Every finding on record at Madonna Manor

Based on observation, interview, and review of the facility's policies, the facility failed to store and prepare foods under sanitary conditions. Observations on 09/30/2025, 10/01/2025, and 12/03/2025 included cleaning cloths lying on the counter and not in the sanitizer bucket, trash cans without lids in the food production area, and foods in the dry storage area not labeled, dated, and expired. This deficient practice had the potential to affect all 53 current residents.The findings include:Review of the facility's policy titled, Food Safety Guidelines, not dated, revealed cross-contamination could be biological, chemical, and physical.Review of the facility's policy titled, Food Preparation, not dated, revealed wiping cloth buckets should be assigned an area, stored off the floor and away from food and food contact surfaces. Per the policy, wiping cloths shall be stored in sanitizer solution off the floor and away from food and food contact surfaces, and wiping cloths shall be stored in sanitizer solution when not in-use. The policy stated food products shall be labeled and must include the following: date opened or created date to be consumed or discarded, with a maximum of seven days.Review of the facility's policy titled, Wiping Cloths, not dated, revealed wet wiping cloths shall be stored in an approved sanitizing solution. Per the policy, wiping cloths shall be changed frequently to prevent cross-contamination.Observation during the initial Kitchen tour on 09/30/2025 at 10:40 AM revealed, upon entering the kitchen, there were two cleaning cloths not in the sanitizer buckets and lying on the food production counters. The large gray trash can was open in the food production area. The dry storage area had several foods not labeled and dated. There was a one-half bag of opened marshmallows with no date; three bags of dry cereal with one which had been opened and taped closed; all dry cereal packages had no date or label; four gelatin mixes had no date; walnuts in clear packaging was taped closed without date or label; one clear package of vanilla wafers on the shelf had no date or label, and the side of the vanilla wafer package had a round hole and was opened; a variety of gravy mixes had no date; and 12 packages wrapped closed with powdered sugar had no label or date.Additional observation of the kitchen on 10/01/2025 at 8:30 AM revealed numerous food items in dry storage not labeled or dated on the shelves. The vanilla wafers bag was still on the shelf within view and continued to have a visible hole in the package. A vanilla wafer had fallen out of the package onto the shelf. Further observation revealed a cleaning cloth on the counter and not in the sanitizer bucket. Further observation revealed two open large trash cans in the food production area of the kitchen, and one of them was near the stand mixer while it was in food production.Additional observation of the kitchen dry storage on 12/03/2025 at 10:10 AM revealed several food items taken out of their box and lying on the shelf without a date. Also observed was a cornmeal package with a use-by-date of 04/22/2023; one opened assorted pasta in a clear package with no date; five assorted pasta in a clear package with no date; one pasta of colored rotini was opened and undated; 12 cornstarch packages had no dates; several gravy mix packages on the shelf with no date; eight powdered sugar packages with no date; two large chip bags on the top shelf with no date; and four yellow cake mixes out of the box with no date.In an interview with the Dietary Manager on 12/03/2025 at 10:59 AM, he stated dry storage food products needed to be dated if taken out of the box. He stated the food was stocked and rotated by Dietary staff. He stated the cleaning cloth was kept in the sanitizer bucket when not in use, and the sanitizer bucket was changed every four hours or with the appearance of a soiled solution. He stated the open trash receptacle could not be kept beside the stand mixer because it could cause cross contamination.In an interview with the Director of Nursing (DON) on 12/04/2025 at 10:08 AM, she stated staff should follow all the food service policies: trash receptacles should have lids, proper labeling and dating of food should occur; and cleaning cloths should be kept in the sanitizing solution when not in use. She stated the food in dry storage should be rotated correctly. In an interview with the Administrator on 12/05/2025 at 8:52 AM, she stated she expected staff to follow all state and federal sanitation regulations.

Based on observation, interview, record review, review of a disinfectant label, and review of the facility's policies, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases by ensuring staff involved in direct resident contact followed hand hygiene procedures and wore required personal protective equipment (PPE) for 1 of 16 sampled residents, Resident (R) 20. In addition, the facility failed to ensure a barrier was used to protect an enhanced barrier precautions (EBP) supply cart from a blood pressure cuff that had not been sanitized.The findings include:Review of the facility's policy titled, Infection Prevention and Control Program, dated 08/30/2022, last revised date 10/07/2025, revealed the program was designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections and that all staff were responsible for following all policies and procedures related to the program. Per the policy, Transmission-based precautions were placed on residents based on current Centers for Disease Control and Prevention (CDC) guidelines for infection or communicable disease. The policy stated all reusable items that had potential for contamination with infectious materials should be placed in an impervious clear plastic bag, labeled contaminated, and placed in the soiled utility room for pickup and processing. Review of the facility's policy titled, Hand Hygiene, dated 05/10/2023, last revised 09/16/2025, revealed all staff working in all locations within the facility would perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. Further review revealed hand hygiene was required after handling contaminated objects, before and after providing care to residents in isolation, and after handling items potentially contaminated with blood, body fluids, secretions, or excretions.Review of the facility's policy titled, Infection Surveillance, dated 08/30/2022, last revised date 05/22/2025, revealed the purpose was to monitor adherence to recommended infection prevention and control practices in order to reduce infections and prevent spread of infection. The policy stated surveillance activities were to be monitored facility-wide using a combination of processes and outcome measures through data collection, identification of ineffective practices through observation of staff, rounding observation data, skills validation for hand hygiene, PPE, and communication to staff information related to infection rates and outcomes.Review of the facility's policy titled, Personal Protective Equipment [PPE], dated 03/02/2023, revealed the guidelines and compliance included all staff having contact with residents and/or their environment, and they must wear PPE appropriate for care activities and any time that exposure to body fluids was likely. Per the policy, indications/considerations included performing hand hygiene before donning (to put on) and after doffing (to take off) PPE. It stated staff would receive training on why, what, and how PPE was used upon hire, annually, when any new product was introduced, and as needed.Review of the facility's policy titled, Transmission-Based (Isolation) Precautions [TBP], dated 08/30/2022, revealed Contact Precautions were defined as measures intended to prevent transmission of infectious agents spread by indirect contact with the resident or the resident's environment, and the category determined the type of PPE to be used. The policy stated signage that included instructions for use of specific PPE, would be placed in a conspicuous location outside the resident's room, PPE would be readily available near the entrance of the room, and staff would don appropriate PPE before or upon entry in the room. Review of an attachment titled, Recommendations for Personal Protective Equipment (PPE), revealed for contact isolation gloves should be donned upon entry to the room whenever touching the resident's skin or surfaces and articles in close proximity to the resident was anticipated. It also stated gowns should be donned upon entry to the room whenever staff members anticipated their clothing would have direct contact with a resident or potentially contaminated environmental surfaces or equipment in close proximity.Review of the label for Micro-Kill One (a fast-acting disinfectant bleach wipe with a one-minute kill time for most pathogens, including Tuberculosis (TB), Norovirus, and other bacteria/viruses) revealed surfaces must stay visibly wet for that duration to effectively clean and disinfect hard, nonporous surfaces like medical equipment and countertops.Review of R20's admission Record revealed the facility admitted the resident on 03/04/2024 with relevant diagnoses of cognitive communication disorder, chronic kidney disease, and acute kidney failure. Review of R20's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 09/08/2025, revealed a Brief Interview for Mental Status [BIMS] score of 12 out of 15, indicative of moderate cognitive impairment. The bladder and bowel assessment revealed occasional incontinence of bladder and always incontinent of bowel. The functional abilities assessment revealed a functional limitation in range of motion on both sides of lower extremities, requiring partial/moderate assistance with toileting hygiene, shower/bathing. Review of R20's Order Entry, dated 09/27/2025, revealed an order placed for meropenem, an antibiotic, to be administered intravenously (IV) every eight hours for seven days, to treat Extended-Spectrum Beta-Lactamase-producing bacteria (ESBL), a complex bacterium easily spread, resulting in serious infections. Further review revealed an order placed for Contact Isolation related to ESBL in urine was placed on 10/01/2025.1. Observation on 09/30/2025 at 10:25 AM revealed R20's room had a sign posted outside the door titled, Contact Isolation. Further observation revealed a three-drawer plastic bin outside the room entrance. Continued observation revealed at 10:29 AM the call light for the resident's room activated, and at 10:30 AM, a staff person was observed entering the room, while the door remained open. Continued observation made of the staff person standing by the resident at the bedside revealed the staff member picked up and held a cup without wearing a gown, gloves, or other PPE. At 10:32 AM, the staff member exited the room, carrying the cup. Further observation revealed she walked to the kitchenette area on the unit, opened the partial door, and sat the cup in a plastic bin. Further observation revealed she walked to the medication cart, touched the computer keyboard, and then used a hand sanitizing gel attached to the wall. In an interview with Licensed Practical Nurse (LPN) 1 on 09/30/2025 at 10:49 AM, she stated she had been the staff person observed entering and exiting R20's room, and she had not donned any PPE prior to or while in the room. LPN1 stated she was aware that R20 had orders for Contact Isolation due to ESBL in the urine, but he did not realize she had forgotten to don PPE until she was already standing in the room. She stated proper signage was in place, PPE was available outside of the room, and she should have been wearing gloves and a gown before entering the room. She stated it was important to follow the posted TBPs to prevent R20 from being exposed to any germs potentially being carried into the room and to prevent germs being carried to other residents. LPN1 stated she used hand sanitizer gel after placing the cup in the kitchen area, and she did not recall touching any other items before doing so. She stated, in hindsight, since she had not worn gloves, she should have washed her hands with soap and water. She stated she had received annual training on infection prevention and control policies and guidelines, hand washing, and how to don and doff PPE. However, she stated she had been busy and forgot to follow the guidelines.In an interview with the Administrator on 12/05/2025 at 10:10 AM, she stated she expected all staff to follow the required isolation procedures for the assigned contact precautions. She stated signs were placed outside the resident's door, PPE was readily available for staff, the facility provided all needed education and re-education for updates and as reminders. Therefore, she stated there would be no reason for staff not to follow the guidelines. She also stated the posted signage informed staff what PPE was required.2. Observation on 09/30/2025 at 11:15 AM revealed the red top wipes product, Micro-Kill One, was on the floor next to the enhanced barrier precaution (EBP) box by room [ROOM NUMBER]. Further observation revealed Registered Nurse (RN) 1 entered room [ROOM NUMBER] with gloves on and closed the door to assist the resident, who was not on EBP. He then exited the room without wearing the gloves and picked up the blood pressure (BP) wrist cuff from inside the treatment cart. He brought the BP wrist cuff monitor back out of the room, with his bare hands, and laid it down on the top of the EBP box, without use of a barrier. He used the red top wipe to sanitize the BP wrist cuff, with one hand, and talked on his phone with his other hand. In an interview with RN 1 on 09/30/2025 at 2:52 PM, he stated he used the pink/red top sanitizer wipes to sanitize the BP monitor/wrist cuff. He stated the kill time was about two minutes. He stated a barrier was needed on the top of the EBP box to prevent cross contamination of equipment between residents, and if the equipment was wet while used on the resident, it could cause skin irritation. In an interview with the Director of Nursing (DON) on 12/04/2025 at 10:27 AM, she stated the BP cuff should be cleaned between residents and a barrier put down if setting the BP cuff on top of the EBP box between the EBP box and the BP cuff. In an interview with the Staff Development Coordinator (SDC) on 12/04/2025 at 11:51 AM, she stated she provided the in-person orientation for all new hire employees. She stated it included instruction and return demonstrations of handwashing, donning, and doffing of PPE.In an interview with the Infection Preventionist (IP) on 12/04/2025 at 3:26 PM, she stated all staff received training at new hire orientation provided by the SDC on the different types of TBP, handwashing, and donning and doffing of PPE. In addition to the new hire orientation, she stated annual trainings on Infection Prevention and Control were assigned to staff through web-based training and were mandatory. She stated she performed routine observations of staff on all units for hand hygiene, cough etiquette, and proper donning/doffing of PPE based on TBP type. She stated if observations were made of staff not performing correctly, then direct education was provided at the time of the observation. The IP stated she did audits to confirm correct orders for the required type of TBP were in place. She stated she then followed up with an observation that the correct signage was posted at the room, and PPE was readily available outside of the isolation door. She stated the expectation was for all staff to follow the level of required PPE at all times and in all situations. She stated staff must follow handwashing and hand sanitizing policies and guidelines as written in the facility's policy. She stated per the facility's policy, any staff in contact with a resident in contact isolation was expected to wear a gown and gloves and to wash hands after leaving the room.In an additional interview with the DON on 12/04/2025 at 4:45 PM, she stated all staff received the required training concerning hand washing, proper donning/doffing of PPE, and infection prevention and control. She stated she expected all staff to follow the protocols that were in place for the resident's level of isolation.In an additional interview with the Administrator on 12/05/2025 at 8:58 AM, she stated she expected all staff to follow sanitation and infection control polices.

Based on interview, record review, review of the website www.weather.gov, and review of the facility's policies, the facility failed to have an effective system in place to ensure each resident received the electronic monitoring devices to prevent unsafe wandering and elopement, for 1 of 18 sampled residents, Resident (R) 1.Review of R1's Investigation Report revealed R1 was found by State Tested Nurse Aide (STNA) 2 outside the building, approximately 84 feet from the employee entrance/exit, on 08/07/2025 at 11:10 PM as she was getting out of her car from the back parking lot of Household B. Per the report, STNA2 brought R1, who appeared to be confused and was unstable with ambulation, back into the facility to get warm. During interviews conducted with facility staff who were on duty during the time of the 08/07/2025 elopement, they stated they had last seen the resident at approximately 9:30 PM and were unaware R1 left the building unsupervised until they received notice from Registered Nurse (RN) 1.The facility's failure to have an effective system in place to ensure residents' safety is likely to cause serious injury, impairment, or death, if immediate action is not taken. Immediate Jeopardy (IJ) was identified on 08/21/2025 and was determined to exist on 08/07/2025 in the area of 42 CFR 483.25. Substandard Quality of Care (SQC) was identified at 42 CFR 483.25 Quality of Care, F689. The facility was notified of IJ on 08/21/2025.The facility provided an acceptable Immediate Jeopardy Removal Plan, on 08/22/2025, alleging removal of the IJ on 08/23/2025. The State Survey Agency (SSA) validated the IJ was removed on 08/23/2025, prior to exit. Remaining non-compliance continues at a Scope and Severity of a D while the facility develops and implements a Plan of Correction (PoC) and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes.The findings include:Review of the facility's policy titled, Elopements and Wandering Residents, dated 08/12/2022, revealed the facility must establish and utilize a systematic approach to monitoring and managing residents at risk for elopement and or unsafe wandering, including identification and assessment risk, evaluation and analysis of hazards and risk, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. The policy also stated the IDT (Interdisciplinary Team) would evaluate the unique factors contributing to risk in order to develop a person-centered care plan, including if a resident should wear a Wander Gard bracelet.Review of R1's admission Record, located in the resident's electronic medical record (EMR), revealed the facility admitted the Resident on 07/23/2025 with diagnoses which included cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery, other sequelae following unspecified cerebrovascular disease, and Alzheimer's disease with late onset. Review of R1's Comprehensive Care (CCP), dated 07/25/2025, located in the resident's EMR, revealed the Resident was an elopement risk/wanderer related to impaired safety awareness and wandered aimlessly. The goal stated the resident would not leave the facility unattended. Interventions included: engage resident in purposeful activity and schedule regular walks and appropriate activity.Review of R1's Elopement Assessment, completed on admission on [DATE], revealed R1 had a history of elopement or an attempted elopement while at home as communicated by her family. Per the assessment, R1, having a history of elopement and R1's wandering behaviors were likely to affect the safety or wellbeing of self/others and was determined to be at high risk. Review of R1's admission Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 07/25/2025, located in the resident's EMR, revealed the facility assessed R1 to have a Brief Interview for Mental Status [BIMS] score of three out of 15, which indicated she had severe cognitive impairment.Review of R1's Facility Investigation, 08/07/2025, revealed on 08/07/2025 at approximately 11:10 PM as State Trained Nurse Aide (STNA) 2 was getting out of her car to walk into the back door entrance of Household B, she found R1 sitting alone in the grass near a tree. STNA2 approached R1 and asked R1 if she was okay and did she need any help. STNA2 stated R1 appeared to be confused because R1 stated she did not know where she was. STNA2 stated she told R1 she would be okay, and she was going to take her inside so she could get warm. STNA2 assisted R1 into the building, holding her close as R1 was unstable when walking. Per the investigation, STNA2 asked R1 if she was hurt anywhere, and R1 stated she did not know. STNA2 stated once she got inside the building, she asked staff, including the DON (who was working at the time), why R1 was outside, and no one knew how or why R1 was outside the building.Review of the website www.weather.gov revealed the temperature at the facility on the evening of 08/07/2025 was 78 degrees Fahrenheit with clear skies. Review of the distance taken by R1 when she exited the facility on 08/07/2025 in a measurement taken by a measuring wheel on 08/20/2025 at 2:00 PM by the facility's Physical Therapy Assistant 1 and the State Survey Agency (SSA) Surveyor revealed from Household C to the employee entrance/exit door was 18.9 feet. A second measurement taken on 08/20/2025 at 2:58 PM with the same participants revealed, from the tree where STNA2 saw R1 to the building, was 84.4 feet.Review of the facility provided security video with the Executive Director on 08/23/2025 at 12:12 PM revealed on 08/07/2025, time unknown, Security Officer 1 was observed walking to the employee entrance door and pressed the code to unsound the alarm. Further review of the video revealed Security Office 1 did not make any observations outside the facility or complete a perimeter check to verify any resident had left the facility. Observation of R1 on 08/19/2025 at 4:27 PM revealed R1 was sitting in her wheelchair. The Resident showed no acknowledgement of the State Survey Agency (SSA) Surveyor.During an interview with STNA2 on 08/20/2025 at 2:47 PM, she stated on 08/07/2025 she was reporting to work for her shift. She stated after parking her car, she exited the vehicle and started walking toward the facility from the back parking lot of Household B. She stated she saw a person sitting alone under a tree. At first glance, she stated she thought it was an employee; then at second glance, she realized it was an older resident. She stated she had not worked in Household C and had not had a chance to get acquainted with R1, but she instantly knew the person did not belong outside. She stated she asked R1 if she was okay or hurt, and R1 stated she did not know. She stated she was able to get R1 up from the ground; however, R1 was unstable. She stated she held on close to her, hugging her to keep R1 from falling. She stated she entered the building with R1 and asked staff on Household B if they were aware R1 was outside.During an interview with STNA3 on 08/20/2025 at 2:09 PM, she stated she was working on Household C with R1 on 08/07/2025. She stated the last time she saw R1 she was sitting quietly in her wheelchair. She stated during her shift she had not seen R1 wandering or having exit seeking behaviors. STNA3 stated after R1 was found outside and was back on Household C, she got the resident ready for bed, and she stayed in bed all throughout her shift. She stated she kept a closer eye on her that night due to her exiting the facility earlier that evening. Per the interview, she stated when the door alarms sounded, staff checked immediately to see if anyone got out. She stated she did not hear the alarm go off or see a Security Officer come to the unit and turn off an alarm. The STNA stated she checked on residents every two hours to make sure everyone was in the building and did not need anything. She stated a nurse from Household B told her R1 had been outside over on their unit and had no signs of distress except for being cold, so R1 was given a blanket.During an interview with STNA1 on 08/20/2025 at 2:24 PM, she stated R1 was sitting in her wheelchair in the dining area of Household C, and she saw the resident get up to walk. She stated she asked the resident to sit down, and the resident sat down. She stated she went to Household B and came back past the dining room, and the resident was gone. She stated she thought R1's aide had put the resident to bed. She stated she did not hear the alarm and never saw a Security Officer come to Household C to turn off an alarm. She stated if a resident tried to open the door, the alarm went off. She stated the alarms only sound if a resident had a Wander Gard. She stated the employee entrance/exit door required a code or badge to enter and exit. She stated all doors were fire doors, so if one held the door handle for 15 seconds, the door would automatically open.During an interview with Security Officer 1 on 08/20/2025 at 6:33 AM, he stated he reviewed the facility's videotape of the incident, the day of R1's elopement. Per interview, he stated 30 minutes prior to the resident getting out, a family member of another resident was trying to get out and triggered the alarm. He stated when he went back 30 minutes after the prior triggered alarm, he did not think a resident had gotten out and that maybe an employee or family member set off the alarm. Security Office 1 stated he reset the alarm by entering the code. He stated he looked out the glass panels of the door, did not see anyone, and left the unit. He stated the exit door employees used to come and go were right outside of the Household C where the resident resided. He stated he reviewed the security video feed after he was informed of the elopement and got the timeline of the events with R1 that night. He stated at 10:08 PM R1 was seen at the exited door, reading the sign that stated if you press on the door handle and hold for 15 seconds the alarm would sound and the door would open. He stated the resident held the door handle for 15 seconds, and she was out of the facility. He stated he had multiple people, family members, and staff who sounded the alarm on the door. He stated R1 was escorted back to Household C at 11:19 PM. He stated he had never had any specific procedures in place for him or the security team when the alarms were triggered. During an interview with Registered Nurse (RN1) on 08/20/2025 at 3:04 PM, she stated she was the admitting nurse the night R1 came to the facility on [DATE]. She stated she completed the Elopement Assessment on admission on [DATE], and R1 scored as a high risk. She stated if the resident who scored as high risk did not want to be at the facility, they could be confused and wander. She stated she added wandering/elopement to the Resident's Baseline Care Plan, so staff was aware to keep an eye on the resident. She stated with R1 being high risk, the nursing staff would document the resident's whereabouts and put a Wander Gard on the resident. She stated the night of 07/23/2025 with R1, she did not know why she did not apply the Wander Gard to the resident. She stated it was nighttime, and she figured R1 would just stay in bed. In an interview with the Director of Nursing (DON) on 08/19/2025 at 4:43 PM, she stated the resident was not wearing a Wander Gard at the time she was found outside the facility. She stated due to R1's behaviors and being high risk for wandering and elopement, R1 should have been given a Wander Gard. She stated the resident was last seen by STNA3 on 08/07/2025 at approximately 9:30 PM sitting in her wheelchair in the dining room. The DON stated she was working as an RN for the shift and did not have any recollection of the resident wandering or exit seeking behaviors. She stated the resident was able to exit the building by going out the Household C employee entrance/exit. Per the DON, the Resident was found outside in the parking lot alone sitting under a tree at the back door of Household Entrance B around 11:10 PM. The DON stated there were many system failures by the facility. She stated R1 was not given a personal safety device due to her scoring on the Elopement Assessment on admission. She stated the admitting RN1 had received disciplinary action due to not applying a Wander Gard to R1. She stated Security Officer 1 also received disciplinary action as he was aware the door alarm was going off, cut off the door alarm by entering the code, but failed to do a security check on the perimeter to verify no resident left the facility through the door. She stated anytime an alarm was triggered it needed to be treated as if a resident could have possibly left the facility. During an interview with the Executive Director on 08/22/2025 at 3:03 PM, she stated R1 did get out of Household C where she was residing and exited the employee entrance/exit of the facility. She stated R1 should have been given a Wander Gard bracelet considering her family informed RN1, the admitting nurse, the night of 07/23/2025 that R1 had wandered/eloped from her residence and was assessed to be an elopement risk. She stated under no circumstances was it okay for an admitting nurse to think the resident would just go to bed and ignore facility policy to implement interventions to keep residents safe.The facility's IJ Removal Plan verbatim:The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. (Completion Date: 8/13/2025) The DON, ADON, SOC, and RN Manager re-evaluated all residents for risk of wandering/elopement using N Adv - Elopement Evaluation in Point Click Care. Completed 8/13/2025 All residents were reassessed using the N Adv - Elopement Evaluation. 18 residents scored at 1+ on the N Adv - Elopement Evaluation as possible elopement/wandering risk. Completed 8/13/2025 The MOS Coordinator and ADON reviewed and updated care plans for the 18 identified elopement/wandering risk individuals as needed. Completed 8/13/2025 DON/RN Managers completed an audit to confirm all Wanderguards were functioning properly and in place for all residents care-planned for Wanderguards. Completed 8/13/2025 DON/RN Managers audit that nurses test the function of the wanderguard daily and placement each shift. Audit results are communicated by the DON/RN Manager at QAPI meetings until substantial compliance is achieved. All staff on all shifts received education on wandering, elopement, and resident safety from the DON, SOC, RN Manager, and ADON. 169 staff received education. 6 staff are on LOA, 47 staff are on vacation or are PRN and have not worked yet. Any staff on leave, PRN or vacation will receive education on their next scheduled work day by RN Manager/DON/ED. [NAME] Manor does not use agency staff. Completed 8/13/2025 or by their next scheduled shift. DON/Nurse Managers/ED administer quizzes to all staff. DON/Nurse Managers/ED follow up with all staff if a question was answered incorrectly, education was provided immediately. Completed 8/13/2025 or by their next scheduled shift. DON/RN Managers provided education for all licensed nurses regarding assessment and developing care plans and interventions for residents who are at risk for elopement. The Director of Facilities tested the Doors, Locks, & Alarms on both 8/7/2025 and 8/13/2025. All functioning properly. Doors, Locks & Alarms will continue to be tested weekly. An Elopement Drill was conducted on day shift and night shift on 8/22/2025 to assure staff understanding of proper process during an elopement.[NAME] Manor took the following actions to prevent an adverse outcome from reoccurring. (Completion Date: 8/13/2025 Elopements and Wandering Residents policy was reviewed by ED, VP of Operations, and SOC. Completed. No changes were made to the policy. 8/8/2025. Elopements and Wandering Residents policy was reviewed again by ED, VP of Clinical, VP of Operations and DON. No changes were made to the policy. Completed 8/11/2025. The admitting nurse completes an admission N Adv - Elopement Evaluation assessment and places interventions as appropriate. Starting on admission after 8/13/2025. The DON/Nurse Managers will audit all new admissions for elopement risk and ensure appropriate interventions are in place. Starting with admissions after 8/13/2025 until substantial compliance is achieved. The DON/Nurse Managers will audit all new admission care plans to ensure it reflects individual needs identified. Starting with new admissions after 8/13/2025 until substantial compliance is achieved. Newly hired employees will receive education on wandering, elopement, and resident safety by the DON/Nurse Managers in orientation starting 8/13/2025. An Adhoc QAPI with Medical Director, Director of Social Services, DON, and Executive Director was completed on 8/13/2025 to review QAPI plan created on 8/8/2025 Medical Director agrees with QAPI plan. DON/Nurse Managers will report results of audits, follow up and trends to QAPI committee on 8/22/2025 and will continue to report data to QAPI weekly for 4 weeks and then every other week until we are in substantial compliance. An Elopement Drill was held on 8/22/2025 at approximately 11:30am. An additional Elopement Drill will be held 8/22/2025 for night shift (after7pm) An Ad Hoc QAPI meeting is scheduled for 8/22/2025 at 8pm to discuss the results of the Elopement Drills and the IJ Abatement plan progress.Date facility alleges IJ removal: 8/23/2025

