident to have severely impaired cognition. A review of the Plan of Care for Resident #13 dated 12/02/13 revealed a Dycem Pad was to be in the resident's chair. A review of a facility investigation for Resident #13 dated 06/30/14, at 7:15 PM, revealed Resident #13 slid out of a chair in the activity room and sustained two skin tears to the left elbow. Documentation revealed the Dycem Pad was not in Resident #13's chair when the resident fell . An interview conducted with SRNA #1 on 10/23/14, at 6:40 PM, revealed she was responsible for placing the Dycem Pad on Resident #13's chair and had not. A review of a facility investigation for Resident #13 dated 08/03/14, at 11:05 AM, revealed Resident #13 scooted out of a chair in the activity room. Documentation revealed the resident sustained [REDACTED]. However, the documentation revealed a Dycem Pad was not in the resident's chair at the time of the fall. An interview conducted with LPN #1 on 10/23/14, at 7:30 PM, revealed she was responsible for ensuring the Dycem Pad was on the chair for Resident #13 on 10/23/14. The LPN stated it was just an oversight and the Dycem Pad should have been underneath the resident. An interview conducted with the DON on 10/23/14, at 8:00 PM, revealed all fall investigations were reported to her and she attended a falls committee meeting every week. The DON stated staff was required to review residents' Plans of Care at the beginning of every shift and to ensure the Plans of Care were followed. The DON stated she made compliance rounds daily and conducted random spot checks to ensure care and adequate supervision to prevent accidents were being provided.

Based on observation, interview, record review, and facility policy review, the facility failed to develop a comprehensive care plan to address a history of positive reaction to [MEDICATION NAME] skin testing for one (1) of fifteen (15) sampled residents (Resident #6). The findings include: A review of the Comprehensive Care Plan policy (updated May 2012) revealed the comprehensive care plan was an interdisciplinary communication tool that 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 on an ongoing basis to reflect changes in the resident and the care that the resident was receiving. A review of the "Identification and Management of TB," (not dated) revealed residents with a history of a positive skin test shall be monitored for development of [MEDICAL CONDITION] symptoms such as cough, sputum production, or chest pain. Review of the medical record revealed the facility admitted Resident #6 on 04/29/14 with [DIAGNOSES REDACTED]. A review of the immunization record revealed the resident had a history of [REDACTED]. Review of the comprehensive care plan for Resident #6 dated 04/29/14 revealed the facility failed to develop a plan of care to address the resident's past positive PPD history to include monitoring for complications or signs/symptoms of [MEDICAL CONDITION]. Interview with the Director of Nursing (DON) on 10/23/14 at 10:30 AM revealed the DON was also the infection control nurse and was responsible for developing Resident #6's plan of care but failed to ensure Resident #6's care plan addressed monitoring for signs and symptoms of [MEDICAL CONDITION].

Based on interview, record review, and a review of facility guidelines, the facility failed to provide laboratory services for one of fifteen sampled residents (Resident #1). Resident #1 had a physician's orders [REDACTED]. However, a review of documentation conducted on 09/12/12 revealed the laboratory test was not obtained in July 2012. The findings include: Review of the facility's guidelines for Labs revealed lab tests would be done as ordered by the physician. The guidelines noted prior to each physician visit the Director of Nurses (DON) or designee would review the chart to ensure that labs were obtained as ordered. A review of the medical record revealed the facility admitted Resident #1 on 06/30/09 with [DIAGNOSES REDACTED]. A review of the 07/30/12 physician's orders [REDACTED]. The physician's orders [REDACTED]. A review of the laboratory tests revealed a CMP, CBC, and TSH was obtained on 07/10/12; however, there was no evidence the facility obtained a Lipid Panel in July 2012. Continued review of the medical record revealed staff obtained a Lipid panel on 01/18/12, six months prior to the test ordered for 07/30/12, and at that time the resident's Lipid panel revealed the resident's Total Cholesterol was out of normal range at 257 mg/dL (normal range 11-199 mg/dL), the Triglycerides were out of normal range at 486 mg/dL (normal range 0-149 mg/dL), and the HDL (high density lipoprotein) Cholesterol was out of normal range at 37 mg/dL (normal range >39 mg/dL). Interview conducted with Licensed Practical Nurse (LPN) #2 on 09/12/12, at 10:15 AM, revealed the facility staff nurses were responsible to obtain lab specimens as ordered by the resident's physician. LPN #2 stated she obtained a lab specimen for Resident #1 on 07/10/12 for the six-month routine lab tests. The LPN stated she failed to mark the box for Lipid Panel on the lab requisition slip and the lab test was not conducted as ordered. Interview with the Director of Nursing (DON) on 09/12/12, at 12:00 PM, revealed the facility did not have a policy related to obtaining lab tests. The DON stated the lab guidelines were utilized to ensure lab tests were performed as ordered by the resident's physician. The DON stated she routinely checked the lab test orders/results when the physician's 60-day orders were reviewed, prior to the physician's visit to the facility, to ensure lab tests were obtained as ordered. The DON stated Resident #1's physician was not due to visit the facility until the end of September 2012, she had not checked the lab orders and, as a result, she failed to identify the Lipid Panel was not obtained as ordered.