Based on interview, record review, and review of the facility's policy, the facility failed to implement the abuse policy for 1 of 5 sampled residents, Resident (R) 15. A Dining Aide (DA) 1 tied a washcloth around one wheel of R15's wheelchair around 2:00 PM on 01/13/2025. State Trained Nurse Aide (STNA) 13 witnessed DA1 tie the washcloth to the wheel of R15's wheelchair, but failed to report the incident, and R15 fell from her wheelchair. The facility provided an acceptable Plan of Correction (POC) on 01/31/2025 alleging past noncompliance. The State Survey Agency (SSA) survey team validated the deficient practice was corrected on 02/01/2025, following the facility's implementation of the acceptable POC and before the start of the survey. The findings include: Review of the facility's Abuse policy titled, Compliance with Reporting Allegations of Abuse/Neglect/Exploitation, effective 10/24/2022, revealed the facility reported all allegations of abuse/neglect/exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property. Per the policy, staff was to immediately report any of those incidents to the Administrator of the facility, and the Administrator would report to other appropriate agencies in accordance with current state and federal regulations within prescribed timeframes. Review of R15's Face Sheet revealed the facility admitted the resident on 03/17/2022 with diagnoses of dementia, cognitive communication deficit, and disorientation. Review of R15's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/24/2024, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of eight of 15, indicating she was moderately cognitively impaired. This assessment also revealed R15 was ambulatory, self-propelling for mobility, and used a manual wheelchair. Review of R15's Comprehensive Care Plan (CCP), created on 03/21/2022, revealed R15 was at risk for falls related to impaired mobility, risk for pain, hospice admission, weakness, diagnosis, and being totally dependent on physical assist of one to two staff members with performing activities of daily living (ADL). Review of the facility's Investigation Report, dated 01/13/2025, revealed DA1 admitted in a written statement he tied a washcloth on the wheel of R15's wheelchair to keep an eye on her due her wandering around Household A. The report also revealed STNA13 witnessed the DA1 place the washcloth on the wheel of R15's wheelchair and failed to report the incident. In an interview with Nurse 8 on 02/27/2025 at 11:13 AM, she stated she was called to Household A to assess R15 who was lying on the floor. R15 was located on the floor underneath a table with her head propped up with a pillow. Nurse 8 stated R15 had no physical wounds, abrasions, or bleeding. Nurse 8 stated R15 answered all her questions that she had asked. Nurse 8 stated she and Kentucky Medication Aide 14 looked down and saw what appeared to be a washcloth tied to the wheel of the wheelchair making the wheelchair stationary and unable to be moved. During an interview with STNA13 on 02/27/2025 at 3:51 PM, she stated the incident happened after lunchtime, and she witnessed DA1 tie a washcloth to the wheel of R15's wheelchair. STNA13 stated she was unsure if tying the washcloth to the resident's wheelchair was a restraint. STNA13 stated she did not report it to anyone at the facility where she was employed. STNA13 stated after R15 fell from her wheelchair she left the building. Review of the facility's documented phone call to STNA13 from Human Resources (HR) on 01/15/2025 at 4:55 PM, she stated she was aware DA1 placed a restraint on the wheelchair of R15. Per the document, STNA13 was asked by HR what she should have done based on the information she received from the restraint and abuse training and test which was done the prior Tuesday and Wednesday. The document revealed STNA13 stated she should have removed the restraint and reported it. During an interview with the Administrator on 02/27/2025 at 9:52 AM, she stated she was informed of the incident regarding DA1 tying a washcloth to the wheel of R15's wheelchair after R15 was found lying on the ground. The Administrator stated she immediately opened an investigation on how R15 fell as she would on any fall that took place in the facility. The Administrator Stated Nurse 8 found the washcloth tied to the to the wheel of R15's wheelchair. The Administrator stated tying a washcloth to a wheel or any resident to keep them from moving freely inside the facility was a form of physically restraining a resident and was not a standard for quality care. The Administrator stated the facility provided in-services and Relias (online) training on physical and chemical restraints and Abuse and Reporting for all employees. The Administrator stated STNA13 should have reported DA1 immediately to her Unit Nurse if she was unsure or had any question of the DA1 tying the washcloth to the wheel of R15's wheelchair. The Administrator stated STNA13 failing to report the incident conflicted with the facility's policy on reporting abuse. The Administrator stated any allegations of abuse should be reported immediately. The facility provided an acceptable Plan of Correction on 01/31/2025 alleging past non-compliance of the deficient practice and a date of compliance of 02/01/2025 with corrective actions as follows verbatim: 1. Corrective actions for identified resident(s) affected by the deficient practice. Review of document titled, Restraints used educate staff on Physical and Chemical Restraints. Review of document titled; Alzheimer's Association used to educate staff on Wandering. Review of the facility's, CHI Skin One Time Observation, dated for 01/13/2025 revealed R15 had no abnormalities and her skin was intact. Review of the disciplinary action/termination of the STNA13 revealed she was terminated on 01/15/2025. Review of the facility staff training log dated 01/14/2025 revealed every employee within the facility signed stating they received training on Resident Abuse, Reporting and Restraints.

Based on interview, record review, and review of the facility's policies, the facility failed to ensure each resident had the right to be free from restraint for 1 of 5 sampled residents, Resident (R) 15. On 01/13/2025 at approximately 2:00 PM, a Dining Aide (DA) 1 tied a washcloth around one wheel of R15's wheelchair. Activity Assistant 2 saw R15 on the floor around 3:00 PM. At that time, Activity Assistant 2 notified State Trained Nurse Aide/Kentucky Medical Aide (STNA/KMA) 14 who was in the hall and STNA15. The facility provided an acceptable Plan of Correction (POC) on 01/31/2025 alleging past noncompliance. The State Survey Agency (SSA) survey team validated the deficient practice was corrected on 02/01/2025, following the facility's implementation of the acceptable POC and before the start of the survey. The findings include: Review of the facility's policy titled, Compliance with Reporting Allegations of Abuse/Neglect/Exploitation, effective 10/24/2022 and reviewed 02/26/2025, revealed staff was to immediately report all allegations of abuse/neglect/exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property, immediately to the Administrator of the facility. It also stated the Administrator would then report to the appropriate agencies in accordance with current state and federal regulations within prescribed timeframes. Review of the facility's policy titled, Resident Rights, effective 10/24/2022 and reviewed 02/11/2025, revealed residents had a right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. Per the policy, the resident had a right to be treated with respect and dignity, including: the right to be free from physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms. Review of R15's Face Sheet revealed the facility admitted the resident on 03/17/2022 with diagnoses of dementia, cognitive communication deficit, and disorientation. Review of R15's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/24/2024, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of eight of 15, indicating she had moderate cognitive impairment. This assessment also revealed R15 was ambulatory and self-propelling for mobility when she used a manual wheelchair. Review of R15's Comprehensive Care Plan (CCP), created on 03/21/2022, revealed R15 was at risk for falls related to impaired mobility, risk for pain, hospice admission, weakness, diagnosis, and being totally dependent on physical assist of one to two staff members with performing activities of daily living (ADL). Review of the facility's Falls List, dated 11/01/2024 to 01/26/2025, revealed R15 had two falls, one on 01/10/2025 and one on 01/13/2025. Per the list, R15 had no injuries from either fall. Review of DA1's employment file revealed his hire date was 08/21/2024. Further review revealed his abuse/criminal abuse check was completed on 08/07/2024, and the results showed there were no prior abuse or criminal convictions. Review of the facility's Investigation Report, dated 01/13/2025, revealed DA1 admitted in a written statement he tied a washcloth on the wheel of R15's wheelchair to keep an eye on her due her wandering around Household A. Further review revealed STNA13 witnessed DA1 place the washcloth on the wheel of R15's wheelchair and failed to report the incident. In an interview with STNA13 on 02/27/2025 at 3:51 PM, she stated the incident happened after lunchtime, and she witnessed DA1 tie a washcloth to one of the wheels of R15's wheelchair. STNA13 stated she was unsure if the tying of the washcloth to the resident's wheelchair was a restraint. STNA13 stated she did not report it to anyone at the facility. In an interview with the Administrator on 02/27/2025 at 9:52 AM, she stated she was informed of the incident regarding DA1 tying a washcloth to the wheel of R15's wheelchair after R15 was found lying on the ground. The Administrator stated she immediately opened an investigation on how R15 fell , as she would on any fall that took place in the facility. The Administrator stated R15 had a habit and was care planned for getting out of her wheelchair and lying on the floor with a blanket over her head. The Administrator stated she had Nurse 8 and the Scheduler/Former STNA16 help assess R15 and get her back into her wheelchair. The Administrator stated Nurse 8 assessed R15 to have no physical wounds, abrasions, or bleeding, and R15 responded appropriately to the questions being asked. The Administrator stated Nurse 8 found the washcloth tied to the to the wheel of the wheelchair. The Administrator stated tying a washcloth to a wheel or any resident to keep them from moving freely inside the facility was a form of physically restraining a resident and was not a standard for quality care. The facility provided an acceptable Plan of Correction on 01/31/2025 alleging past non-compliance of the deficient practice and a date of compliance of 02/01/2025 with corrective actions as follows verbatim: 1. Corrective actions for identified resident(s) affected by the deficient practice. Review of document titled, Restraints used educate staff on Physical and Chemical Restraints. Review of document titled; Alzheimer's Association used to educate staff on Wandering. Review of the facility's, CHI Skin One Time Observation, dated for 01/13/2025 revealed R15 had no abnormalities and her skin was intact. Review of the disciplinary action/termination of the Dining Aid1 revealed his was terminated on 01/13/2025. Review of the disciplinary action/termination of the STNA13 revealed she was terminated on 01/15/2025. Review of the facility staff training log dated 01/14/2025 revealed every employee within the facility signed stating they received training on Resident Abuse, Reporting and Restraints.

Based on interview, record review, and review of the facility's policy, the facility failed to have an effective system in place to ensure residents were free from significant medication errors for 1 of 2 sampled residents receiving intravenous (IV) antibiotic therapy, Resident (R) 3. On 11/26/2024, the facility admitted R3 with diagnoses to include post laminectomy syndrome (chronic pain following back surgery; a laminectomy was removing part or all of the bony arch that covered the spinal cord) and post-surgical infection of the intrathecal (the space between the spinal cord and the membranes that protect it) pain pump. The resident was scheduled to receive two weeks of intravenous (IV) antibiotic therapy while at the facility. Review of R3's Medication Administration Record [MAR] revealed the physician had ordered cefepime (an antibiotic given for infection) to be administered IV twice daily, but he did not receive four of those ordered doses. In addition, the MAR revealed the physician ordered metronidazole (an antibiotic) to be administered orally every eight hours, but he did not receive five of those doses. On 12/01/2024 at approximately 11:30 AM, R3's family alerted Licensed Practical Nurse (LPN) 1 that R3 was febrile, unresponsive, and had tremors. The family requested the nurse to call emergency medical services (EMS) for transfer to the local emergency department (ED). R3 presented to the ED in an altered mental status, septic, and in atrial fibrillation with rapid ventricular response (AFib RVR). R3 spent five days in a critical care unit (CCU) and was in the hospital for 12 days. Immediate Jeopardy (IJ) was identified on 12/20/2024 and was determined to exist on 11/26/2024, in the area of 42 CFR S483.45, F760 Free of Significant Medication Errors at a Scope and Severity (S/S) of a J related to KY00044335. The IJ at F760 also constituted Substandard Quality of Care (SQC) at 42 CFR 483.45. The facility was notified of the IJ on 12/20/2024 at 1:15 PM. On 12/20/2024 at 1:15 PM, the facility's Executive Director, Unit Manager, and Infection Preventionist were provided a copy of the IJ Template and notified that the facility failed to have a system to ensure R3's medications were administered as ordered and verified. This failure is likely to cause serious injury, impairment, or death. The facility provided an acceptable IJ Removal Plan, on 01/02/2025 at 1:45 PM, alleging removal of the IJ on 01/02/2025. The State Survey Agency (SSA) validated the IJ had been removed on 01/02/2025 at 1:45 PM, after an acceptable Removal Plan was received and further interviews, observations, and record reviews were conducted to verify the immediate corrections. Remaining non-compliance continued at a S/S of a D (no actual harm with a potential for more than minimal harm that is not immediate jeopardy) at F760. Refer to F655 and F684 The findings include: Review of the facility's policy titled, Medication Administration, undated, revealed medications were administered as prescribed by the physician and in accordance with established professional standards of practice. Further review revealed the facility upheld the rights related to medication administration, which included ensuring medications were given at the appropriate times. Per the policy, all medications should be administered within 60 minutes prior to or after the scheduled time. Closed Record Review of R3's Face Sheet, located in the resident's electronic medical record (EMR), revealed the facility admitted the resident on 11/26/2024 with diagnoses to include post laminectomy syndrome, post-surgical infection of the intrathecal pain pump, and idiopathic peripheral neuropathy. Review of R3's admission Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 12/01/2024, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 14 out of 15, which indicated R3 was cognitively intact. Review of R3's Physician Orders, located in the resident's electronic medical record (EMR), revealed on 11/26/2024, R3 was ordered cefepime, 2 grams (gm) IV twice daily at 9:00 AM and 9:00 PM for the treatment of infections. Additionally, on the same date, R3 was prescribed metronidazole, 500 milligrams (mg) one oral tablet taken every eight hours for infections. Review of R3's MAR, dated 11/2024, and located in the resident's EMR, revealed the facility failed to administer three doses of ordered cefepime on 11/26/2024 at 9:00 PM; 11/27/2024 at 9:00 AM; and on 11/29/2024 at 9:00 AM. Further review revealed nursing staff administered IV antibiotics to R3 outside the scheduled parameters according to facility policy on four occasions: 1) on 11/27/2024 the 9:00 PM dose was administered on 11/28/2024 at 12:06 AM, resulting in a delay of two hours and six minutes; 2) on 11/29/2024 the 9:00 PM dose was administered at 10:30 PM, resulting in a delay of 30 minutes; 3) on 11/30/2024 the 9:00 AM dose was administered at 12:36 PM, resulting in a delay of two hours and 36 minutes; and 4) on 11/30/2024 the 9:00 PM dose was administered to R3 at 12:04 AM on 12/01/2024, resulting in a delay of two hours and four minutes. Review of R3's MAR, dated 12/2024, revealed the facility failed to administer one dose of ordered cefepime on 12/01/2024 at 9:00 AM. Review of R3's MAR, dated 11/2024, revealed the facility failed to administer the following four doses of metronidazole: 11/26/2024 at 10:00 PM; 11/27/2024 at 6:00 AM or 2:00 PM; and 11/28/2024 at 2:00 PM. Review of R3's MAR, dated 12/2024, revealed the facility failed to administer one dose of metronidazole on 12/01/2024 at 6:00 AM. Review of R3's Nurse's Note, dated 12/01/2024 at 11:52 AM and authored by LPN1, revealed R3 was transferred to the local ED. LPN1 stated R3's family alerted staff that R3 was not responding. LPN1 stated upon assessment, R3 was lethargic, difficult to arouse, and would only respond to painful stimuli. She noted bodily tremors were observed. Review of R3's ED Provider Notes, dated 12/01/2024, revealed R3 presented to the ED in an altered mental status, septic, and in atrial fibrillation with rapid ventricular response (AFib RVR). R3 was febrile. His mental status was noted as somnolent, opened eyes to verbal stimuli, but was not conversant. Further review of the note revealed the physician stated, Upon my evaluation the patient [resident] had a high probability of imminent or life-threatening deterioration due to presentation which required my direct attention, intervention, and immediate management. During an interview with Family Member (F) 2 on 12/18/2024 at 12:23 PM, she stated when family came to visit R3 on 12/01/2024 at 11:10 AM, they found R3 unresponsive, feverish, sweaty, and exhibiting seizure like activity. F2 stated the family alerted LPN1 of R3's change in condition (CIC), and they requested LPN1 to call emergency medical services (EMS) for transfer to the local emergency department. F2 stated R3 was admitted to the local hospital's critical care unit (CCU) for several weeks. She stated R3 had returned home and required an additional 10 weeks of intravenous [IV] antibiotic therapy. During an interview with LPN1 on 12/18/2024 at 11:58 AM, she stated at the time the family made her aware of R3's CIC at around 11:00 AM, she had not seen R3 and had not given him his 9:00 AM dose of IV antibiotics. LPN1 stated that all medications should be given as ordered. During further interview, LPN1 stated that on 12/01/2024, it was a particularly busy day, and she had fallen behind on her assessments and medication administration. She stated she had tried her best to manage her tasks. Additionally, LPN1 stated she did not recall if she communicated her need for assistance or asked the unit coordinator (UC) for support. During an interview with the Advanced Practice Registered Nurse (APRN) on 12/20/2024 at 1:15 PM, she stated she expected the nursing staff to administer medication as ordered by the medical provider. She stated administering medication on time, every time, was important to ensure that all bacteria causing the infection were eliminated. She stated this was also the best approach to prevent the infection from recurring. During a telephone interview with the Medical Director on 12/19/2024 at 12:40 PM, he stated he expected the nursing staff to administer medication as ordered by the medical provider. The Medical Director stated administering antibiotics on time was important to ensure that all bacteria causing the infection were eliminated and to prevent the infection from recurring. Per the interview, the Medical Director stated it was his expectation that staff followed all facility policies to ensure quality of care and the safety of the residents. During an interview with Registered Nurse (RN) 4/Unit Manager (RN/UM) on 12/18/2024 at 12:51 PM, she stated nursing staff should administer antibiotic medication as ordered to treat and prevent the infection from recurring. She stated that administering medication timely was important for the resident's safety and well-being. During an interview with the Interim Director of Nursing (IDON) on 12/18/2024 at 10:06 AM, she stated the unit managers were responsible for auditing medication administration on their units; however, there was no formal documentation of those audits. The IDON stated it was her expectation that licensed staff should administer antibiotics as prescribed and timely to ensure the infection was treated and to prevent recurrence. She further stated that timely medication administration was crucial for the resident's safety and well-being. During an interview with the Executive Director (ED) on 12/19/2024 at 1:08 PM, she stated it was her expectation that staff adhered to the facility's medication administration policy. The ED stated following the medical provider's orders was crucial for ensuring safe and appropriate care for all residents. The facility provided an acceptable removal action plan on 01/02/2025 at 1:45 PM that read verbatim: Resident #3 was discharged from [Facility Name] on 12/1/24. Identification of Residents Affected or Likely to be affected: Residents currently at [Facility Name]. Actions to prevent occurrence/recurrence: l. An Ad Hoc QAPI meeting was held with DON, Medical Director and ED on 12/20/24 discussed IJ regarding Medication Administration for Medical Director input. 2. The Corporate Clinical team, VP of Operations, Executive Director and DON discussed the Medication Administration policy and the plan for abatement. 12/20/24 3. The Director of Clinical Risk Management reviewed the Medication Administration policy. Completed 12/20/24. 4. The Director of Clinical Risk Management educated the DON and Nurse Managers regarding the Medication Administration policy. Completed 12/20/24 5. The Director of Clinical Risk Management and the DON audited all missed meds using the Medication Admin Audit Report in PCC and communicated with MD and responsible party as needed. Completed 12/20/24 6. The DON/Nurse Managers provided education for all nurses and KMAs regarding Medication Administration policy and the Nurse Clinical Binder. Agency Nurses are educated prior to their shift. 100% complete with 1 nurse on leave who will be educated prior to her return to work. 7. Nurses were educated by the DON/Nurse Managers on the Nurse Clinical Binder that includes information on Daily Nurse Expectations, pharmacy cut off times, admission/readmission orders, what to do when a medication is unavailable, what to do when someone admits to the facility, what to do when a resident receives new orders, what to do when sending someone to the hospital, what to do when you receive medications from the pharmacy and Medication Administration Special Considerations. Education was initially completed by the DON on [DATE]th and [DATE]th at the Monthly All Staff Clinical Meeting. Beginning 12/21 the DON/Nurse Managers started referencing the Nurse Clinical Binder as education on step by step guides for nurses and KMAs. 8. DON/Nurse Managers administer quizzes to nurses and KMAs regarding Medication Administration. DON/Nurse Managers follow up with Nurse/KMA if a question is missed and reports results to QAPI team weekly. 9. Starting 12/21/24, DON/Nurse Manager completes audit daily 7 days per week using Medication Admin Audit Report in PCC. DON/ Nurse Managers address issues immediately with appropriate nurse or KMA and assures follow up regarding notification policy. 10. Starting on 12/21 Nurse Managers provided daily 1:1 Nurse/KMA coaching to ensure medication administration per MD orders. 11. Starting with admissions on or after 1/1/25 DON/Nurse Managers compare the hospital discharge summary to the MD orders in PCC for all new admissions, within 12 hours of admission, to assure accuracy and timeliness of medication administration. Results of the audits will be reported to the QAPI committee weekly for 4 weeks and every other week until substantial compliance is achieved. 12. DON/Nurse Manager reported results of audits, follow up, and trends to QAPI committee on 12/27/24 and will continue to report data to QAPI weekly for 4 weeks and then every other week until we are in substantial compliance. 13. QAPI meeting on 12/27/24 was attended by Medical Director, Nurse Practitioner, ED, DON, Diet Tech, Nurse Manager, IP Nurse, Social Worker designee, Director of Facilities, Business Office Manager, MDS nurse, Director of Therapy and Life Enrichment Director. IP abatement plan audits, results, and follow up were discussed. 14. The next QAPI meeting is scheduled for 1/3/25. Date facility alleges IJ removal: 1/2/2025

Based on interview, record review, and review of the facility's policy, the facility failed to promptly identify and intervene with a significant change in a resident's condition, for the resident to receive treatment and care in accordance with professional standards of practice for 1 of 11 sampled residents, Resident (R) 3. R3 was admitted to the facility on [DATE] with diagnoses to include post-surgical infection of the intrathecal (the space between the spinal cord and the membranes that protect it) pain pump. The resident was to receive two weeks of intravenous (IV) antibiotic therapy by a peripherally inserted central catheter (PICC) line. However, the resident did not receive four of those ordered doses. In addition, the MAR revealed the physician ordered metronidazole (an antibiotic) to be administered orally every eight hours, but R3 did not receive five of those doses. On 12/01/2024, in the early hours of the morning, R3 was observed by Registered Nurse (RN) 2 to have a significant change in mental status. At 7:00 AM, during the shift change, RN2 communicated to Licensed Practical Nurse (LPN) 1 that the resident's mental status had deviated from baseline during the night. However, neither nurse rounded on R3 to assess his condition and failed to notify the physician or provider. On 12/01/2024 at approximately 11:30 AM, R3's family alerted LPN1 that R3 was febrile, unresponsive, and had tremors. The family requested the nurse to call emergency medical services (EMS) for transfer to the local emergency department (ED). The resident was admitted to the hospital with life-threatening deterioration and spent five days in a critical care unit (CCU) and was in the hospital for 12 days. Immediate Jeopardy (IJ) was identified on 12/20/2024 and was determined to exist on 11/26/2024, in the area of 42 CFR S483.25, F684 Quality of Care at a Scope and Severity (S/S) of a J related to KY00044335. The IJ at F684 also constituted Substandard Quality of Care (SQC) at 42 CFR 483.25. The facility was notified of the IJ on 12/20/2024 at 1:20 PM. On 12/20/2024 at 1:20 PM, the facility's Executive Director, Director of Corporate Risk Management, Unit Manager, and Infection Preventionist were provided a copy of the IJ Template and notified that the facility's failure to have an effective system to ensure residents received treatment and care in accordance with professional standards of practice has caused or is likely to cause serious injury, serious harm, or death. The facility provided an acceptable IJ Removal Plan, on 01/02/2025 at 1:45 PM, alleging removal of the IJ on 01/02/2025. The State Survey Agency (SSA) validated the IJ had been removed on 01/02/2025 at 1:45 PM as alleged, after an acceptable Removal Plan was received and further interviews, observations, and record reviews were conducted to verify the immediate corrections. Remaining non-compliance continued at a S/S of a D (no actual harm with a potential for more than minimal harm that is not immediate jeopardy) at F684. Refer to F580, F655, and F760 The findings include: Review of the facility's policy titled, Provision of Quality of Care, dated 12/20/2024, revealed the facility would ensure residents received treatment and care by qualified persons in accordance with professional standards of practice, the comprehensive person centered care plan, and the resident's choice. Further review revealed each resident would be provided care and services to attain or maintain his or her highest practicable physical mental and psychosocial well-being. Additionally, per the policy, all employees were responsible for following established policies and procedures. Closed record review of R3's Face Sheet, located in the resident's electronic medical record (EMR), revealed the facility admitted the resident on 11/26/2024, with diagnoses to include post laminectomy syndrome, post-surgical infection of the intrathecal pain pump, and idiopathic peripheral neuropathy. Review of R3's admission Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 12/01/2024, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 14 out of 15, which indicated R3 was cognitively intact. Continued review revealed R3 was assessed as having a wound infection and receiving oral and IV antibiotic therapy. Review of R3's Baseline Care Plan, dated 11/26/2024, located in the resident's EMR, revealed there was no documented evidence showing the facility had created a baseline care plan with treatments and interventions to address R3's current infection, antibiotic therapy, care of the PICC line, or physician notification for worsening condition. Review of R3's EMR clinical documentation revealed, from 11/27/2024 at 11:43 AM until 12/01/2024 at 11:52 AM, no nursing progress notes were documented that showed nursing staff had performed clinical assessments per professional standards of practice to evaluate the resident's condition. Review of R3's Physician Orders, located in the resident's electronic medical record (EMR), revealed on 11/26/2024, R3 was ordered cefepime, 2 grams (gm) IV twice daily at 9:00 AM and 9:00 PM for the treatment of infections. Additionally, on the same date, R3 was prescribed metronidazole, 500 milligrams (mg) one oral tablet taken every eight hours for infections. Review of R3's Medication Administration Record (MAR), dated 11/2024, and located in the resident's EMR, revealed the facility failed to administer three doses of ordered cefepime on 11/26/2024 at 9:00 PM; 11/27/2024 at 9:00 AM; and on 11/29/2024 at 9:00 AM. Further review revealed nursing staff administered IV antibiotics to R3 outside the scheduled parameters according to facility policy on four occasions: 1) on 11/27/2024 the 9:00 PM dose was administered on 11/28/2024 at 12:06 AM, resulting in a delay of two hours and six minutes; 2) on 11/29/2024 the 9:00 PM dose was administered at 10:30 PM, resulting in a delay of 30 minutes; 3) on 11/30/2024 the 9:00 AM dose was administered at 12:36 PM, resulting in a delay of two hours and 36 minutes; and 4) on 11/30/2024 the 9:00 PM dose was administered to R3 at 12:04 AM on 12/01/2024, resulting in a delay of two hours and four minutes. Review of R3's MAR, dated 12/2024, revealed the facility failed to administer one dose of ordered cefepime on 12/01/2024 at 9:00 AM. Review of R3's MAR, dated 11/2024, revealed the facility failed to administer the following four doses of metronidazole: 11/26/2024 at 10:00 PM; 11/27/2024 at 6:00 AM or 2:00 PM; and 11/28/2024 at 2:00 PM. Review of R3's MAR, dated 12/2024, revealed the facility failed to administer one dose of metronidazole on 12/01/2024 at 6:00 AM. Review of R3's Nurse's Note, dated 12/01/2024 at 11:52 AM and authored by LPN1, revealed R3 was transferred to the local ED upon the request of family. LPN1 stated the resident's family alerted staff that R3 was not responding. LPN1 stated upon her assessment, R3 was lethargic, difficult to arouse, and would only respond to painful stimuli. She noted bodily tremors were observed. Review of R3's ED Provider Notes, dated 12/01/2024 at 2:47 PM, found in the local hospital records, revealed R3 presented to the ED in an altered mental status, septic, and in atrial fibrillation with rapid ventricular response (AFib RVR). R3 was febrile. His mental status was noted as somnolent, opened eyes to verbal stimuli, but was not conversant. Further review of the note revealed the physician stated, Upon my evaluation the patient had a high probability of imminent or life-threatening deterioration due to presentation which required my direct attention, intervention, and immediate management. Review of R3's Infectious Disease Progress Note, dated 12/08/2024 at 8:12 AM, found in the local hospital records, revealed R3 was admitted to the hospital and found to have an enterococcus faecium (VRE, a type of bacteria that could cause serious infections) bacteremia (a type of bacteria found in blood). Review of R3's Infectious Disease Progress Note, dated 12/12/2024 at 11:13 AM, found in the local hospital records, revealed R3 presented with a temperature of 102.2 degrees Fahrenheit (F) upon admission to the local hospital. Further review revealed the resident continued on IV and oral antibiotic therapy for an additional six weeks. Review of R3's clinical records, located in the resident's EMR, revealed there was no documentation on 11/30/2024 or 12/01/2024 by RN2 during the 7:00 PM to 7:00 AM shift related to R3's lethargy or change in mental status. Review of R3's Weights and Vitals Summary, dated 11/26/2024 through 11/29/2024, located in the resident's EMR, revealed the last documented completed set of vital signs taken on R3 was on 11/29/2024 at 2:23 PM. Observation and resident interview not conducted due to the resident being discharged from the facility. During an interview with Family Member (F) 2 on 12/18/2024 at 12:23 PM, she stated when family came to visit R3 on 12/01/2024 at 11:10 AM, they found R3 unresponsive, feverish, sweaty, and exhibiting seizure like activity. F2 stated the family alerted LPN1 of R3's change in condition (CIC), and they requested LPN1 to call emergency medical services (EMS) for transfer to the local emergency department. F2 stated R3 was admitted to the local hospital's CCU for one week. She stated R3 had returned home and required an additional 10 weeks of IV antibiotic therapy. Additionally, F2 stated LPN1 told the family she was made aware of R3's CIC at 7:00 AM, during the shift change report. However, F2 stated LPN1 told F2 she had not seen R3 or assessed him that morning, and he had not received his 9:00 AM dose of IV antibiotic therapy. During an interview with LPN1 on 12/18/2024 at 11:58 AM, she stated she received a verbal report from RN2 that R3 had been lethargic and had altered mental status overnight, but she stated RN2 stated R3 was fine after aides changed him. LPN1 stated at around 11:00 AM, when the family made her aware of R3's deterioration, she had not seen or assessed the resident and had not given him his 9:00 AM dose of antibiotic. LPN1 stated that particular day (12/01/2024) was busy and got behind on her medication administration. She stated she managed her tasks as best she could. Additionally, LPN1 stated she did not remember if she communicated her need for assistance or asked the unit coordinator (UC) for support. Furthermore, she stated residents should be checked on at least every two hours to ensure their safety, noting that rounding on a resident included entering the resident's room to visually assess their condition. On 12/18/2024 at 11:57 AM and 12/19/2024 at 12:50 PM, the State Survey Agency (SSA) Surveyor left voice messages for RN2 to return the call for an interview. The interview was not conducted because RN2 did not return the calls from the SSA Surveyor. During an interview with RN4 on 12/18/2024 at 12:51 PM, she stated nursing staff should round on every resident every hour. According to RN4, rounding included the nurse laying eyes on the resident, assessing the resident's status, and asking purposeful questions to ensure the resident's needs were met. She stated that hourly rounding was important for the resident's safety and well-being. During a telephone interview with the Medical Director on 12/19/2024 at 12:40 PM, he stated he expected the nursing staff to administer medications as ordered by the medical provider. The Medical Director stated administering antibiotics on time was important to ensure that all bacteria causing the infection were eliminated and to prevent the infection from recurring. Per the interview, the Medical Director stated it was his expectation that staff followed all facility policies to ensure quality of care and the safety of the residents. During an interview with the Interim Director of Nursing (IDON) on 12/18/2024 at 10:06 AM, she stated per policy, RN2 should have notified R3's physician related to the resident's change in mental status and condition. Additionally, the IDON stated RN2 should have completed an assessment of R3's condition, which included all vital signs, and documented her findings in the resident's EMR. Furthermore, the IDON stated that LPN1 should have assessed R3 immediately after she received report from RN2. The IDON stated nursing staff should check on every resident every hour. She stated clinical rounding involved the nurse visually assessing the resident's condition and asking intentional questions to ensure that the resident's needs were being met. She stated timely assessments, notification of a change in condition, documentation, and hourly rounding were all crucial for the safety and well-being of the residents. The IDON stated her expectation was for nursing staff to follow clinical guidelines and policies and provide quality care according to current nursing care standards. During an interview with the Executive Director (ED) on 12/19/2024 at 1:08 PM, she stated it was her expectation that staff followed the facility's policy related to quality of care. She stated it was her expectation that the facility's staff provided care according to current nursing care standards. The ED stated it was important to ensure safe and appropriate care for all residents. The facility provided an acceptable removal action plan on 01/02/2025 at 1:45 PM that read verbatim: Resident #3 discharged from [Facility Name] on 12/1/24 Identification of Residents Affected or Likely to be affected: Residents currently at [Facility Name]. Actions to prevent occurrence/recurrence: 1 .An Ad Hoc QAPI meeting was held with DON, Medical Director and ED on 12/20/24 to discuss quality of care related to Medication Administration, Baseline Care Plans, and Notification of Changes in Resident Condition for Medical Director input. Completed 12/20/24 2. Notification of Changes Policy The Baseline Care Plan Policy and the Medication Administration Policy were reviewed immediately for accuracy by the Director of Clinical Risk Management. Completed 12/20/24 3. The Executive Director, Corporate Clinical Team and DON discussed the Notification of Changes in Condition, Medication Administration, and Baseline Care Plan policies and the plan for abatement. Completed 12/20/24 4. The Executive Director, Corporate Clinical Team and DON discussed the Provision of Quality Care policy. Completed 12/20/24 5. The Director of Clinical Risk Management educated the DON, Nurse Managers and ED regarding Baseline Care Plans, Medication Administration and Notification of Changes in Resident Condition and Provision of Quality Care policies. Completed 12/20/24 6. The DON/Nurse Managers provided education for all nurses and KMAs regarding Notification of Changes, Baseline Care Plan, and Medication Administration policies and provisions of the Quality of Care policy prior to their next shift. Agency nurses received education prior to their shift by DON/Nurse Managers. 100% completion of active staff, 1 nurse on leave will be educated by the DON/Nurse Manager prior to returning to work. Completed 12/20/24. 7. Going forward all newly hired nurses and all agency staff will be educated by the DON/Nurse Managers on the Notification of Changes, Baseline Care Plan, Medication Administration, Provision of Quality Care policies and the Nurse Clinical Binder. 8. On 12/20/24 DON/Nurse Managers completed an audit of all progress notes 11/26/24 through current immediately for changes in condition of identified residents and proper notification of MD and Responsible Party as appropriate. Completed 12/20/24 9. STNAs, Housekeepers and Dining staff received information via text regarding: if they notice a change in a residents' condition that they should report it to the nurse immediately. Completed 12/20/24 10. Director of Clinical Risk Management/DON audited all missed meds for identified residents using the Medication Administration Audit Report. Completed 12/20/24 11. DON notified the Medical Director of results of the Medication Admin Audit report and asked for any new orders. No new orders given. DON notified responsible parties of any current affected residents. Completed 12/20/24 12. The Director of Clinical Reimbursement and MDS nurse audited baseline care plans for admissions 11/1/24 through 12/20/24 for completion and accuracy. If incomplete or inaccurate, comprehensive care plans have been completed by the Director of Clinical Reimbursement/MOS nurse. Completed 12/20/24 13. Beginning on 12/21/24 in morning clinical meeting- DON/Nurse Managers review 24 hour report sheet and 24 hour summary report in PCC daily 7 times per week for appropriate notification of changes in resident condition. The DON reported results of the audit to the QAPI committee on 12/27/24 and will continue to report audit results to QAPI weekly for 4 weeks then every other week until substantial compliance is achieved. 1. Beginning on 12/21/24 - The Medication Admin Audit Report in PCC is completed daily 7 days per week by DON/Nurse Managers. Missed medications will be reported to the MD and responsible party immediately as per policy by the DON/Nurse Manager. Report audit results to QAPI weekly for 4 weeks then every other week until substantial compliance is achieved. 2. Starting on 12/21 Nurse Managers provide daily 1:1 Nurse/KMA coaching to ensure medication administration per MD orders and following the nursing process to assure quality care. 14. Beginning on 12/21/24 - Audit of baseline care plans will be by the DON/Nurse Managers daily 7 days per week with immediate follow up. 100% compliance has been achieved to date. DON reported results to QAPI committee on 12/27/24 and will continue to report audit results to QAPI weekly for 4 weeks then every other week until substantial compliance is achieved. 15. QAPI meeting on 12/27/24 was attended by Medical Director, Nurse Practitioner, ED, DON, Diet Tech, Nurse Manager, IP Nurse, Social Worker designee, Director of Facilities, Business Office Manager, MOS nurse, Director of Therapy and Life Enrichment Director. IJ abatement plan audits, results, and follow up were discussed. 16. Next QAPI meeting scheduled for 1/3/25 (1/3/25).