Based on observation, interview, and review of facility policy, it was determined the facility failed to establish and maintain an effective Infection Control Program to provide a safe, sanitary, and comfortable environment and to prevent the development and transmission of disease. Observation on 09/22/11, revealed Licensed Practical Nurse (LPN) #1 failed to wear gloves while performing skin assessments for three (3) of fifteen (15) sampled residents (Resident #1, #5, and #9). The findings include: Review of the facility policy titled Standard Precautions (not dated) revealed standard precautions would be used in the care of all residents regardless of the [DIAGNOSES REDACTED]. Observation on 09/22/11, at 9:05 AM, revealed LPN #1 conducted a skin assessment on Resident #5. LPN #1 was observed to remove Resident #5's clothing, touch the resident's arms, and lift the resident's breast with her ungloved/bare hands. LPN #1 assisted Resident #5 to a standing position and then touched Resident #5's buttocks with ungloved/bare hands. LPN #1 removed Resident #5's shoes and socks to examine the resident's feet and failed to wear gloves. Further observation on 09/22/11, at 9:40 AM, revealed LPN #1 conducted a skin assessment on Resident #9. Resident #9 was dressed in a robe and was seated in a recliner in the resident's room. LPN #1 was observed to remove the resident's robe and began the skin assessment. LPN #1 touched Resident #9's hair, ears, arms, and breast with ungloved/bare hands. LPN #1 assisted Resident #9 to a standing position and then touched the resident's buttocks with her ungloved/bare hands. LPN #1 removed Resident #9's shoes, touched the resident's toes to examine between the toes, and rubbed the resident's heels with ungloved/bare hands. Observation on 09/22/11, at 10:15 AM, revealed LPN #1 conducted a skin assessment on Resident #1. Upon entering Resident #1's room, Resident #1 was neatly dressed and seated in a chair. LPN #1 removed Resident #1's clothing, touched the resident's ears, hair, arms, and breast with ungloved/bare hands. LPN #1 assisted Resident #1 to a standing position, examined the resident's perineal area and buttocks with ungloved/bare hands. LPN #1 examined and touched Resident #1's legs and feet with ungloved/bare hands. Interview on 09/22/11, at 3:20 PM, with LPN #1 revealed gloves should be worn when conducting any procedure for a resident. LPN #1 stated Universal Precautions should be observed by staff at all times to protect the residents and staff. LPN #1 stated she should have worn gloves during the skin assessments. Interview on 09/22/11, at 3:30 PM, with the Director of Nursing (DON)/ Infection Control Nurse revealed staff was expected to follow Standard Precautions by wearing gloves during any physical contact with residents. The DON stated staff should wear gloves during a skin assessment. The DON referred to information provided to staff during orientation which stated Standard Precautions means staff should assume that everyone has a disease, germ, or microorganism and should protect themselves by wearing gloves and washing hands when providing care to residents.