Based on interview, record review, and review of the facility's policy, the facility failed to develop and implement a baseline care plan within 48 hours for each resident that included instructions needed to provide effective and person-centered care of the resident to meet professional standards of quality care for 2 of 11 sampled residents, Resident (R) 2 and R3. 1. On 11/26/2024, the facility admitted R3 with an intrathecal (the space between the spinal cord and the membranes that protect it) pain pump infection, which was being treated with intravenous (IV) antibiotic therapy via a peripherally inserted central catheter (PICC) line. The facility failed to develop a person centered baseline care plan with interventions to address R3's infection, antibiotic therapy, care of the PICC line, or physician notification for worsening condition. Immediate Jeopardy (IJ) was identified on 12/20/2024 and was determined to exist on 11/26/2024, in the area of 42 CFR S483.21 Baseline Care Plan, F655 at a Scope and Severity (S/S) of a J. The facility was notified of the IJ on 12/20/2024 at 1:11 PM. On 12/20/2024 at 1:11 PM, the facility's Executive Director, Unit Manager, and Infection Preventionist were provided a copy of the IJ Template and notified that the facility's failure to ensure a baseline person-centered care plan was developed based on R3's admission assessment to ensure resident safety is likely to cause serious injury, impairment, or death. The facility provided an acceptable IJ Removal Plan, on 01/02/2025 at 1:45 PM, alleging removal of the IJ on 01/02/2025. The State Survey Agency (SSA) validated the IJ had been removed on 01/02/2025 at 1:45 PM as alleged, after an acceptable Removal Plan was received and further interviews, observations, and record reviews were conducted to verify the immediate corrections. Remaining non-compliance continued at a S/S of a G (isolated actual harm that is not immediate jeopardy) at F655. 2. Additionally, the facility admitted R2 on 10/09/2024 and assessed the resident to be at risk for developing pressure injuries. On 10/18/2024 an unstageable wound to R2's left heel was identified by the Physical Therapy staff, with nursing staff notified by them. R2's baseline care plan, still in effect, did not address or revise for R2's existing skin issues or breakdown. Refer to F580, F684, F686, and F760 The findings include: Review of the facility's policy titled, Baseline Care Plan, dated 02/27/2023, revealed it was developed and implemented to include the minimum healthcare information necessary to properly care for a resident. Per the policy, baseline care plans would be developed and implemented within 48 hours of a resident's admission. 1. Review of R3's Face Sheet, located in the resident's electronic medical record (EMR), revealed the facility admitted the resident on 11/26/2024 with diagnoses to include post laminectomy syndrome (chronic pain following back surgery; a laminectomy was removing part or all of the bony arch that covered the spinal cord), post-surgical infection of the intrathecal pain pump, and idiopathic peripheral neuropathy. Review of R3's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/01/2024, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated R3 was cognitively intact. Continued review revealed R3 was assessed as having a wound infection, was taking antibiotics, and had a PICC line to receive the antibiotics at time of admission. Review of R3's Physician Orders, located in the resident's electronic medical record (EMR), revealed on 11/26/2024, R3 was ordered cefepime (an antibiotic), 2 grams (gm) intravenous (IV) twice daily at 9:00 AM and 9:00 PM for the treatment of infections. Additionally, on the same date, R3 was prescribed metronidazole (antibiotic), 500 milligrams (mg) one oral tablet taken every eight hours for infections. Continued review revealed scheduled PICC line flush using heparin (an anti-coagulant) 10 units/milliliter (u/ml); use 5 ml IV every 12 hours then flush the PICC with 10 ml normal saline and follow with 5 ml of 10 units/ml heparin in a 10 cubic centimeter (cc) syringe. Additionally, per the orders, nurses were to monitor and document any signs and symptoms of infection every shift. Review of R3's Baseline Care Plan, dated 11/26/2024, located in the resident's EMR, revealed there was no documented evidence showing the facility had created a baseline care plan with treatments and interventions to address R3's current infection, antibiotic therapy, care of the PICC line, or physician notification for worsening condition. Review of R3's Nurse's Note, dated 12/01/2024 at 11:52 AM and authored by Licensed Practical Nurse (LPN) 1, revealed R3 was transferred to the local ED. LPN1 stated R3's family alerted staff that R3 was not responding. LPN1 stated upon assessment, R3 was lethargic, difficult to arouse, and would only respond to painful stimuli. She noted bodily tremors were observed. Review of R3's ED Provider Notes, dated 12/01/2024, revealed R3 presented to the ED in an altered mental status, septic, and in atrial fibrillation with rapid ventricular response (AFib RVR). R3 was febrile. His mental status was noted as somnolent, opened eyes to verbal stimuli, but was not conversant. Further review of the note revealed the physician stated, Upon my evaluation the patient had a high probability of imminent or life-threatening deterioration due to presentation which required my direct attention, intervention, and immediate management. During an interview with LPN1 on 12/18/2024 at 11:58 AM, she stated the nurse was responsible for the resident's admission. She stated she had not been aware she was responsible for initiating baseline care plans for residents. LPN1 stated further the MDS Nurse initiated and revised care plans as needed. 2. Closed Record Review of R2's Face Sheet, located in the resident's electronic medical record (EMR), revealed the facility admitted the resident on 10/09/2024, with diagnoses to include idiopathic hydrocephalus, peripheral vascular disease, and chronic total occlusion of artery of the extremities. Review of R2's admission MDS, with an ARD of 10/14/2024, revealed the facility assessed the resident to have a BIMS score of nine out of 15, which indicated R2 was moderately cognitively impaired. Continued review revealed R2 was assessed as being at risk for developing pressure ulcers/injuries. Review of R2's Baseline Care Plan, dated 10/09/2024, located in the resident's EMR, revealed there was no documented evidence showing the facility had created a baseline care plan to address impaired skin. Further review indicated R2's baseline care plan did not include any documentation regarding actual skin breakdown, nor were there any treatments or interventions implemented to prevent further worsening. During an interview with F1 on 12/16/2024 at 9:26 AM, she stated R2 was currently receiving treatment at another facility for an unstageable pressure ulcer (PU) on her left heel, which she developed while at the facility. F1 stated the family requested a transfer to a local facility on 10/25/2024. During an interview with the PT Manager on 12/17/2024 at 10:55 AM, she stated she observed a change in R2's heel on 10/18/2024. The PT Manager stated the wound was closed and had a slight discoloration to the skin, but the area was red and blanchable. She stated she collaborated with the nursing staff to offload pressure and apply boots to both feet. According to the PT Manager, the wound status changed significantly from Friday (the 18th) to Monday (the 21st). On 10/21/2024 the area on R2's left heel was an open blister, and she could not complete her therapy session due to pain in her left foot. She stated she requested nursing staff to assess R2's left heel wound. Upon assessment, she stated the wound had grown in size and was secreting blood and drainage. During a telephone interview with the Wound Care Physician on 12/19/2024 at 12:06 PM, she stated on 10/23/2024, she examined R2's wound and found that the resident had an unstageable deep tissue injury on the left heel caused by pressure. She stated she ordered a new treatment regimen and prescribed an oral antibiotic. Additionally, she stated she instructed the staff to have the resident wear pressure-relieving boots and to ensure the wound was offloaded. During an interview with Registered Nurse (RN) 4 on 12/18/2024 at 12:51 PM, she stated the admitting nurse or Unit Manager initiated the baseline care plan based on the resident's diagnoses and discharge paperwork. RN4 stated interventions were initiated by nursing staff that addressed the resident's current needs to prevent decline such as infections or skin breakdown. RN4 stated care plans needed to be initiated the day of admission and reviewed by the Supervising Nurse or MDS Nurse within 48 hours. She stated nursing staff or nursing leadership should revise the plan of care to include services to prevent pressure ulcers. During an interview with RN6 on 01/03/2025 at 3:34 PM, she stated the baseline care plan should include nurse-initiated interventions based on diagnoses and discharge paperwork and be completed on the day of admission. She stated the baseline care plan should be reviewed by the MDS Nurse within 48 hours. She stated each care plan should be resident-centered. RN6 stated resident assessments and diagnosis codes helped the nursing staff ensure that interventions addressing the resident's current needs were initiated, which was crucial for improving care and preventing declines in health. During an interview with the Infection Preventionist/Wound Care Nurse (IP/WCN) on 12/19/2024 at 10:17 AM, the IP/WCN stated that R2's care plan should have identified the existing skin breakdown upon admission due to her diagnosis of an arterial pressure injury to the left calf. She stated interventions should have been included to prevent further deterioration of the wound or the development of new wounds. During an interview with the MDS Nurse on 01/03/2025 at 11:06 AM, she stated baseline care plans should be initiated within 48 hours of a resident's admission. She stated if she was in the building when a newly admitted resident arrived at the facility, she assisted the admitting nurse with assessments and documenting a baseline care plan. The MDS Nurse stated, however, sometimes residents were admitted late on the evening shift or on a weekend, and in those cases, the process was for nursing management to review the baseline care plans within 48 hours. The MDS Nurse stated the baseline care plan should include health and safety concerns to prevent a decline in the resident's health. She stated the baseline care plan should also include any special needs such as antibiotic therapy, IV therapy, or PICC line care. According to the MDS Nurse, she stated she did not know why R2 and R3's baseline care plans were not completed to include interventions to reflect the residents' needs at the time of admission. During an interview with the Interim Director of Nursing (IDON) on 12/18/2024 at 10:06 AM, she stated the facility's process for initiating a new resident's baseline care plan was for the admitting nurse to initiate it within 48 hours, with interventions that addressed the resident's immediate needs. The IDON stated those interventions should include health and safety concerns to prevent a decline in the resident's health. She stated the baseline care plan should also include any special needs such as antibiotic therapy, IV therapy, or PICC line care. The IDON was unable to identify the process breakdown in ensuring that R2 and R3's baseline care plans were completed. During an interview with the Executive Director on 12/19/2024 at 1:08 PM, she stated it was her expectation that staff followed the facility's policies. She stated it was her expectation that the admitting nurse, or member of the nursing management present for an admission, entered a baseline care plan within 48 hours of a new resident's admission. She stated it was important to ensure safe and appropriate care for all residents. The facility provided an acceptable removal action plan on 01/02/2025 at 1:45 PM that read verbatim: Resident #3 discharged from [Facility Name] on 12/1/24. Identification of Residents Affected or Likely to be affected: Residents currently at [Facility Name]. Actions to prevent occurrence/recurrence: 1. An Ad Hoc QAPI meeting was held with DON, Medical Director and ED on 12/20/24 discussing IJ regarding Baseline Care Plans for Medical Director input. 2. The Director of Clinical Risk Management educated the DON and Nurse Managers on the Baseline Care Plan Policy. Completed 12/20/24 3. The Executive Director, Corporate Clinical Leadership Team, Director of Clinical Risk, DON discussed the Baseline Care Plan policy and the plan for the abatement. Completed 12/20 4. The Director of Clinical Reimbursement and the MDS nurse audited all baseline care plans for completion and accuracy. If the baseline care plan was missed during this time frame, comprehensive care plans from admissions dated 11/1/24 through 12/20/24 have been completed. 12/20/24. 5. Education was provided by DON/Nurse Managers for all nurses and KMAs regarding the Baseline Care Plan policy. Agency nurses are educated prior to their shift by the DON/Nurse Managers. 100% of nurses educated ( 1 nurse on leave will be educated prior to returning to work by the DON/Nurse Managers.) 6. Starting on 12/26/24 DON/Nurse Managers administer quizzes to nurses and KMAs regarding Baseline Care Plans and report results to the QAPI team weekly. Any nurses/KMAs not receiving a 100% correct will receive 1:1 education provided by the DON/Nurse Managers. 7. Beginning 12/21/24 - DON/Nurse Managers will audit Baseline Care Plan daily 7 days per week in morning clinical meetings. 100% Baseline Care Plans have been completed per policy. 8. DON/Nurse Managers reported results of the audit of baseline care plans, issues that needed resolution and how resolution was achieved to the QAPI committee on 12/27/24 and will continue to report to QAPI weekly for 4 weeks and then every other week until substantial compliance is achieved. 9. QAPI meeting on 12/27/24 was attended by Medical Director, Nurse Practitioner, ED, DON, Diet Tech, Nurse Manager, IP Nurse, Social Worker designee, Director of Facilities, Business Office Manager, MDS nurse, Director of Therapy and Life Enrichment Director. IJ abatement plan audits, results, and follow up were discussed. 10. The next QAPI meeting is scheduled for 1/3/25 and will review Baseline Care Plan completion. Date facility alleges IJ removal: 1/2/2025

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to notify the resident's physician of a significant change in the resident's physical status for 2 of 11 sampled residents, Resident (R) 2 and R3. 1. On 12/01/2024, in the early hours of the morning, R3 was observed by Registered Nurse (RN) 2 to have a significant change in mental status. Despite this critical finding, RN2 failed to notify the physician about the resident's condition. At 7:00 AM, during the shift change report, RN2 relayed to Licensed Practical Nurse (LPN) 1 that the resident's mental status had deviated from the baseline during the night. However, neither nurse assessed R3 or notified the physician of his change in mental status. At approximately 11:30 AM, R3's family alerted LPN1 that R3 was febrile, unresponsive, and had tremors. The family requested the nurse to call emergency medical services (EMS) for transfer to the local emergency department (ED). R3 presented to the ED in an altered mental status, septic, and in atrial fibrillation with rapid ventricular response (AFib RVR). Immediate Jeopardy (IJ) was identified on 12/20/2024 and was determined to exist on 11/26/2024, in the area of 42 CFR S483.10 Resident Rights, F580 at a Scope and Severity (S/S) of a J related to KY00044335. The facility was notified of the IJ on 12/20/2024 at 1:08 PM. On 12/20/2024 at 1:08 PM, the facility's Executive Director, Unit Manager, and Infection Preventionist were provided a copy of the IJ Template and notified that the facility failed to ensure the physician was notified of a change in condition for Resident (R) 3 when the resident experienced a significant altered mental status and life-threatening deterioration. This failure to notify the physician of the need to alter treatment is likely to cause serious injury, impairment, or death. The facility provided an acceptable IJ Removal Plan, on 01/02/2025 at 1:45 PM, alleging removal of the IJ on 01/02/2025. The State Survey Agency (SSA) validated the IJ had been removed on 01/02/2025 at 1:45 PM as alleged, after an acceptable Removal Plan was received and further interviews, observations, and record reviews were conducted to verify the immediate corrections. Remaining non-compliance continued at a S/S of a G (isolated actual harm that is not immediate jeopardy) at F580. 2. In addition, on 10/18/2024, an unstageable wound to R2's left heel was found by the physical therapy (PT) staff. The nursing staff was notified. However, the nursing staff failed to notify the physician of a change in condition (CIC) immediately. A review of a progress note dated 10/23/2024 by the Wound Care Physician revealed the provider noted a newly acquired unstageable deep tissue injury (DTI) measuring (length (L) x width (W) x depth (D)): 5.0 x 8.0 x 0.1 centimeter (cm) with etiology (cause) noted from pressure. Refer to F655, F684, F686 The findings include: Review of the facility's policy titled, Notification of Change of Condition, undated, revealed the facility would consult with the resident's medical provider when there was a significant change in the resident's physical health. 1. Closed Record Review of R3's Face Sheet, located in the resident's electronic medical record (EMR), revealed the facility admitted the resident on 11/26/2024 with diagnoses to include post laminectomy syndrome (chronic pain following back surgery; a laminectomy was removing part or all of the bony arch that covered the spinal cord); post-surgical infection of the intrathecal (the space between the spinal cord and the membranes that protect it) pain pump, and idiopathic peripheral neuropathy. Review of R3's admission Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 12/01/2024, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 14 out of 15, which indicated R3 was cognitively intact. Continued review revealed R3 was assessed as being independent with activities of daily living (ADL), and R3 ambulated per self via wheelchair and walker. Review of R3's Nurse's Note, dated 12/01/2024 at 11:52 AM and authored by LPN1, revealed R3 was transferred to the local ED. LPN1 stated R3's family alerted staff that R3 was not responding. LPN1 stated upon assessment, R3 was lethargic, difficult to arouse, and would only respond to painful stimuli. She noted bodily tremors were observed. Review of R3's ED Provider Notes, dated 12/01/2024, revealed R3 presented to the ED in an altered mental status, septic, and in atrial fibrillation with rapid ventricular response (AFib RVR). R3 was febrile. His mental status was noted as somnolent, opened eyes to verbal stimuli, but was not conversant. Further review of the note revealed the physician stated, Upon my evaluation the patient had a high probability of imminent or life-threatening deterioration due to presentation which required my direct attention, intervention, and immediate management. During an interview with Family Member (F) 2 on 12/18/2024 at 12:23 PM, she stated when family came to visit R3 on 12/01/2024 at 11:10 AM, they found R3 unresponsive, feverish, sweaty, and exhibiting seizure like activity. F2 stated the family alerted LPN1 of R3's CIC, and they requested LPN1 to call emergency medical services (EMS) for transfer to the local emergency department. F2 stated R3 was admitted to the local hospital's critical care unit (CCU) for several weeks. She stated R3 had returned home and required an additional 10 weeks of intravenous [IV] antibiotic therapy. Additionally, F2 stated LPN1 admitted she was made aware of R3's CIC at 7:00 AM, during the shift change report. F2 stated LPN1 told her LPN1 had not seen R3 or assessed him that morning. During an interview with LPN1 on 12/18/2024 at 11:58 AM, she stated she received in report from RN2 that R3 was lethargic and had an altered mental status overnight, but RN2 reported to her that R3 was fine after aides changed him. She further stated she did not assess R3's condition at the beginning of her shift. Furthermore, LPN1 stated she did not chart or notify the physician of the resident's CIC. LPN1 stated at the time the family made her aware of his CIC at around 11:00 AM, she had not seen R3 and had not given him his 9:00 AM dose of IV antibiotics. During an interview with the Advanced Practice Registered Nurse (APRN) on 12/20/2024 at 1:15 PM, she stated she expected the nursing staff to notify the provider of any changes in the resident's mental or physical condition. The APRN stated nursing staff should notify the provider immediately when a resident's mental status changed. She further stated that making the provider aware of a CIC was necessary for the resident's safety and well-being. During a telephone interview with the Medical Director on 12/19/2024 at 12:40 PM, he stated the nurse on duty should have communicated changes in the resident's condition immediately to the providers. He stated nurses were to use their nursing judgment and notify the provider on-call in emergency situations. Per the interview, the Medical Director stated it was his expectation that staff followed all facility policies to ensure the safety of the residents. 2. Closed Record Review of R2's Face Sheet, located in the resident's EMR, revealed the facility admitted the resident on 10/09/2024 with diagnoses to include idiopathic hydrocephalus, peripheral vascular disease, and chronic total occlusion of artery of the extremities. Review of R2's admission MDS, with an ARD of 10/14/2024, revealed the facility assessed the resident to have a BIMS score of nine out of 15, which indicated R2 was moderately cognitively impaired. Continued review revealed R2 was assessed as being dependent (helper did all the effort) with mobility, toileting, and transfers. R2 was assessed as needing substantial/maximal assist (helper did more than half the effort) with positioning in bed. Review of R2's Physical Therapy Treatment Encounter Note, dated 10/18/2024 at 5:11 PM, revealed the Physical Therapist (PT) noted an unstageable wound to R2's left heel. According to the note, PT notified nursing staff and educated them to float R2's heels when in bed. Review of R2's EMR revealed there was no documentation by nursing on 10/18/2024 related to the wound found by PT. Additionally, there was no documentation indicating the facility notified the physician about R2's change in physical condition. Review of R2's Occupational Therapy (OT) Treatment Encounter Note, dated 10/19/2024 at 11:16 AM, revealed R2 attempted activities of daily living (ADL) tasks but could not continue due to a wound that caused a barrier to OT treatment. The note stated the resident is struggling to move the left leg. Review of R2's EMR revealed there was no documentation by nursing on 10/19/2024 related to the wound found by PT. Additionally, there was no documentation indicating the facility notified the physician about R2's change in physical condition. Review of R2's Occupational Therapy (OT) Treatment Encounter Note, dated 10/21/2024 at 4:01 PM, revealed the resident had a new wound on her left lower extremity and nursing instructed OT not to stand [R2] this date. Review of R2's EMR revealed no documentation regarding the wound's worsening condition or an order for non-weight bearing status by nursing on 10/21/2024. Review of R2's Physical Therapy Treatment Encounter Note, dated 10/21/2024 at 4:58 PM, revealed the PT noted, after attempting gait training, that nursing entered the therapy gym and examined R2's left heel ulcer. According to PT, the ulcer appeared to have grown in size since 10/18/2024 and was secreting bloody drainage. Nursing instructed PT to hold gait training. Review of R2's EMR revealed no documentation regarding the wound's worsening condition by nursing on 10/21/2024. Additionally, there was no documented evidence nursing staff informed the physician about R2's change in physical condition. Review of R2's EMR revealed new orders were given by the Advanced Practice Nurse Practitioner (APRN) on 10/21/2024 at 11:39 AM, for bilateral pressure boots and new skin treatment orders. Review of Wound Evaluation and Management Summary, dated 10/23/2024, revealed the wound specialty physician noted R2 to have developed an unstageable deep tissue injury to her left heel measuring (L x W x D): 5.0 x 8.0 x 0.1 cm, with etiology noted from pressure. New treatment and medication orders were given. During an interview with F1 on 12/16/2024 at 9:26 AM, she stated R2 was currently receiving treatment at another facility for an unstageable pressure ulcer (PU) on her left heel, which she developed while at the facility. F1 expressed concern that the former Director of Nursing (DON) did not listen to the family's concerns or notify the medical provider when physical therapy discovered the pressure ulcer. During an interview with the PT Manager on 12/17/2024 at 10:55 AM, she stated she observed a change in R2's heel on 10/18/2024. The PT Manager stated the wound was closed and had a slight discoloration to the skin, but the area was red and blanchable. She stated she collaborated with the nursing staff to offload pressure and apply boots to both feet. According to the PT Manager, the wound status changed significantly from Friday (the 18th) to Monday (the 21st). She stated, on 10/21/2024, the area on R2's left heel was an open blister, and she could not complete her therapy session due to pain in R2's left foot. She stated she requested nursing staff to assess R2's left heel wound. She stated, upon assessment, the wound had grown in size and was secreting blood and drainage. During an interview with the Infection Preventionist/Wound Care Nurse (IP/WCN) on 12/19/2024 at 10:17 AM, she stated, on 10/22/2024, she completed a skin assessment on R2 and found an open area on the resident's left heel. She stated she notified the Wound Care Physician, who provided new treatment orders. During an interview with the Wound Care Physician on 12/19/2024 at 12:06 PM, she stated on 10/23/2024, she examined R2's wound and found that the resident had an unstageable deep tissue injury on the left heel caused by pressure. She stated she ordered a new treatment regimen and prescribed an oral antibiotic. Additionally, she stated she instructed the staff to have the resident wear pressure-relieving boots and to ensure the wound was offloaded. During an interview with the former DON on 12/16/2024 at 1:45 PM, she stated R2 had not been at the facility for long, and her daughter had some medical background. She stated R2 developed a wound on her left heel while at the facility and was seen by the wound care team. She stated she could not state who called the physician, but she was confident nursing staff had notified the physician immediately when the wound was discovered. She stated the nurses on duty at the time of the discovery of the wound no longer worked at the facility. During an interview with the Interim Director of Nursing (IDON) on 12/19/2024 at 9:38 AM, she stated it was her expectation for all nursing staff to follow the facility's policies and procedures regarding a resident's CIC. She stated nursing staff should notify the physician immediately of any injury, fall, or decline in status as per the policies and procedures. The IDON stated following procedures related to a resident's CIC ensured the resident received appropriate and timely care. During an interview with the Executive Director on 12/19/2024 at 1:08 PM, she stated it was her expectation that staff followed the facility's policy to notify the physician to ensure safe and appropriate care for all residents. The facility provided an acceptable removal action plan on 01/02/2025 at 1:45 PM that read verbatim: Resident #3 was discharged from [Facility Name] on 12/1/24. Identification of Residents Affected or Likely to be affected: All residents currently at [Facility Name]. Actions to prevent occurrence/recurrence: l. An Ad Hoc QAPI meeting was held with DON, Medical Director and ED on 12/20/24 discussing IJ regarding Notification of Changes for Medical Director input. 2. Notification of Changes policy was reviewed immediately by the Director of Clinical Risk Management. Completed 12/20/24 3. The Director of Clinical Risk Manager provided education for the Director of Nursing, Executive Director and Nurse Managers regarding the Notification of Changes policy. Completed 12/20/24. 4. The Executive Director, Corporate Clinical Leadership Team, Director of Clinical Risk, DON discussed the Notification of Changes policy and the plan for the abatement. Completed 12/20 5. Education was provided by Nurse Managers for all nurses and KMAs regarding Notification of Changes policy. Agency nurses were educated prior to their shift by DON/Nurse Managers. 25/28 completed = 93%, 1 nurse on leave will be educated by DON/Nurse Managers prior to her return to work., 2 staff still to complete prior to their next shift. 6. Starting 12/21/24 all nurses and KMAs who are hired will be educated by the DON/Nurse Managers regarding the Notification of Changes policy prior to working. 7. All progress notes were reviewed from 11/26/24 to current by DON/Nurse Manager for changes in condition of identified residents and proper notification of MD and Responsible Party as appropriate. Completed 12/20/24 8. Information was given to STNAs, housekeepers and dietary staff regarding what to do when you notice a change in a residents' condition. Information sent by ED via text. Completed 12/20/24. 9. Beginning 12/21/24 - The 24 hour report sheet and the 24 hour summary in Point Click Care {PCC) will be reviewed by DON/Nurse Manager daily 7 times per week for appropriate notification of changes in the morning Clinical Meeting. 10. Starting DON/Nurse Managers administer quizzes to nurses and KMAs regarding Notification of Changes in Condition and report results to QAPI team. If a question is missed, DON/Nurse Managers will educate the nurse immediately and document the education. 11. DON reported audit results regarding notification of changes missed at the 12/27 QAPI meeting and will continue to report audit results and how findings were resolved to QAPI weekly for 4 weeks then every other week until substantial compliance is achieved. 12. QAPI meeting on 12/27/24 was attended by Medical Director, Nurse Practitioner, ED, DON, Diet Tech, Nurse Managers, IP Nurse, Social Worker designee, Director of Facilities, Business Office Manager, MOS nurse, Director of Therapy and Life Enrichment Director. IJ abatement plan audits, results, and follow up were discussed. 13. Next QAPI meeting scheduled for 1/3/25. Date facility alleges IJ removal: 1/2/2025

Based on interview, record review, and review of the facility's policies, the facility failed to provide services to prevent pressure ulcers for 1 of 11 sampled residents, Resident (R) 2. On 10/18/2024 an unstageable wound to R2's left bottom heel was found by Physical Therapy (PT) staff. The nursing staff was notified; however, they failed to put interventions in place to care for the wound and prevent further worsening. In addition, the facility failed to include interventions to address R2's need to ensure pressure off-loading boots were on the resident and to off-load the wound while in the bed or up in the wheelchair. The findings include: Review of the facility's policy titled, Pressure Injury Prevention Guidelines, revised 11/23/2022, revealed measures would be taken to prevent avoidable pressure injuries and to promote the healing of existing ones. Per the policy, the facility would implement evidence-based interventions for all residents assessed as being at risk or who currently had a pressure injury. The policy stated these interventions would be resident-centered and carried out according to physician orders. Review of the facility's policy titled, Wound Treatment Management, revised 11/23/2022, revealed wound treatments would be provided by physician orders and were based on the etiology (cause) of the wound, characteristics, location, and the preferences of the resident or their representative. Additionally, the policy stated all treatments would be recorded in the treatment administration record (TAR). The effectiveness of treatments would be monitored through ongoing assessments of the wound. Closed Record Review of R2's Face Sheet, located in the resident's electronic health record (EHR), revealed the facility admitted the resident on 10/09/2024 with diagnoses to include idiopathic hydrocephalus, peripheral vascular disease, and atherosclerosis of native arteries of left leg with ulceration of calf. Review of the pre-admission to the facility local hospital's Wound Care Note, dated 10/07/2024 at 11:23 AM, found in the EHR, revealed R2 had a stage 3 pressure injury to the left calf area (Achilles) that was red, yellow, moist, and with full-thickness skin loss. Per the note, the wound was complicated by poor vascular status. Additionally, the note stated there was an open laceration/cut in skin on the left lateral heel, and the remainder of the left heel was red and blanchable. Review of the local hospital's Discharge Summary, dated 10/09/2024 at 12:14 PM, found in the EHR, revealed R2 was admitted with an arterial occlusion (restriction of arterial blood flow) of the lower extremity and atherosclerosis of native artery of left lower extremity with ulceration (a sore in the skin or mucous membrane) of calf. Review of R2's admission Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 10/14/2024 and found in the EHR, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of nine out of 15, which indicated R2 was moderately cognitively impaired. Continued review revealed R2 was assessed as being at risk for pressure ulcer development; however, the facility did not assess the resident as having current skin breakdown, current venous and arterial ulcers, or other skin problems. Furthermore, the facility assessed the resident as needing substantial/maximal assistance (helper did more than half the effort) for bed mobility and transferring. Review of R2's Baseline Care Plan [BCP], initiated 10/09/2024 and last updated 11/04/2024, found in the EHR, revealed the facility identified the resident was at risk for pressure ulcer development and included interventions such as assisting and encouraging the resident to reposition routinely and as needed. Further review revealed the facility noted in the interventions to administer treatments as ordered, monitor for effectiveness, and provide a pressure reducing cushion and mattress. However, the facility failed to include resident-centered interventions to off-load the wound while in the bed or up in the wheelchair. Continued review revealed the facility failed to include interventions to address the need to ensure pressure off-loading boots were on the resident. Review of R2's Physician Orders, dated 10/2024 and found in the EHR, revealed an order for weekly skin assessments to be done every Thursday evening beginning 10/10/2024 at 7:00 PM. Review of R2's TAR, dated 10/2024, found in the EHR, revealed only one skin assessment was performed, on 10/10/2024, during her admission to the facility. Skin assessments scheduled for 10/17/2024 and 10/24/2024 were not documented as being completed. Review of R2's PCC Skin & Wound - Total Body Skin Assessment, dated 10/10/2024 at 11:51 PM, found in the EHR, revealed R2 was assessed as having 0 wounds. Her skin was assessed as having good elasticity, normal color, warm temperature, and normal moisture and condition. Review of R2's provider's Progress Note, dated 10/10/2024 at 2:38 PM, found in the EHR, revealed the Advanced Practice Registered Nurse (APRN) documented an ulcer to left Achilles and a lateral heel laceration with skin breakdown. The note stated to encourage off-loading pressure and to monitor for signs and symptoms of infection. R2's TAR and BCP were not revised to add these nursing care measures. Review of R2's CHI Skilled/Episodic Note - V.5, dated 10/12/2024 at 5:26 PM, found in the EHR, revealed Licensed Practical Nurse (LPN) 4 documented R2 had no skin abnormalities, and her skin was intact. Review of R2's provider's Progress Note, dated 10/14/2024 at 11:32 AM, found in the EHR, revealed the APRN documented an ulcer to left Achilles and a lateral heel laceration with skin breakdown. Per the progress note, there were no signs or symptoms of infection. The APRN wrote to encourage off-loading pressure and to monitor for s/s of infection. The TAR and BCP were not revised to add these nursing care measures. Review of R2's provider's Progress Note, dated 10/16/2024 at 3:59 PM, found in the EHR, revealed the Infection Preventionist/Wound Care Nurse (IP/WCN) documented R2 was seen by the Wound Care Physician, and the area to the posterior left lower extremity (Achilles area) was healed. Review of R2's Physical Therapy Treatment Encounter Notes, dated 10/18/2024, found in the EHR, revealed the physical therapist noted an unstageable wound to the left heal. According to the note, the therapy staff notified nursing staff of the wound and educated them to float heels when in bed. Review of R2's CHI Skilled/Episodic Note - V.5, dated 10/20/2024 at 3:53 PM, found in the EHR, revealed Registered Nurse (RN) 7 documented R2's skin integrity was not intact and an impaired skin condition is noted. No further details were provided. Review of R2's Progress Note, dated 10/22/2024 at 10:42 AM, from the EHR, revealed RN3 completed R2's skin assessment and documented that R2 had an open area and a blister on her left heel. Per the note, the open area measured approximately 3.0 inches by 2.0 inches. The wound was observed to have clear drainage accompanied by a slight odor. It was noted that new treatment orders were received. Review of R2's CHI Skilled/Episodic Note - V.5, dated 10/23/2024 at 1:12 PM, found in the EHR, revealed LPN5 documented R2's skin integrity was not intact and an impaired skin condition is noted. No further details were provided. It was noted that R2 was compliant with skin interventions. Review of R2's provider's Progress Note, dated 10/23/2024, found in the EHR, revealed the APRN documented an unstageable ulcer to left heel. Per the progress note, she stated there was a blister on left heel, 3 x 2, clear drainage with foul odor. Per the note, the APRN consulted with the Wound Care Physician who was in the building. Review of R2's Progress Notes, on 10/23/2024 at 1:22 PM, found in the EHR, revealed the IP/WCN documented R2 was seen by the Wound Care Physician for a wound on the left heel. Per the note, new orders were given, including the initiation of oral antibiotic therapy to treat the wound infection. Review of R2's Wound Evaluation and Management Summary, dated 10/23/2024 at 2:32 PM, found in the EHR, revealed the Wound Care Physician was referred by the facility to assesses R2's wound. Per his assessment, he noted the resident had an unstageable DTI from pressure to her left bottom heal measuring (length (L) x width (W) x depth (D)): 5.0 L x 8.0 W x 0.1 D centimeters (cm), with moderate serous exudate (bloody drainage). Further review revealed the wound care provider wrote orders to cleanse the wound with saline at the time of dressing change, off-load the wound, use pressure boot, and start on oral antibiotic therapy. Per the note, the physician stated the updated plan of care was discussed with the resident, the assigned nurse, and a nursing staff member. Review of R2's CHI Skilled/Episodic Note - V.5, dated 10/24/2024 at 7:10 PM, found in the EMR, revealed LPN6 documented R2's skin integrity was intact and without abnormalities. Review of R2's Discharge (return anticipated) MDS, dated [DATE], revealed the facility identified the resident as having an unstageable DTI to the left heel that was not present on admission. Review of R2's Progress Note, dated 10/25/2024 at 2:33 PM, found in the EHR, revealed R2 was discharged from the facility at the family's request, but it did not specify the facility to which the family was taking the resident. According to the note, R2's family was given the resident's order summary. Observation and interview of R2 could not be conducted due to R2 being discharged from the facility. During interview with Family Member (F) 1 on 12/16/2024 at 9:26 AM, she stated R2 had currently received treatment at a local hospital for an unstageable pressure ulcer (PU) on her left heel, which she developed while at the facility. F1 expressed concern that the nursing staff and former Director of Nursing (DON) did not listen to the family's concerns or notify the medical provider when the Physical Therapist discovered the pressure ulcer. According to F1, on 10/14/2024, during a care conference held with the former Director of Nursing (DON), it was agreed that R2's leg would remain elevated to prevent further pressure wounds. However, she stated this agreement had not been honored. F1 stated despite repeated requests, the staff failed to off-load pressure on R2's left heel or place pressure relieving boots on when up and in bed. During interview with the former DON on 12/16/2024 at 1:45 PM, she stated R2 had not been at the facility very long. She stated the resident developed a wound on her left heel during her stay and was evaluated by the Wound Care team. Following this assessment, she stated the facility physician prescribed oral antibiotic therapy. However, the former DON could not recall the timeline regarding when the wound was first noticed, when the physician was notified, or when the resident first received the oral antibiotics. Additionally, she stated while heel boots had been ordered for the resident, R2 repeatedly kicked them off. The former DON stated she was unable to remember if the nursing staff had documented the resident's non-compliance with this care. During interview with the PT Manager on 12/17/2024 at 10:55 AM, she stated during a physical therapy session on 10/18/2024 with R2, she observed a change in the resident's heel. The PT Manager stated the wound was closed and had a slight discoloration to the skin, but the area was red and blanchable. She stated she collaborated with the nursing staff to offload pressure and apply boots to both feet. According to the PT Manager, the wound status changed significantly from Friday (the 18th) to Monday (the 21st). She stated on 10/21/2024 the area on R2's left heel was an open blister, and R2 could not complete her therapy session due to pain in her left foot. She stated she requested nursing staff to assess R2's left heel wound. Upon assessment, she stated the wound had grown in size and was secreting blood and drainage. During interview with RN4 (also a Unit Manager) on 12/18/2024 at 12:51 PM, she stated nursing should document findings and assessments in the nursing progress notes and communicate concerns on the 24-hour report. RN4 stated nurses should document treatments in the TAR when completed. During interview with the Interim Director of Nursing (IDON) on 12/18/2024 at 10:06 AM, she stated it was her expectation for nursing staff to document all their assessments and treatments. She stated record-keeping was crucial in demonstrating that care was provided. She also stated it was important for nursing staff to have initiated pressure wound interventions and followed treatment orders for R2 to wear bilateral pressure boots and off-loaded the extremity to prevent a pressure ulcer from developing or worsening. She further stated it was her expectation that nursing staff followed facility policies and protocols to prevent pressure ulcers, as this was important for the safety and well-being of the resident and to prevent further harm. During interview with the Infection Preventionist/Wound Care Nurse (IP/WCN) on 12/19/2024 at 10:17 AM, she stated she became aware of R2's heel wound on 10/21/2024. At that time, she stated she communicated with the Wound Care Physician. On 10/22/2024, she stated she conducted a skin assessment on R2 and discovered an open area on the resident's left heel. The IP/WCN stated she informed the Wound Care Physician, who then issued new treatment orders. She stated the admitting nurse should have performed a comprehensive head-to-toe assessment of the resident to check for any skin breakdown and document the findings in the resident's EHR. She stated any areas of concern should be communicated to the healthcare provider. The IP/WCN stated she did not know why nursing staff did not inform her of R2's newly developed wound on 10/18/2024. Additionally, the IP/WCN stated R2's care plan should have included interventions to prevent further deterioration of the wound or the development of new wounds. During telephone interview with the Wound Care Physician on 12/19/2024 at 12:06 PM, she stated on 10/23/2024, she examined R2's wound and found R2 had an unstageable deep tissue injury (DTI) on the left heel caused by pressure. She stated she ordered a new treatment regimen and prescribed an oral antibiotic. Additionally, she stated she instructed the nursing staff to have the resident wear pressure-relieving boots and to ensure the wound was offloaded. During interview with the APRN on 12/20/2024 at 1:00 PM, she stated she was made aware of R2's new wound on her left heel by nursing staff on 10/21/2024. She stated she provided new orders for the resident to wear pressure boots on bilateral lower extremities at night and a new wound treatment. She stated on 10/23/2024, she examined the resident and collaborated with the Wound Care Physician, recommending R2 start oral antibiotics. She stated the decision to initiate the antibiotic treatment course was made after the Wound Care Physician assessed the resident later the same day. She stated it was her expectation that nursing staff followed the medical provider's orders and provided services to prevent pressure ulcers from developing or worsening. She stated it was important to ensure safe and appropriate care for all residents. During interview with the Executive Director on 12/19/2024 at 1:08 PM, she stated it was her expectation that staff followed the facility's policies and protocols for resident care. She stated it was her expectation that nursing staff provided services to prevent pressure ulcers. She stated it was important to ensure safe and appropriate care for all residents.

Based on observation, interview, record review, review of the Centers for Disease Control and Prevention (CDC) guidelines, review of the manufacturer's instructions for use, and review of the facility's policies, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 11 sampled residents, Residents (R) 4 and R8. 1. Observation on 12/12/2024 of R4's room revealed the resident was under contact isolation precautions. However, staff was observed in the room without wearing the appropriate personal protective equipment (PPE). Further observation on 12/12/2024 revealed another staff member entered R4's room and did not don (put on) PPE. 2. Observation and interview on 12/12/2024 with Licensed Practical Nurse (LPN) 1 revealed she carried a contaminated glucometer (blood sugar measuring device), without wearing gloves, across the common area and placed it on the medication cart without first placing a barrier down. Further observation on 12/18/2024 revealed LPN1 failed to clean the glucometer according to the Environmental Protection Agency (EPA) registered disinfectant manufacturer's instructions. The findings include: Review of the CDC's Guidelines, provided by the facility, titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 09/10/2021, revealed reusable medical equipment should be cleaned and disinfected according to manufacturer's instructions or the facility's policies before and after use. The guidelines stated facilities should maintain separation between clean and soiled equipment to prevent cross-contamination. Further review of the guidelines revealed staff should be trained in the correct steps for cleaning and disinfection of shared equipment. Review of the facility's policy titled, Infection Prevention and Control Program [IPCP], dated 10/24/2022, revealed the facility maintained an infection prevention and control program designed to provide a safe sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections per accepted national standards and guidelines. Continued review revealed all staff was responsible for following policies and procedures related to the IPCP program to include transmission based precautions. Furthermore, the policy stated all staff should use personal protective equipment (PPE) according to established facility policy governing the use of PPE. Review of the facility's policy titled, Cleaning and Disinfection of Resident Care Equipment, dated 03/01/2023, revealed shared reusable equipment could be a source of indirect transmission of pathogens. The policy stated resident care equipment would be cleaned and disinfected in accordance with current CDC recommendations in order to break the chain of infection, and staff would clean and disinfectant in accordance with manufacturers' recommendations. Furthermore, per the policy, staff would clean and disinfect reusable equipment after each use. Review of the cleaning and disinfecting instructions for the Assure Prism Multi-Blood Glucose Monitoring System, no date, revealed to minimize the risk of transmitting bloodborne pathogens, the exterior of the glucometer should be cleaned of all dirt, blood, and bodily fluids before performing the disinfection procedure, which would prevent the transmission of bloodborne pathogens. Per the instructions, the exterior of the glucometer should remain wet for the appropriate dwell time (time a surface must remain visibly wet after the application of a disinfectant) according to the disinfectant's instructions. Review of the cleaning and disinfecting instructions for Medline's MicroKill One (blue lid) container revealed for cleaning to use one or more wipes as necessary to wet surfaces sufficiently and to thoroughly clean the surface. Then, the instructions stated to use a second wipe as necessary to thoroughly wet all surfaces to be treated. According to the instructions, all surfaces must remain visibly wet for a one minute dwell time to assure complete disinfection of all pathogens. 1. Review of R4's Face Sheet, located in the resident's electronic health record (EHR), revealed the facility admitted the resident on 12/11/2024 with diagnoses to include pyogenic arthritis right knee, cellulitis of right lower limb, Sjogren syndrome (disorder of the immune system), and history of multidrug-resistant organisms (MDRO). Review of R4's admission Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 12/12/2024, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 15 out of 15, which indicated R4 was cognitively intact. Review of R4's Discharge Summary, from the resident's previous facility, dated 12/11/2024, located in the resident's EHR, revealed the resident had an infection of the right knee which was positive for staph pseudointermedius and streptococcus mitis, and there was an order for contact isolation precautions. Observation on 12/12/2024 at 10:33 AM of R4's room, a contact isolation room, revealed the Advanced Practice Registered Nurse (APRN) was in the room sitting on the resident's unmade bed while she talked with the resident. The APRN did not wear a gown or gloves during her time in R4's room. During interview with the APRN on 12/12/2024 at 10:33 AM, she stated she had entered the room to check on the resident. She stated it was the facility's policy to wear a gown and gloves at all times while in a contact precaution room to protect both the resident and staff from the spread of infection. She further stated it was not appropriate to sit on the bed, and sitting on a resident's bed could facilitate the spread of infection. The APRN stated she had completed multiple education modules related to IPCP training. Continued observation on 12/12/2024 at 10:35 AM, revealed Registered Nurse (RN) 3 was standing inside R4's room at the end of the bed without wearing a gown and gloves. During interview with RN3 on 12/12/2024 at 10:50 AM, she stated she was in R4's room just to say hello and did not don (put on) PPE because she was not providing care. When asked by the State Survey Agency (SSA) Surveyor what was required before entering a contact precaution isolation room, RN3 stated gloves and a gown must be worn. She stated transmission-based precautions were important to prevent the spread of infection to other staff and residents. RN3 stated she had received IPCP education upon hire and had multiple in-services related to infection control. 2. Review of R8's Face Sheet, located in the resident's EHR, revealed the facility admitted the resident on 11/28/2024 with diagnoses to include left hemiplegia and hemiparesis following cerebral infarction (stroke), type 2 diabetes mellitus, and chronic obstructive pulmonary disease (COPD). Review of R8's admission MDS, with an ARD of 12/02/2024, revealed the facility assessed the resident to have a BIMS score of 15 out of 15, which indicated R8 was cognitively intact. Observation on 12/12/2024 at 10:35 AM revealed LPN1, without wearing gloves, brought a glucometer out of R8's room, walked across the common area to the medication cart sitting outside of room [ROOM NUMBER], and then placed the glucometer on the medication cart without using a barrier. During interview with LPN 1 on 12/12/2024 at 10:38 AM, she stated she had just performed a blood glucose fingerstick on R8 and was coming back to the cart to clean and disinfect the glucometer (because it was contaminated after R8's blood glucose fingerstick). When asked what the process for cleaning the glucometer after use on a resident, she stated it should be cleaned immediately with disinfectant wipes. She further stated she knew not to put it down on the cart without a barrier but added she was nervous due to the SSA Surveyor's presence. LPN1 stated she had received IPCP education upon hire and had also received education through in-service trainings provided by the Infection Preventionist/Wound Care Nurse (IP/WCN) and the Interim Director of Nursing (IDON) related to infection control. Observation on 12/18/2024 at 12:47 PM revealed LPN1 performed a blood glucose fingerstick on R8. The LPN took the glucometer to the medication cart and placed it on top of the cart without first placing a protective barrier down. LPN1 took a disinfectant wipe out of the MicroKill One Wipes container and wiped the glucometer for 10 seconds. She then placed the glucometer in the top drawer of the medication cart. During additional interview with LPN1 on 12/18/2024 at 12:47 PM, she stated she was educated to place the glucometer on a barrier and clean and disinfect it with the MicroKill One Wipes. When asked what the dwell time for the wipes was, she stated, One minute. When asked to discuss the facility's protocol for cleaning and disinfecting the shared glucometer, LPN1 could not articulate what the kill time meant and was unable to correctly list the steps for cleaning the glucometer. During interview with the IP/WCN on 12/17/2024 at 11:15 AM, she stated the facility followed CDC guidelines and recommendations related to IPCP. She stated she provided education to all staff related to IPCP, and all staff was trained on the use of PPE and isolation precautions to include contact precautions. She stated gowns and gloves must be worn whenever staff entered a contact precaution room. Per the interview, the IP/WCN stated she and other nurse leaders had not observed any concerns related to staff's failure to follow infection control or transmission-based precautions protocols. She stated it was her expectation that all staff followed infection prevention control practices. The IP/WCN stated it was important for the safety of residents and staff and to prevent the spread of infection. She also stated nursing staff was trained to clean and disinfect the glucometer after each use using the blue topped MicroKill One Wipes cleaning and disinfectant wipes with a one minute dwell time. She stated contaminated glucometers should be placed on a barrier cloth to prevent the spread of infection and cleaned, then disinfected for the appropriate time and stored separately to keep clean. During interview with the IDON on 12/18/2024 at 1:19 PM, she stated all staff received IPCP training upon hire and periodically throughout the year. In addition, the IDON stated staff was updated on current CDC guidelines when they changed. She stated nursing leadership audited staff for compliance. However, she stated there was no documentation of staff IPCP audits. Per interview, it was the IDON's expectation that all staff maintained IPCP guidelines at all times to decrease the potential spread of infection. During interview with the Executive Director on 12/19/2024 at 1:08 PM, she stated it was her expectation that staff followed the facility's IPCP policies and procedures to prevent the spread of infection to residents and staff.

Based on interview, record review, and facility policy review, the facility failed to ensure drugs and biologicals were stored according to professional standards for 1 of 3 medication carts where an opened pharmacy delivery tote with medications was left unattended. The findings include: Review of the facility's policy titled, Storage of Medications, undated, revealed drugs and biologicals stored in the facility were kept in locked compartments, accessible only to authorized personnel. According to the policy, nursing staff was responsible for managing medication storage. Per the policy, compartments containing drugs and biologicals must be locked when not in use, and any unlocked medications should not be left unattended. Observation of a medication cart in the Household B Hall on 12/12/2024 at 10:31 AM, revealed an opened pharmacy delivery tote full of medications. The delivery tote was left opened, unsecured, and unattended out in the open as residents and staff walked by. The tote contained two boxes of multiple single dose albuterol (bronchodilator) inhalation solution packets for nebulizer treatments, several intravenous (IV) fluid bags containing normal saline, multiple heparin (an anticoagulant) flush injections, and two 100-milliliter (mL) bags of IV ceftriaxone (an antibiotic). During interview with Licensed Practical Nurse (LPN) 1 on 12/12/2024 at 10:38 AM, she stated the pharmacy had just delivered the medication, and she had not had a chance yet to place the storage tote in the medication storage room. She stated she had stepped away from the cart to administer medication to a resident and was going to place the contents of the tote in the medication cart. LPN1 stated facility protocol was to place medication in the medication storage room or in the designated medication cart when inventory was received from the pharmacy. During interview with Registered Nurse (RN) 3 on 12/12/2024 at 10:45 AM, she stated medication inventory should be stored in the medication room when it was received from the pharmacy and should never be left unlocked and unattended. She stated leaving medication out could pose a risk to residents. During interview with the Interim Director of Nursing (IDON) on 12/12/2024 at 10:32 AM, she stated when inventory was received from the pharmacy, it should be put away in its correct location, either in the medication room or in the medication cart. She stated not ensuring medication was stored properly and locked when unattended could pose a safety risk to residents. She stated nursing staff was responsible for the medication cart, and medication should not be left unattended. The IDON further stated storing medications appropriately prevented the diversion of drugs by other staff members or visitors. During interview with the Executive Director on 12/19/2024 at 1:08 PM, she stated it was her expectation that staff followed the facility's policy. She stated it was her expectation that staff properly stored and locked medication when it arrived from the pharmacy. She further stated it was important to ensure safe and appropriate care for all residents.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure the resident's right to privacy was honored for 1 of 11 sampled residents, Resident (R) 8. On 12/18/2024, Licensed Practical Nurse (LPN) 1 lifted R8's shirt and exposed her abdomen while she administered an insulin injection to the resident. R8 was seated at a dining table with three other residents eating lunch. The findings include: Review of the facility's policy titled, Resident Rights, dated 10/24/2022, revealed the resident had a right to be treated with respect and dignity. Further review revealed the resident had a right to personal privacy and confidentiality to include personal privacy for medical treatment. Review of R8's Face Sheet, located in the resident's electronic medical record (EMR), revealed the facility admitted the resident on 11/28/2024 with diagnoses to include left hemiplegia and hemiparesis following cerebral infarction (stroke), type 2 diabetes mellitus, and chronic obstructive pulmonary disease (COPD). Review of R8's admission Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 12/02/2024, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 15 out of 15, which indicated R8 was cognitively intact. Review of R8's Physician Orders, dated 11/2024, revealed the resident was to be administered insulin lispro subcutaneous solution 200 units/milliliter (u/mL), per sliding scale before meals and at bedtime for type 2 diabetes. Observation on 12/18/2024 at 12:45 PM of the lunch service in the common area of Household B, LPN1 lifted R8's shirt, which exposed the right side of her abdomen. LPN1 then administered an insulin injection in the right upper quadrant of R8's abdomen, while R8 was seated at a dining table with three other residents who were also eating lunch. During interview with R8 on 12/18/2024 at 1:35 PM, she stated when LPN1 asked her about getting her insulin injection, she consented to receive it at the table while she ate lunch. She stated LPN1 was late administering medications. She stated had she not received her insulin injection in the dining area, she would have been required to return to her room for the injection, resulting in her food getting cold. Additionally, R8 stated it was common practice for nursing staff to administer medication during meals or outside of residents' rooms. During interview with LPN1 on 12/18/2024 at 12:47 PM, she stated she did not provide privacy for R8 while administering the insulin injection. She stated R8 had given her permission to perform the injection at the dining table while R8 was having lunch. LPN1 stated she was having a busy day and was behind on giving medications. When the State Survey Agency (SSA) Surveyor asked LPN1 if she had consulted all the residents about their comfort with watching her administer an injection while they ate, she stated, No. Furthermore, LPN1 stated, according to facility policy, every resident had the right to privacy and dignity. When asked if she ensured privacy during the medication administration for R8, she stated that she did not. During interview with the interim Director of Nursing (IDON) on 12/18/2024 at 1:19 PM, she stated nursing staff must always adhere to facility policies and protocols concerning resident rights and privacy. She stated even though the resident had given permission, the facility's protocol required medication to be administered privately in the resident's room. The IDON stated it was unacceptable for LPN1 to administer an injection to a resident in public view while the resident and others were eating a meal. She stated it was her expectation that nursing staff would follow the facility policy to ensure the resident's privacy and dignity. During interview with the Executive Director on 12/19/2024 at 1:08 PM, she stated it was her expectation that staff followed the facility's policy to include the resident's right to dignity and privacy. She stated following facility policies and protocols was important to ensure safe and appropriate care for all residents. During interview with the Director of Clinical Risk Management on 12/20/2024 at 12:51 PM, he stated the facility adhered to all nursing care standards set by the Centers for Medicare and Medicaid Services (CMS).

Based on interview, record review, and review of the facility's policy, the facility failed to ensure that the resident's medical record included documentation that indicated the resident either received the influenza immunization or did not receive the influenza immunization due to medical contraindications or refusal for 1 of 5 sampled residents, Resident (R) 43. A review of R43's immunization record revealed the absence of documentation confirming the administration or refusal of the influenza vaccine for 2023-2024. The findings include: Review of the facility's policy titled, Infection Prevention and Control Program, dated 10/24/2022, revealed residents would be offered the influenza vaccine each year between October 1 and March 31. Further review revealed documentation would reflect the education provided and details regarding whether the resident received the immunization. Review of R43's Admission Record revealed the facility admitted the resident on 11/19/2023 with diagnoses of chronic obstructive pulmonary disease (COPD) and Alzheimer's disease. Review of R43's, Minimum Data Set (MDS), with an assessment reference date (ARD) of 08/16/2024, revealed a Brief Interview for Mental Status (BIMS) score of 00 out of 15, which indicated the resident was severely cognitively impaired. Review of R43's immunization record revealed the absence of documented evidence of administration or refusal of an influenza immunization for 2023-2024. The State Survey Agency (SSA) Surveyor requested verification of R43's administration or refusal of the influenza vaccine for 2023-2024 from the facility on 08/21/2024 at 5:00 PM; however, verification of documentation was not provided. During an interview with the Infection Preventionist (IP) Nurse on 08/23/2024 at 9:52 AM, she stated residents received educational information related to the benefits versus the side effects of vaccines prior to administration. She further stated educational information was also included in the admission packets. The IP Nurse stated immunization education and administration or refusal of administration were documented in the residents' charts under their immunization record. During an interview with the Director of Nursing (DON) on 08/23/2024 at 11:05 AM, she stated residents and/or family were educated verbally and consented for immunizations prior to administration. She further stated administration of immunizations or refusals of immunizations were documented in a resident's chart. The DON stated it was important for staff to follow the facility's policies and procedures for infection prevention and control to prevent the spread of infections. During an interview with the Administrator on 08/23/2024 at 11:44 AM, she stated she expected a resident's medical record to reflect documentation of either administration or refusal of immunizations. She further stated it was her expectation staff followed the facility's infection prevention guidelines to prevent the spread of infection and to protect residents.

Based on interview, record review, and review of the facility's policies, the facility failed to ensure each resident had the right to be informed of and participate in his or her treatment for 1 of 22 sampled and supplemental residents, Resident (R) 10. Staff refused to administer a COVID-19 test to R10 when requested by the resident. The findings include: Review of the facility's policy titled, Resident Rights, dated 10/24/2022, revealed the resident had the right to be informed of, and participate in, his or her treatment, including the right to request, refuse, and/or discontinue treatment. Review of the facility's policy titled, Coronavirus Testing, revised 09/26/2022, revealed anyone with even mild symptoms of COVID-19, regardless of vaccination status, should receive a viral test as soon as possible. Further review revealed the facility would obtain an order for COVID-19 testing from the physician, physician assistant, nurse practitioner, or clinical nurse specialist to provide or obtain laboratory services for a resident. Additional review revealed the facility would document the resident's test results in the medical record in accordance with the standard for protected health information. Review of R10's Admission Record revealed the facility admitted the resident on 08/01/2022 with diagnoses of congestive heart failure (CHF) and chronic kidney disease (CKD). Review of R10's Annual Minimum Data Set (MDS), with an assessment reference date (ARD) of 07/31/2024, revealed the resident had a Brief Interview for Mental Status (BIMS) score of four out of 15 which indicated the resident was severely cognitively impaired. Review of R10's August 2024 Orders revealed no open or completed orders for COVID testing. Review of R10's August 2024 Progress Notes revealed no documented COVID testing or results. During an interview with family member (F) 7 on 08/23/2024 at 8:50 AM, she stated on 08/04/2024 she arrived at the facility around 10:30 AM, and before they left for lunch, she overheard a staff member yell not to let a particular resident out of his room because he had COVID. F7 stated she took her mother out for lunch and a drive and returned to the facility about two hours later. F7 stated a short time later she noticed R10 had a slight cough that was new, and the resident asked for a tissue because of a mild runny nose. F7 stated she requested a COVID test for her mother from one of the nurses. F7 did not identify the nurse. F7 stated the nurse refused and said it was not necessary because the facility had no positive COVID cases. F7 further stated the nurse turned around and left the room. F7 stated she approached another nurse (that she did not wish to identify) and begged for a COVID test for her mother. F7 stated the nurse agreed to the test and walked away. F7 stated she assumed the test was administered after she left, but when she requested the result, the facility was unable to provide that information. F7 stated she had a scheduled appointment with the Director of Nursing (DON) today to discuss this and other concerns, but the DON contacted her today to reschedule and told her she was not working today. During an interview on 08/22/2024 at 1:55 PM with F4, he stated the facility failed to administer a COVID test to R10 when requested. F4 stated when his sister visited R10 a couple of weekends ago, she requested a COVID test, and staff refused to administer one. He further stated nursing staff told R10 and his sister she did not need one because there was no COVID in the building. During an interview with the Infection Preventionist (IP) Nurse on 08/23/2024 at 9:52 AM, she stated the facility's current COVID testing guidelines were based on exposure and/or presence of symptoms. The IP Nurse stated COVID testing administration and results were documented in residents' progress notes. She further stated a resident could request a COVID test at any time regardless of symptoms or exposure, and there was no reason a resident would be denied a COVID test. During an interview with the DON on 08/23/2024 at 11:05 AM, she stated COVID testing was available for residents at any time, and there was not a reason to ever tell residents they could not have a test. She further stated COVID testing and test results were documented in progress notes. The DON stated it was important for staff to follow the facility's infection prevention and control policies and procedures to prevent the spread of infections. During an interview with the Administrator on 08/23/2024 at 11:44 AM, she stated the facility would never deny a resident a COVID test if one was requested. She further stated it was her expectation staff followed facility infection prevention guidelines to prevent the spread of infection and to protect residents.

Based on interview, record review, and review of the facility's policy, the facility failed to ensure each resident was treated with respect and dignity and cared for in a manner and in an environment that promoted the maintenance or enhancement of his/her quality of life. The facility failed to ensure residents had a right to communicate with and had access to persons and services inside and outside the facility for 2 of 22 sampled and supplemental residents, Resident (R) 7 and R10. R7's representative and R10's representative stated they were unsuccessful when they attempted multiple times to communicate with the facility via telephone. The findings include: Review of the facility's policy titled, Resident Rights, dated 10/24/2022, revealed the resident had the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. 1. Review of R7's Admission Record revealed the facility admitted the resident on 08/08/2013 with diagnoses of vascular dementia, hereditary and idiopathic neuropathy, and cerebrovascular disease. Review of R7's, Minimum Data Set (MDS), with an assessment reference date (ARD) of 08/02/2024, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. Review of a facility written communication document provided to residents and families on 08/08/2024 revealed a listing of updated numbers for Household (the facility's nursing units) floor phones and nurse cell phones. During an interview with family member (F) 5 on 08/20/2024 at 2:55 PM, she stated R7 developed COVID a few weeks ago, and she was unable to reach anyone at the facility to check on his condition. She further stated each time she called the facility, the phone rang and went straight to voicemail; however, the voice mailbox was full. F5 stated since that time, she learned from the Director of Nursing (DON) the facility had new telephone numbers that became effective a couple of months earlier. F5 further stated she did not receive information related to the new telephone numbers. F5 stated she was very upset and worried when she was unable to reach the facility to check on her father's condition. During an interview on 08/22/2024 at 8:54 AM with Licensed Practical Nurse (LPN) 2, she stated she had difficulty reaching the Households when she called from outside the facility, and her calls went straight to voicemail. LPN2 stated possible reasons phones were not answered included the location in the building at the time, phones were on silent, or the nurse laid the phone down unattended. During an interview with the Maintenance Director on 08/22/2024 at 10:45 AM, he stated no recent changes were made to the facility's phone system. He further stated incoming calls after hours were rolled over to staff cell phones. During an interview with the DON on 08/23/2024 at 11:05 AM, she stated incoming phone calls went to the Receptionist until around 7:00 PM, and then calls were diverted to the Households. She further stated, if calls were not answered at the Household landline, they were forwarded to the nurses' cell phones, and messages could be left on any of the phones. The DON stated any staff member could check phone messages, and that responsibility was not assigned to a single individual. She stated family members also had the ability to directly dial the nurses' cell phones. The DON stated there were family members that complained to her they were unable to reach the facility, and the facility determined they had incorrect phone numbers. The DON offered no explanation as to why residents' family members had incorrect numbers. On 08/23/2024 at 6:37 AM, the State Survey Agency (SSA) Surveyor attempted a call to the Household A floor phone. The phone rang, no one answered, and it went straight to voicemail. The voice mailbox was full, and the SSA Surveyor was unable to leave a message. 2. Review of R10's Admission Record revealed the facility admitted the resident on 08/01/2022 with diagnoses of congestive heart failure (CHF) and chronic kidney disease (CKD). Review of R10's MDS, with an ARD of 07/31/2024, revealed the resident had a BIMS score of four out of 15, which indicated the resident was severely cognitively impaired. During an interview on 08/22/2024 at 1:55 PM with F4, he voiced concerns about staff response to telephone calls. He further stated he observed on multiple occasions the facility cell phones lying unattended on the dining tables in Household A. F4 stated the call lights were tied to the cell phones, and the nurses often silenced the phones. F4 stated he visited his mother daily, Monday through Friday, but still called her every morning on her cell phone. F4 stated two Sundays ago he called R10's cell phone numerous times, but she failed to answer. He further stated he then called the Household nurse's cell phone, and it went straight to voicemail, but the mailbox was full. F4 stated at that point he called the main number to the reception desk. He stated he heard a recording with several options that included one that directed him to leave a message. F4 stated he chose that option but was not given the opportunity to leave a message. F4 stated he hung up, called back, pressed the option for the physician line, and still no one answered. F4 stated at that point he was concerned and drove to the facility to check on his mother. During an interview with the Receptionist on 08/23/2024 at 8:31 AM, she stated a Receptionist was at the front desk from 6:00 AM to 8:00 PM. She stated when a call came in, she initially told the caller not to hang up during the transfer process, and if for some reason the call was disconnected, they should call back. The Receptionist further stated she then transferred the call to the appropriate extension, and if no answer, it bounced back to her if the caller stayed on the line. The Receptionist stated she then tried to track down the intended recipient, and if unsuccessful, she took a message. The Receptionist stated there were individual phones on each of the Households as well as cell phones the nurses carried. She further stated, after hours calls rerouted somewhere else, but she was not exactly sure where they went. During an interview with F7 on 08/23/2024 at 8:50 AM, she stated she visited R10 every Sunday, took her to Mass, lunch, and usually a drive in the car. F7 stated on 08/04/2024 she arrived at the facility around 10:30 AM and was surprised to find her brother there because he typically visited Monday through Friday. She further stated her brother informed her he tried unsuccessfully to reach both the resident and the facility multiple times that morning and was concerned, so he drove to the facility. F7 stated one of the nurses on duty at the time told her the phone must have been turned off, and she did not hear it. F7 was unable to identify the nurse. During an interview with the Administrator on 08/23/2024 at 11:44 AM, she stated the phones the nurses carried were cell phones, and they were also tied to the call light system. She further stated each Household had a floor phone and a nurse cell phone, and outside callers were able to leave voicemail messages on the phones. Additionally, she stated no one person was designated to check and return voicemail messages. The Administrator stated the facility sent a list of updated numbers for both Household phones and cell phones to residents and family. The Administrator stated it was her expectation outside callers were able to reach staff and/or family members when they called the facility.

Based on observation, interview, review of the COVID-19 test user manual, review of the Centers for Disease Control and Infection Prevention (CDC) guidelines and website, and review of the facility's policy, it was determined the facility failed to conduct testing in a manner that was consistent with current standards of practice for COVID-19 tests. Two (2) observation, on 03/02/2021, revealed the Infection Preventionist not donning a gown prior to conducting in-room nasal swabbing of Resident #15 and Resident #16. The findings include: Review of the facility's policy titled, Infection Prevention and Control Policy [DIAGNOSES REDACTED]-CoV2, Coronavirus Disease 2019 (COVID-19) VERSION 12, last revised 10/27/2020, revealed, during specimen collection, facilities must maintain proper infection control and use recommended personal protective equipment (PPE), to include an N95 or higher-level respirator or facemask, eye protection, gloves, and a gown. Review of the Abbott BinaxNOW COVID-19 Ag Card User Manual for conducting on-site COVID-19 testing revealed, under the section on specimen collecting and handling, to refer to CDC Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens from Persons for Coronavirus Disease 2019 (COVID-19). The manual then provided a web address, https://www.cdc.gov/coronavirus/2019-nCoV/lab/guidelines-clinical-specimens.html. Review of the above website, under a section titled, Collecting and Handling Specimens Safely, the following was documented: For healthcare providers collecting specimens or working within 6 feet of patients suspected to be infected with [DIAGNOSES REDACTED]-CoV-2, maintain proper infection control and use recommended personal protective equipment (PPE), which includes an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection, gloves, and a gown. Observation, on Household A, on 03/02/2021 at 8:05 AM, revealed the Infection Preventionist (IP) already masked and wearing a face shield, donned gloves, prior to entering Resident #15's room, and performed a nasal swab for COVID-19 testing. The IP was then observed to seal and label the sample following collection, prior to disposal of gloves and sanitation of hands. Second observation, on Household A, on 03/02/2021 at 8:15 AM, revealed the IP, masked and wearing a face shield, donned gloves, prior to entering Resident #16's room, and performed a nasal swab for COVID-19 testing. The IP was then observed to seal and label the sample following collection, prior to disposal of gloves and sanitation of hands. Interview with the IP, on 03/02/2021 at 9:40 AM and at 6:20 PM, as well as on 03/04/2021 at 9:36 AM, revealed none of the collected samples tested positive. She stated she had been trained by the Director of Nursing (DON) on how to conduct testing. The IP stated she was not aware of the need to wear a gown when collecting specimens. To her knowledge, floor staff was also unaware of the need to wear a gown when collecting specimens. She stated she did not think the collection process would aerosolize, unless a resident sneezed or coughed as a result of the collection process. During further interview, the IP stated for staff COVID-19 testing, staff collected their own specimens, under supervision by the HR staff or other staff, who also did not wear a gown while observing collection. The IP stated the potential dangers of not wearing the appropriate PPE when collecting specimens could lead to staff exposure and possible infection. Interview with State Registered Nurse Aide (SRNA) #2, on 03/02/2021 at 10:22 AM, revealed she self-swabbed for COVID-19 testing and got results from the rapid test within fifteen (15) minutes. She revealed staff could self-swab, or if they did not feel comfortable doing that, nursing staff could swab them. Interview with Resident #2, on 03/02/2021 at 3:00 PM, revealed he/she was tested last night and observed the nurse to wear a mask, goggles, and gloves, but not a gown. Resident #2 revealed he/she was tested twice weekly and was informed when there were new cases of COVID-19 in the facility. Interview with SRNA #6, on 03/03/2021 at 8:45 AM, revealed she self-swabbed for facility COVID-19 testing twice weekly. She stated she went to a designated area for testing and was not aware if staff observing the process was wearing a gown. Interview with Licensed Practical Nurse (LPN) #4, on 03/03/2021 at 3:22 PM, revealed floor nurses did resident COVID-19 testing. She stated, when testing residents, she wore masks, face shield or goggles, and gloves. She revealed she had never worn a gown while conducting resident COVID-19 testing and had not been educated to do so. Interview with LPN #1, on 03/03/2021 at 3:46 PM, revealed when she tested residents for COVID-19, she wore a gown, gloves, an N 95 mask with a surgical mask over it, and goggles. She stated that was something she knew to do from her experience and training as a nurse and was not aware other staff was not wearing a gown for testing of residents. Interview with LPN #3, on 03/04/2021 at 9:17 AM, revealed she did not wear a gown when collecting resident nasal swab specimens for COVID-19 testing. She stated she was given instruction on the collection process, but it did not include education on the need to wear a gown when collecting specimens. Per interview, she stated, when staff conducted self-swabbing for COVID-19 testing, they were observed by management staff, sometimes HR or one (1) of the secretaries. In addition, she stated staff typically wore scrubs, when monitoring self-swabbing, with masks, goggles, and gloves on, but no gown. Interview with SRNA #12, on 03/04/2021 at 10:35 AM, revealed she collected her own samples for COVID-19 testing, and staff was always present observing, wearing gloves, goggles, and a mask. She stated she had not observed staff wearing gowns while observing and assisting in specimen collection. Interview with the DON, on 03/02/2021 at 3:44 PM, revealed she was not aware staff needed to wear gowns when collecting nasal swabs from residents or when observing staff self- swabbing. She revealed the danger of not wearing appropriate PPE when collecting samples would be the potential for staff to become infected. Interview with the Administrator, on 03/02/2021 at 3:44 PM, and again, on 03/04/2021 at 1:59 PM, revealed when staff self-swabbed for COVID-19 testing, he/she was observed by management staff, although they were unaware staff needed to wear gowns while collecting specimens. The Administrator stated, without wearing proper PPE, there was a possibility staff involved in the collection process would become infected.

Based on observation, interview, and review of the facility's policies, it was determined the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections, such as COVID-19. 1. Observation, on 03/01/2021 at 1:37 PM, noted six (6) rooms, on Household B, and one (1) room, on Household A, with isolation carts in front of doors, without signage indicating the nature of the isolation. 2. Observation, on 03/01/2021 at 3:15 PM, on Household C, revealed residents not social distancing and not wearing masks. Observation on 03/02/2021 at 8:18 AM, on Household A, revealed multiple residents seated around tables in the dining area, not socially distanced. 3. Observation, on 03/01/2021 at 3:17 PM, on Household C, revealed a pile of loose gloves on top of a soiled housekeeping cart. Further observation revealed a housekeeper donned a pair of the gloves and placed the other gloves in a clean storage container. The findings include: Review of the facility's policy titled, Infection Prevention and Control Policy COVID-19, Basic Policy VERSION-3, revised 02/23/2021, revealed communal dining would be permitted, however, social distancing would remain in effect. Further review revealed residents who were in isolation would have a sign posted Please see a nurse before entering. Review of the facility's policy titled, Infection Prevention and Control Policy [DIAGNOSES REDACTED]-CoV-2, Coronavirus Disease 2019 (COVID-19) VERSION 12, revealed if unable to use dedicated or disposable equipment, equipment used should be disinfected and cleaned according to manufacturer's guidelines. Further review of the policy revealed core principles to reduce the risk of COVID-19 transmission included the use of face coverings or masks and social distancing of at least six (6) feet between persons. 1. Observation, during the initial tour, on 03/01/2021 at 1:37 PM, on Household B, revealed six (6) rooms with personal protective equipment (PPE) storage outside of the rooms with no signage on the doors or near the rooms indicating the nature of the isolation precautions (Rooms 166, 168, 169, 170, 173, and 177). Another room (room [ROOM NUMBER]) was observed, on Household A, with PPE storage outside, yet no signage on the door or near the room. Continued observation of these areas revealed staff donned full PPE (gowns, face masks, eye protection, gloves), prior to entering rooms, with PPE storage outside. Interview with the Infection Preventionist (IP), on 03/01/2021 at 9:40 AM, and again at 6:20 PM, revealed she knew the Director of Nursing (DON) had been in contact with the Corporate Office regarding signage, prior to the State Survey Agency (SSA) Surveyor noting the lack of signage. She further stated all residents with PPE by their doors were either new admissions, readmissions, or residents who had been out for appointments. She stated all of those residents were considered to be on Droplet Precautions; but, if the facility was not enforcing use of Droplet Precautions for all residents, signage would be important to prevent potential staff exposure. Interview with State Registered Nurse Aide (SRNA) #5, on 03/02/2021 at 5:54 PM, revealed aides were not always informed of the nature of precautions residents were on; however, staff was told to treat everyone in precautions as if on Droplet Precautions, utilizing full PPE. He stated, although nursing staff would not necessarily say residents were isolated due to COVID-19 and there was no signage to indicate the type of precaution, the assumption would be any resident in isolation was due to COVID-19. Interview with Licensed Practical Nurse (LPN) #1, on 03/03/2021 at 3:46 PM, revealed most new admits were on her unit (Household B). She stated she was informed during report, at shift change, the nature of the residents' isolation precautions. Per interview, she stated all residents on any type of isolation had isolation carts outside of their doors with full PPE available to staff. In addition, LPN #1 stated when aides saw the isolation carts, they typically asked nurses about the nature of the isolation. Interview with the Director of Nursing (DON), on 03/01/2021 at 5:00 PM, revealed she was uncertain about the specifics on signage to be posted outside of residents' rooms. The DON stated she had contacted the Corporate Office regarding this, on 02/26/2021, but had not received clarification. She stated she was uncertain what type of signage needed to be posted, but all residents on any type of isolation currently were treated as if on Droplet Precautions, which required staff to wear full PPE when caring for those residents. Interview with the Administrator, on 03/04/2021 at 1:59 PM, revealed she expected the facility to have signage posted in accordance with the Centers for Medicare and Medicaid Services (CMS) regulations. 2. Observation, on 03/01/2021 at 3:15 PM, on Household C, revealed two (2) incidents of residents in the television area not socially distanced (Resident #11 and Resident #12; Resident #1 and an unsampled resident) and not wearing masks. Further, masks were visible hanging off one (1) resident and hanging on the wheelchair of a second resident. Further observation, during the time period observed, revealed staff was not encouraging, promoting social distancing amongst the residents. Observation, on 03/02/2021 at 8:18 AM, on Household A, revealed residents seated around dining tables awaiting breakfast. Further, observation revealed five (5) residents were seated around two (2) tables pushed together, not social distancing; four (4) residents were seated around one (1) table, not social distancing; four (4) residents were seated around two (2) tables pushed together, with two (2) social distancing and two (2) others within three (3) feet of each other; and three (3) residents were seated at one (1) table, not socially distanced. Interview with the IP, on 03/02/2021 at 9:40 AM, and again at 6:20 PM, revealed there was not a lot of space on Household A for residents to social distance, although masks were encouraged until meal service was about to begin, for those that would listen. She stated it was a struggle to keep residents socially distanced and to utilize masks. The IP stated residents ate better and were less depressed when they had communal dining. She stated she would love to be able to ensure residents maintained a six (6) foot distance, but it was difficult with wanderers, and during meals, as residents desired to sit near their friends. Further interview reveled this had been more difficult lately for Household C, following recovery from a recent isolation due to a COVID-19 outbreak. She stated she expected staff to encourage mask use among residents and to try to keep residents separated from wandering residents who refused to wear masks. The IP stated Resident #11 was particularly difficult to social distance, as he/she always wanted to spend time near others. Interview with State Registered Nurse Aide (SRNA) #2, on 03/02/2021 at 10:22 AM, revealed most cognitively impaired residents removed their masks and threw them on the floor, and it was a challenge for staff to keep their masks on them. She stated staff reiterated the need to wear masks, and most residents wore masks or kept them on their wheelchairs when not wearing them. She further revealed staff were trained to keep residents six (6) feet apart, but it could be hard to do, especially at meal time. Interview with SRNA #9, on 03/03/2021 at 9:59 AM, revealed she worked on Household B. She stated there were more residents with Dementia on Household C who refused to wear masks, and staff did the best they could to encourage residents to keep masks on or to put masks back on. Interview with LPN #3 from Household A, on 03/03/2021 at 3:02 PM, revealed staff tried to keep residents apart and encouraged mask use. She revealed not all residents were compliant with wearing masks, and staff was more vigilant about maintaining social distancing with those residents. LPN #3 also revealed, if a resident refused to use a mask, she would try and approach him/her later to again encourage mask use. She stated there was a danger of transmitting COVID-19, or any virus, if residents did not wear masks and did not socially distance. Interview with LPN #4, on 03/03/2021 at 3:22 PM, revealed she worked on various units. She revealed residents were encouraged to socially distance when outside of their rooms and to wear masks. Per interview, alert and oriented residents were generally compliant with these requirements. However, LPN #4 stated it was more challenging for residents with Dementia, who required frequent redirection by staff, and staff did the best they could to ensure these residents were compliant with wearing masks and social distancing. Interview with LPN #1 of Household B (used to be Household C), on 03/03/2021 at 3:46 PM, revealed about one-half (1/2) of the residents on the unit were cognitively impaired and about one-third (1/3) required feeding encouragement or assistance. She revealed staff encouraged residents to keep masks on, although many would remove them. Further, LPN #1 stated staff had to keep encouraging residents to put masks back on and would place masks on their wheelchairs when residents refused to wear them. She stated staff tried to keep residents socially distanced. Interview with SRNA #12 of Household A, on 03/04/2021 at 10:35 AM, revealed a few residents with Dementia either would not wear masks or would not keep them on. She revealed staff focused more to encourage wandering residents to mask up, as they came in contact with other residents. Interview with the DON, on 03/02/2021 at 3:44 PM, revealed staff had been educated on residents to maintain social distancing and to encourage residents to wear masks when out of their rooms; however, it could be difficult to achieve compliance with some residents. Interview with the Administrator, on 03/02/2021 at 3:44, and again, on 03/04/2021 at 1:59 PM, revealed staff had to respect residents' rights and could not force mask usage but did provide masks and encouraged their use. The Administrator stated, although staff were not observed by the SSA Surveyor encouraging social distancing or mask use, they did those things. She stated she expected staff to encourage social distancing and to ensure residents had masks available to them. 3. Observation, on 03/01/2021 at 3:17 PM, on Household C, revealed a pile of gloves sitting on top of the soiled-appearing lid of a housekeeping cart, as Housekeeper #1 returned to the cart. Interview with Housekeeper #1, on 03/01/2021 at 3:17 PM, revealed someone had placed gloves on the lid of the cart because she had asked staff on the unit for gloves. She stated gloves were usually kept in a box and were stored in the cart, not on top of it. In addition, she stated she had cleaned the housekeeping cart the previous week and did so approximately every other week. During interview related to the gloves being left atop an unclean housekeeping cart, she responded very probably that they may be contaminated. Housekeeper # 1 then placed the gloves in a clean storage bag, hanging on the back of the cart, and donned a pair of the gloves before entering a resident's room to clean. Interview with the IP, on 03/02/2021 at 9:40 AM, and at 6:20 PM, revealed there would be a danger of cross-contamination for a housekeeper to take gloves from the top a dirty cart and use them. She further stated PPE should be stored in a way to prevent it from becoming soiled, prior to use, and housekeeping carts should be cleaned daily. Interview with the Housekeeping Supervisor, on 03/02/2021 at 2:05 PM, revealed Housekeeper #1 had worked on Household C for approximately six (6) months. She stated the housekeeping carts were supposed to be wiped down when taken to the storage closet at the end of each shift, but unfortunately, some of the housekeepers were a little messier than others and did not clean their carts as they were supposed to. She stated she expected the carts to be cleaned at the end of each shift with disinfectant cleaner. Per interview, she stated housekeepers were to inform her when they needed supplies, such as gloves, and she would get the supplies. She stated boxes of gloves were sometimes kept on top of housekeeping carts, but they should not be lying loose on top of a cart. In addition, she stated it was unsanitary to store gloves in a pile on top of the housekeeping cart. Further, the Housekeeping Supervisor stated the gloves on top of the housekeeping cart should not have been worn but thrown away. Interview with the Administrator, on 03/03/2021 at 2:35 PM, and again, on 03/04/2021 at 1:59 PM, revealed she expected housekeeping carts to be clean and gloves to be stored appropriately.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to ensure drugs and biologicals were stored in locked compartments with only authorized personnel permitted access. Observation, on 03/02/2021 at 11:54 AM, revealed State Registered Nurse Aide (SRNA) #5 accessed a medication cart, then secured the medication cart, after Licensed Practical Nurse (LPN) #2 asked for an alcohol pad to clean a glucometer prior to usage. The findings include: Review of the facility's policy titled, Storage of Medications, revised April 2007, revealed compartments containing drugs and biologicals, including medication carts, were to be locked when not in use and should not be left unattended or potentially available to others. The policy further stated only persons authorized to prepare and administer medications should have access to the medication room, including any keys. Observation, on 03/02/2021 at 11:54 AM, revealed LPN #2 left her medication cart unlocked in the common area and out of sight while entering a resident's room to conduct a glucometer check. Once the LPN put on appropriate personal protective equipment (PPE), to include gown, gloves, mask, and face shield, she realized she did not have an alcohol prep pad to sanitize the glucometer, prior to its usage. LPN #2 proceeded to call out for someone to get her an alcohol prep pad. Continued observation revealed SRNA #5 left the nearby kitchen area, proceeded to the medication cart, withdrew an alcohol prep pad from the cart, secured the cart, and then met LPN #2 in the doorway to the room with the alcohol prep pad. SRNA #5 then returned to his duties. Interview with LPN #2, on 03/02/2021 at 11:55 AM, revealed she should have locked her cart but did not consider it an issue to ask an aide to get an alcohol wipe from the medication cart. Interview with the Director of Nursing (DON), on 03/02/2021 at 3:44 PM, revealed medication carts should be locked whenever the nurse stepped from the cart so no one else had access to the cart. Interview with the Administrator, on 03/02/2021 at 3:44 PM, revealed LPN #2 should not have left her medication cart unlocked, and SRNA #5 should not have gotten anything from the cart, and only the nurse responsible for the cart should have access to the cart. In addition, she stated alcohol prep pads could be accessed by aides in the supply room on the unit.

Based on observation, interview, record review, review of Material Safety Data Sheets (MSDS), and review of the facility's policies, it was determined the facility failed to maintain an environment that remained as free of accident hazards as possible. Observation, on 03/01/2021 at 3:17 PM, revealed a housekeeping cart, on Household C, not secured with hazardous chemicals within. Per interview, the cart had no key to secure it. Observation, on 03/01/2021 at 3:23 PM, revealed a medication cart, on Household C, not secured, with the nurse away from the cart. Another observation, on 03/02/2021 at 11:55 AM, revealed a medication cart, on Household B, not secured, with the nurse away from the cart. The findings include: Review of a facility list of residents assessed to be at risk for wandering, provided by the Director of Nursing (DON), revealed seven (7) residents on Household C were considered wanding risk, cognitively impaired and potentially at a high risk due to unlocked medication carts or unlocked housekeeping carts. Three (3) of the residents listed were determined, on review of the Minimum Data Set (MDS), to be potentially at a higher risk due to cognitive impairment: Resident #10, Resident #11, and Resident #13. Review of Resident #10's medical record revealed the facility admitted the resident, on 04/01/2020, with [DIAGNOSES REDACTED]. Review of the 12/31/2020 Quarterly Minimum Data Set (MDS) Assessment revealed the facility assessed Resident #10 as moderately cognitively impaired. In addition, the Assessment revealed the resident required, on the unit, supervision with ambulation and assist of one (1) staff; off the unit, the resident required supervision with ambulation and setup assist only. Review of Resident #11's medical record revealed the facility admitted the resident, on 05/26/2016, with [DIAGNOSES REDACTED]. The facility assessed Resident #11, in a 02/22/2021 Quarterly MDS Assessment, as severely cognitively impaired, requiring supervision and assist of one (1) staff for ambulation. Review of Resident #13's medical record revealed the facility admitted the resident on 06/24/2020, with [DIAGNOSES REDACTED]. The facility assessed Resident #13, in a 06/27/2020 Admission MDS Assessment, as moderately cognitively impaired and required limited supervision and assist of one (1) staff for ambulation on the unit. 1. Review of the facility's policy titled, Safety Precautions, General, revised November 2009, revealed all staff were required to follow general safety precautions as established by the facility. Further, the policy stated staff was to follow manufacturers' guidelines when using chemicals, equipment, and other supplies. Observation, on 03/01/2021 at 3:17 PM, revealed Housekeeper #1's housekeeping cart, on Household C, was unlocked with hazardous chemicals inside, including Ecolution Pro Glass Cleaner; Ecolution Odor Remover Crisp Linen; GBC-34, a germicidal detergent and deodorant; NDC Morning Fresh Disinfectant Cleaner; D-Story Morning Fresh; and Triple Quick [MEDICATION NAME] Meadow. Review of a Material Safety Data Sheet (MSDS) for Ecolution Pro Glass Cleaner revealed it was an eye and skin irritant, with low toxicity risk to vulnerable populations. Further, the MSDS revealed the chemical should be stored locked up. Review of the MSDS for Ecolution Odor Remover Crisp Linen revealed it was an eye irritant and skin irritant that should be stored in a dry place. Review of the MSDS for GBC-34, a germicidal detergent and deodorant, revealed it was capable of causing serious eye damage, severe skin burns, and to avoid breathing chemical vapors. The MSDS further revealed GBC-34 contained toxic chemicals and should be stored locked up. Review of the MSDS for NDC Morning Fresh Disinfectant Cleaner revealed the product caused severe [MEDICAL CONDITION] eye damage; was harmful if inhaled or swallowed; and was to be stored in a dry place and locked up. First aid measures included contacting a poison center if swallowed. Review of the MSDS for D-Story Morning Fresh revealed the product caused skin and eye irritation; was harmful if swallowed; and was to be stored in a dry place and locked up. First aid measures included contacting a poison center, if swallowed. Review of the MSDS for Triple Quick [MEDICATION NAME] Meadow revealed it was a skin and eye irritant that could be harmful if swallowed. Further review revealed the product contained toxic chemicals and should be stored in a dry place and locked up. Interview with Housekeeper #1, as she returned to the housekeeping cart, on 03/01/2021 at 3:17 PM, revealed when she opened the cart to show compartments within her cart, it was not locked. When asked if the cart should be locked, Housekeeper #1 stated it should be, but, there were no keys to match the cart. She also stated she had been unable to lock it since it had been assigned to her. Further, when asked if there had been any training regarding storage of items in the housekeeping cart, she stated she had received training, and the cart should always be secured. Interview with the Housekeeping Supervisor, on 03/02/2021 at 2:05 PM, revealed Housekeeper #1 had worked in the facility for under a year and had been working Household C for about six (6) months. She stated Housekeeper #1 had one (1) of the carts with a missing key, and when she started working as Supervisor, she discovered several housekeeping carts used on residential units had missing keys. Per interview, the Supervisor stated the original plan was to have all housekeeping carts keyed with the same key, which was on a list of things to be done, but unfortunately, had not been done. When interviewed about the importance of having carts locked, she stated staff was trained to keep an eye on housekeeping carts and to shut carts when in a resident's room. She stated she was not aware that any resident had ever bothered the housekeeping carts. Furthermore, the Supervisor stated, based on her experience, an unlocked cart would not be a risk to residents on Household C, as none had ever shown any interest in the housekeeping cart. Interview with the DON, on 03/02/2021 at 3:44 PM, revealed housekeeping carts should be secured when the housekeeper stepped away and at all times. The DON stated the danger of an unsecured housekeeping cart was a confused resident, or any resident could try to consume or use chemicals inside the cart. Interview with the Administrator, on 03/02/2021 at 3:44 PM, revealed housekeeping staff, including the Supervisor of Housekeeping, did not understand the urgency of having secured housekeeping carts, and she was unaware there were housekeeping carts that were not secured, prior to 03/01/2021. The Administrator stated it was a resident safety issue because any resident could get a harmful chemical and possibly spill or ingest it. 2. Review of the facility's policy titled, Storage of Medications, revised April 2007, revealed all drugs and biologicals were to be stored in a safe, secure, and orderly manner. Further review revealed compartments containing drugs and biologicals were to be locked, when not in use, and medication carts should not be left unattended, if opened or potentially available to others. Observation, on 03/01/2021 at 3:22 PM, revealed an unlocked medication cart on Household C. Observation of the area revealed two (2) residents in the television area near the medication cart, Resident #11 and Resident #12. Further observation revealed Resident #6 wheeled past the cart while it was unlocked. Interview with Licensed Practical Nurse (LPN) #1, on 03/01/2021 at 3:23 PM, revealed she left her medication cart briefly to put some Med Pass (a nutritional supplement used during medication administration) in the unit refrigerator, as she had completed medication administration to residents. She stated she locked her cart, when she was away from it, and should have done so when refrigerating the Med Pass because leaving it unlocked could pose a danger to residents. In addition, she stated someone could take medications from it or get into other supplies stored there, such as blood sugar supplies or insulin supplies stored in the medication cart. While interviewing LPN #1, a loose pill was noted under the medication cart, which was later determined to be an eighty-one (81) milligram (mg) aspirin tablet. LPN #1 stated she did not know what the loose medication was but stated someone else might have dropped it and not noticed it. She stated she did not believe anyone had missed medications, and she disposed of the loose pill in the sharps container. Furthermore, LPN #1 stated all Household C residents had medications in the medication cart. Interview with the DON, on 03/01/2021 at 5:00 PM, revealed the facility just switched to medication carts recently, on 02/26/2021. Additional observation on Household B, on 03/02/2021 at 11:54 AM, revealed LPN #2 left the medication cart unlocked when performing glucometer testing of an unsampled resident. Three (3) nurse aides were observed nearby in the unit kitchen area. Interview with LPN #2, on 03/02/2021 at 11:55 AM, revealed she usually locked her cart, and should have done so, when doing glucometer checks on residents, because a confused resident, or any resident, could potentially get into the cart and grab medications. In addition, she stated the facility just started using medication carts. Follow up interview with LPN #1, on 03/03/2021 at 3:46 PM, revealed the facility just started using medication carts, possibly on 02/26/2021, or on 03/01/2021. She again stated medications for all residents on Household C were in the cart on 03/01/2021. She stated she was away from the cart for possibly thirty (30) seconds when the State Survey Agency (SSA)Surveyor noted the unlocked medication cart. LPN #1 stated it was important to keep the medication cart locked when she was not present, as a confused resident, or any resident, could get into the cart and take medications or get sharps that were in the medication cart and harm himself/herself. Interview with LPN #4, of Household B, on 03/03/2021 at 3:22 PM, revealed there had been no formal education at the facility regarding medication cart usage, although she had been a nurse long enough she did not feel there was a need for formal education. She stated it was standard practice to lock the medication cart, when away from it, because there could be a danger of residents taking medications, leading to severe negative physical consequences. Interview with the DON, on 03/02/2021 at 3:44 PM, revealed medication carts should be locked anytime the nurse stepped away from them. The DON stated a dropped medication, including an 81 mg aspirin tablet, could pose a danger of adverse consequences to a resident. Interview with the Administrator, on 03/02/2021 at 3:44 PM, revealed medication carts should not be left unlocked. She revealed this had been the facility's second day using medication carts, and they needed to be kept secured for resident safety.

Based on interview, record review and review of the facility's Policies, it was determined the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for one (1) of seven (7) sampled residents (Resident #3). Resident #3 was assessed to require the assistance of three (3) or four (4) staff or a Hoyer Lift (mechanical lift) for transfers per the Physical Therapy (PT) Discharge Summary dated 05/16/17. However, on 06/01/17 Resident #3 was transferred with the assistance of one (1) person sustaining injury to the left knee. An X-Ray on 07/21/17 revealed the resident had a Fracture of the Left Patella. Additionally, the Magnetic Resonance Imaging (MRI) test on 07/27/17 revealed the resident had an Left Anterior Cruciate Ligament (ACL) tear and Bilateral Meniscal tears, but no evidence of Fracture. The injury resulted in Resident #3 being unable to ride his/her scooter and being confined to a Geri-chair or the bed due to pain when stretching out the left leg. In addition, there was no documented evidence Administration was notified of the incident in order to conduct an investigation. Also, although the resident initially complained of knee pain after the transfer, and continued to complain of knee pain, there was no documented evidence the Physician or Advanced Registered Nurse Practitioner (ARNP) was notified of the injury or continued pain. (Refer to F-157 and F-280) The findings include: Review of the facility Fall Prevention and Fall Management Program Policy, revised September 2016, under the section titled Strategies for reducing risks of falls, revealed for transfer and ambulation: identify and provide needed assistance for safe transfer. Review of the facility Policy titled, Critical Incident Reporting Policy, revised September 2016, revealed a Critical Incident is any actual or alleged event or situation that creates a significant risk of substantial or serious harm to the physical or mental health, safety, or well-being of a resident, visitor, or employee. Continued review of the Policy revealed the reporting process was to immediately notify Supervisor, Manager, or Director of the critical incident. Interview, on 07/28/17 at 2:10 PM, with the facility Administrator, revealed the facility did not have a policy relating to communication between Therapy and Nursing. Review of Resident #3's medical record revealed the facility admitted the resident on 08/21/14 and readmitted the resident on 04/18/17, with [DIAGNOSES REDACTED]. Review of the Comprehensive Care Plan initiated 03/06/17, revealed Resident #3 was at risk for injuries related to falls due to overall poor health status and weakness. The goal stated the resident's risk for falls would be evaluated and therapeutic interventions would be implemented as noted and as tolerated. There were several interventions which included: call light in reach when the resident was in his/her room; remind the resident to call for assistance before attempting to transfer/stand unassisted; encourage the resident to stay in common areas when he/she was awake; ensure the resident was wearing non-slip, well-fitting footwear; and assist the resident with transfers and ambulation as needed. However, the Care Plan was not specific in stating how the resident was to be transferred or how many staff were to transfer the resident. Interview, on 07/27/17 at 4:47 PM, with the Minimum Data Set (MDS) Assessment Nurse, revealed the Care Plan for Resident #3, with the initiated date of 03/06/17, was the care plan being followed on 06/01/17. Review of the Fall Risk assessment dated [DATE], revealed risks included medication use, bowel and bladder incontinence, confined to a chair and oriented, and unable to independently come to a standing position, and uses an assistive device. Per the Assessment, the resident was at moderate risk for falls. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15) indicating the resident was cognitively intact. Further review revealed the facility assessed the resident as requiring extensive assistance of two (2) persons for transfers to or from the bed, chair, wheelchair and standing position; and requiring extensive assistance of two (2) persons for bed mobility. Further review revealed MDS Assessment was marked as the activity of walking did not occur. Review of the Physical Therapy Discharge Summary dated 05/16/17, revealed Resident #3 had a therapy goal of being able to safely transfer to and from the bed and wheelchair, requiring the use of a Sara Steady (mechanical lift), with maximum assistance of two (2) staff persons. Continued review of the Notes, revealed the resident did not meet his/her goal and was only able to safely transfer with the maximum assistance of three (3) to four (4) staff persons or transferred per the Hoyer lift (mechanical lift). Further review of the Notes, revealed Resident #3 had a long term goal for daily life that required maximum assistance of two (2) staff persons with the use of Hoyer lift. Continued review of Resident #3's Comprehensive Care Plan, revealed it was not revised to reflect the needed assistance of three (3) to four (4) staff persons or the use of a Hoyer lift as per the Physical Therapy Discharge Summary dated 05/16/17. Review of the Nurse Aide Care Card, (reference for the SRNAs to use as a guide for providing care) undated, revealed Resident #3 was to be assisted by two (2) staff persons with PRN (as needed) use of a Hoyer lift, indicating the Nurse Aide Care Card had not been reviewed and revised as per the Physical Therapy Discharge Summary dated 05/16/17. Review of the Nurse's Progress Notes dated 06/01/17 at 6:30 PM, completed by LPN #3, revealed Resident #3's left knee was twisted during a transfer with a gait belt from the shower chair to the bed. Continued review revealed the resident complained of severe pain and was medicated with two (2) Percocet Tablets (narcotic pain medication) and the resident's knee was propped on a pillow. Continued review of the Nurse's Progress Notes, dated 06/01/17 through 07/25/17, revealed it was documented the resident received narcotic pain medication due to left leg pain and at times it was documented the resident received the pain medication specifically for left knee pain with the highest pain being a ten (10), on a pain scale of one (1) to ten (10), with ten (10) being the worse possible pain. Review of the Advanced Registered Nurse Practitioner (ARNP) Progress Notes, dated 06/02/17, revealed Resident #3's Chief Complaint was edema and knee pain. Continued review revealed the resident had increased left leg edema, and chronic pain to the left knee that was worse since a recent transfer. Further review revealed pain medication was recently increased by Hospice. Additional review of the Notes revealed , indicates good passive range of motion (PROM) with an assessment/plan for left knee pain: acute on chronic, Percocet, and ace wrap PRN (as needed). Review of the Attending Physician Notes, dated 07/21/17, revealed the Physician saw the resident on this date with the Chief Complaint of Knee Pain. Continued review revealed the resident had been having left knee pain with some swelling. Further review of the Notes, revealed it was acute on chronic; however, pain was the limiting factor at the present time. Per the Notes, assessment/plan was: residents left knee pain was likely arthritic, no signs of septic joint, and an X-Ray was ordered. Review of the Radiology Report, dated 07/21/17, revealed Resident #3 had a Fracture involving the Left Upper Patella. Interview, on 07/26/17 at 9:26 AM, with Resident #3, revealed he/she was a retired Registered Nurse (RN) and had a concern he/she wanted to talk about. Per interview, he/she was injured at the facility due to State Registered Nurse Aide (SRNA) #2's negligence during a transfer from the chair to the bed. Resident #3 stated on or around 06/01/17, SRNA #2, who was a large male staff member, was lifting him/her from the shower chair to the bed, by himself. Per interview, the SRNA told the resident to put his/her arms around the SRNA's neck, and then lifted him/her and swung my bottom on the bed. Further interview revealed when the SRNA transferred him/her to the bed, his/her left knee twisted, he/she heard and felt it pop, and he/she screamed out in pain. The resident stated at the time of the incident he/she was supposed to be transferred with a Hoyer lift. Continued interview with Resident #3, on 07/27/17, at 10:19 AM, revealed there were days when he/she preferred to stay in bed all day due to knee pain with movement. Resident #3 stated the injury to his/her left knee had affected his/her life more than just having pain. The resident further stated since his/her left knee injury, he/she had not been able to use his/her motorized scooter because he/she could not straighten his/her left leg out without having pain. Per interview, when he/she was able to use the motorized scooter, he/she was able to go all around the facility, and would also go on outings off the facility grounds to events such as plays, or shopping with his/her daughter. The resident stated he/she hadn't had been off the facility grounds since the injury and now had to sit in a Geri chair. Additional interview with Resident #3, revealed when staff moved his/her left knee, it caused excruciating pain that was unbearable; so when he/she got into a position that was comfortable he/she stayed in the position for hours and only allowed staff to move him/her if absolutely necessary. The resident further stated since the knee injury on 06/01/17, he/she had taken an increased amount of narcotic pain medication, although he/she did not like to take narcotics. Resident #3 stated he/she told the aides and nurses how bad the pain was in his/her left knee every day since the incident. However, Resident #3 stated he/she never received any treatment for [REDACTED]. Continued interview revealed she had not seen a doctor or a nurse practitioner since he/she learned his/her knee was fractured, but would like to speak to a Physician because he/she wanted to know if he/she was going to have to live in this pain for the rest of his/her life. Interview, on 07/26/17 at 1:45 PM, with SRNA #1, revealed she and another SRNA had transferred Resident #3 on 06/01/17 to the shower chair using the Hoyer Lift. She stated on 06/01/17, Resident #3 required extensive assistance of two (2) staff for transfers and sometimes required the use of a Hoyer lift for transfers. SRNA #1 stated after the resident's shower she and the other SRNA pushed the resident in the shower chair to his/her bedside, and lowered the bed. She further stated a gait belt was placed around the resident's waist in order to transfer the resident, but the resident was feeling weak and fatigued that day, so she did not feel comfortable with a two (2) person transfer for the resident with another female. Further interview with SRNA #1, revealed she went to Unit C to get SRNA #2 to assist her. SRNA #1 stated she told SRNA #2 that Resident #3 was a two (2) person transfer, because she offered to get another male SRNA to assist him, but SRNA #2 did not wait. SRNA #1 further stated SRNA #2 came to Resident #3's room, and instructed the resident to put his/her arms around his neck, lifted the resident to stand up using the gait belt, and performed a one (1) person pivot transfer setting the resident's buttocks on the bed. The SRNA stated during the pivot transfer, Resident #3 started screaming my knee, my knee. SRNA #1 stated Resident #3 then complained of his/her knee hurting, and Licensed Practical Nurse (LPN) #3 who was in the room during the transfer administered medication due to the resident's complaints of knee pain. SRNA#1 stated Resident #3 complained of knee pain the rest of the evening. Continued interview with SRNA #1, revealed she was always assigned to Resident #3 and the resident complained every shift she worked since 06/01/17 of knee pain. SRNA #1 stated she had seen Resident #3 cry and have facial grimaces because of the pain in his/her left knee. Per interview, Resident #3 used to use an electric scooter and was all over the facility doing activities and visiting with friends at the facility, but after the injury, he/she was no longer able to use the scooter because his/her knee would hurt too bad because of how he/she had to sit on the scooter. SRNA #1 stated Resident #3 used the Geri-chair, but now stayed in bed more than he/she was out of bed. Interview, on 07/26/17 at 2:21 PM, with LPN #3, revealed she was assigned to Resident #3 on 06/01/17, and on that date the resident was assisted with a shower by two (2) female SRNAs. She stated after the shower, the aides rolled the resident in the shower chair to his/her bed. Continued interview revealed the SRNAs then went to another unit to ask SRNA #2 to assist them with transferring the resident from the shower chair to the bed. LPN #3 stated she saw SRNA #2 come over to assist, so she went into Resident #3's room to see if they needed any more assistance and that was when she saw SRNA #2 transfer Resident #3 from the shower chair to the bed by himself without any assist or support by staff, using only a gait belt. LPN #3 further stated she heard Resident #3 scream out My Knee. Per interview, after staff finished assisting the resident in the bed, she checked the resident's knee, and was able to move the resident's knee without the resident screaming; however, the resident did complain that his/her knee was hurting. Further interview revealed she offered and administered Percocet for pain. Further interview with LPN #3, revealed she did not remember completing an Incident Report and she did not remember notifying the resident's physician of the improper transfer and the resident's complaint of knee pain on 06/01/17. Per interview, she thought she had notified one of the Physician's about the resident's knee pain on a later date, and requested an X-Ray to be done; however, she was not given an order for [REDACTED]. She stated she could not remember which Physician or the date of the notification. LPN #3 revealed in reviewing the Nurse's Progress Notes, she could find no documentation related to her notification of the Physician or ARNP of the resident's condition on any date since the incident. LPN #3 stated to her knowledge, the first time Resident #3 was seen by a Physician for an assessment of his/her left knee, was on 07/21/17, when the Physician ordered an X-Ray. Continued interview revealed after the incident she re-educated SRNA #2 about not transferring the resident alone; however, did not document the education. The LPN further stated she could not remember telling administrative staff or anyone above her through the chain of command about the improper transfer. Interview, on 07/26/17 at 3:20 PM, with State Registered Nurse Aid (SRNA) #2, revealed on 06/01/17 he was asked by two (2) female SRNAs to come over to their assigned unit and help transfer Resident #3. Per interview, the resident was dressed and sitting in a shower chair in the bathroom, and he assisted by pushing the resident to the bedside in the shower chair. SRNA #2 stated he was in front of the resident, and stood the resident up with the resident's arms on his shoulders, while another SRNA got behind the resident to help support the resident. He stated he completed a quick twist for a pivot transfer and was using a gait belt for the transfer to the bed, sitting the resident down on his/her buttocks, on the bed. The SRNA further stated during the transfer, Resident #3 screamed out because of his/her leg. Continued interview revealed when SRNA #2 completed the quick twist, the resident's legs stayed put. Further interview with SRNA #2, revealed LPN #3 was present during the transfer, and later told him something happened to the resident's leg during the transfer, but she understood he was not familiar with the resident's leg issues. SRNA #2 stated he did not know the resident required two (2) staff to assist with transfers and he was not familiar with the resident. The SRNA #2 stated he relied on the resident's assigned staff that day to let him know how the resident was to be transferred and did not look at the resident's Care Card which was located on the inside of the resident's closet door. Per interview, it was very important for Resident #3 to be transferred with the amount of staff and the transfer technique in which the facility had assessed the resident to need. SRNA #2 stated because he did not know the resident and was not familiar with his/her care, he caused injury to Resident #3's knee that day. Interview, on 07/27/17 at 10:55 AM, with Resident #3's daughter, revealed she was in Resident #3's room on 06/01/17 when the injury happened. Per interview, the resident requested the female SRNAs give him/her a shower, and the SRNAs used a Hoyer lift to transfer him/her into the shower chair. The resident's daughter stated when the resident was finished with his/her shower, he/she was tired and weak, so SRNA #1 did not feel safe for her and the other SRNA to transfer the resident. Per interview, SRNA #1 requested SRNA #2 to assist with the resident's transfer. Continued interview with Resident #3's daughter revealed SRNA #2 came to Resident #3's room and stated he could transfer the resident by himself and instructed the resident to put his/her arms around his neck. Per interview SRNA #2 then using the gait belt stood the resident up, twisted {him/her}to the bed real fast, and the resident screamed out my leg, my leg. The daughter stated the resident was crying, and LPN #3, who was present during the transfer, gave the resident two (2) pain pills and propped his/her leg up. Per interview, the resident had increased leg pain ever since the incident. Resident #3's daughter stated the resident could not straighten his/her leg out all the way in order to ride the scooter without horrible pain, so now the resident used a Geri chair. She stated the resident used to ride the scooter around all the time, but now didn't do much but stay in bed because of the knee injury. Resident #3's daughter stated she used to take the resident shopping, but the resident had not left the grounds that she could remember since the injury occurred. Interview on 07/27/17 at 4:22 PM, with the facility's Therapy Manager, revealed Resident #3 was discharged from Physical Therapy on 05/16/17. Continued interview revealed when the resident was discharged from therapy, the therapy staff was utilizing three (3) to four (4) staff persons to manually transfer the resident or were using the Hoyer lift, which was what the therapy department recommended for bed to wheelchair and wheelchair to bed transfers. The Therapy Manager stated if the resident was in a shower chair, it would have been equivalent to being in a wheelchair, and the same practice for transfers should have been used. Per interview, she would never have recommended for a staff person to attempt a one (1) person transfer for Resident #3. Further interview with the Therapy Manager, revealed the communication process between therapy and nursing when a resident was discharged from therapy was for the therapist to speak with the nurse on the resident's unit, and let them know therapy's recommendation. The Therapy Manager stated the Physical Therapist who completed the Discharge Summary and who communicated with the nurse was no longer employed by the facility. Further interview revealed there was no documentation of the communication. The Therapy Manager stated it was important that the recommendations from Therapy related to transfers be used for resident safety and staff safety. The Therapy Manager further stated if a transfer was not done correctly, it could cause injury to the resident. Interview, on 07/27/17 at 12:40 PM, with the ARNP, revealed per review of her Progress Note, on 06/02/17, she examined Resident #3's left knee and documented the resident had good Passive Range Of Motion (PROM). The ARNP stated based on her assessment notes on 06/02/17, she did not think the resident's knee was fractured; however, the resident was taking chronic pain medication which could have masked the symptoms during the exam. The ARNP further stated Resident #3 had always had chronic leg pain below the knee due to Peripheral Arterial Disease; however, she was not informed after her exam of the resident on 06/02/17, that the resident had increased pain or continued problems with his/her left knee. Per interview, if she or another Provider within their practice had examined the resident and had knowledge of the increased left knee pain, it would have been documented either by paper form, or if electronically documented, it would have been faxed to the facility for the medical record. However, the ARNP stated she could find no documentation that a Provider in her practice had been notified. The ARNP further stated the nurse should have notified her or someone on the resident's primary care team on 06/01/17, of the incident related to the resident's improper transfer and if the resident had a new and continuing knee problem which had caused him/her to have debility such as not being able to continue to use his/her scooter, the resident's primary care team should have been notified so the resident could have been assessed and treated. Continued interview with the ARNP, revealed she came to the facility this week and happened to see an Resident #3's X-Ray report on the nursing counter that revealed the resident had a Patella Fracture. She stated although she was Resident #3's ARNP, she had no idea what was going on, so she questioned the Hospice Nurse about the report and was informed the resident's Attending Physician/Medical Director was at the facility last week and ordered an X-Ray due to the resident being injured from a transfer. Per interview, the ARNP stated she had always known Resident #3 to require a Hoyer lift for transfers since the resident had moved from the rehabilitation unit, and the facility did not notify her of the resident being incorrectly transferred. Per interview, she had not seen Resident #3 since the X-Ray results and was unaware the resident wanted to see a Provider until the State Agency Representative informed her. Interview, on 07/28/17 at 9:43 AM, with the facility's Attending Physician, revealed she was not notified by the facility that Resident #3 had twisted his/her knee during a transfer on 06/01/17. Per interview, when she was at the facility approximately ten (10) days ago, the resident was complaining of left knee pain and told her he/she had the left knee pain since a recent transfer, but it had been worse for the past ten (10) days. Continued interview revealed she examined the resident's left knee which was tender and ordered an X-Ray on 07/21/17. The Attending Physician stated it was her expectation the facility would have notified her or someone on her team at the time of Resident #3's improper transfer, especially if the resident had an increase in pain or change of status. The Attending Physician further stated if the resident had continued knee pain since the injury, there should have been some sort of communication from the nursing staff to the resident's primary care team in order for the resident to be examined and treated. Review of the Hospital Emergency Department (ED) Notes dated 07/27/17, revealed the resident presented for evaluation of the left knee and ankle pain and reported in June the resident was being lifted and was not ambulatory, and felt a crack and twisted the knee. Per the Notes, the resident stated he/she was receiving pain medication, but felt symptoms were getting worse and was having increased pain in the knee and ankle with movement and swelling of the ankle and knee. Review of the Hospital Hospital History and Physical dated 07/27/17, revealed Resident #3 was admitted on [DATE] with knee and ankle pain which started after transfer. Per the Note, the State Inspector was at the facility today and heard what happened, so the facility sent the patient for Magnetic Resonance Imaging (MRI) and orthopedic evaluation. Review of the MRI results and Orthopedic Consult Notes, dated 07/27/17, revealed a Anterior Cruciate Ligament (ACL) (ligament of the knee that attaches the from of the tibia with the back of the femur) tear and Bilateral Meniscal tears (disc that cushions the knee and keeps the knee steady by balancing the weight across the knee). Further review revealed no evidence of Fracture. Further review of the Hospital Orthopedic Consult Notes, dated 07/28/17, revealed the resident had a left ankle and left knee sprain and the best treatment would be symptomatic including ice, rest, and intermittent bracing as needed with a knee immobilizer. Further review revealed the resident received a cortisone injection to the left knee with 40 milligrams of Kenalog and post injection the patient reported good relief. Continued review revealed recommendations for Physical Therapy for strengthening and balance. Post survey interview, on 08/04/17 at 10:02 AM, with the consulting Orthopedic Surgeon, revealed Resident #3's X-Ray results for the mobile X-Ray completed on 07/21/17 was a misreading and the resident at no point had a fractured left patella. Continued interview revealed the resident's ACL tear and bilateral Meniscus tears were consistent with the transfer accident explained by Resident #3. Interview on 07/28/17 at 12:40 PM, with the Director of Nursing (DON), revealed the incident involving Resident #3 complaining of knee pain after an improper transfer should have been reported to the Physician immediately on 06/01/17, and the Physician should also have been notified when the resident continued to have pain in the left knee and was unable to participate in usual activities. The DON stated she was unaware the resident was improperly transferred and sustained injury until yesterday. (07/27/17), and therefore no investigation related to the root cause of the incident had been conducted. Post Survey Phone interview, on 08/10/17 at 12:11 PM, with the DON, revealed when an incident or injury occurred the nurse was to document what happened on the Incident Report which would be forwarded to administrative staff. She stated an Incident Report should have been completed in order for the Administrative Staff to be aware of the improper transfer and Resident #3's complaints of knee pain on 06/01/17. Per interview, due to the severity of the incident involving Resident #3 on 06/01/17, the nurse should have contacted the Assistant Director of Nursing (ADON) and reported the injury. She further stated when an Incident Report was completed, the Report was discussed at the morning clinical meeting the following day with the Interdisciplinary Team. Further interview with the DON, revealed when a resident was discharged from Therapy, the Therapy staff would put a Discharge order in the system and the therapist would go to the unit where the resident resided, and verbally tell the nurse on the unit about the Discharge order. She further stated the Discharge Summary and any recommendations was to be reviewed during morning clinical meeting the following day. The DON stated she did not recall Resident #3's Discharge Summary in May 2017 being discussed in the morning meeting. The DON further stated, when a resident was discharged from therapy, the MDS Nurse was responsible for updating the resident's care plan; however, at that time, the facility did not have a system in place to ensure the care plan was updated. Further interview revealed the facility had no system related to revising the Care Cards which was the reference the SRNAs used to provide care. Interview, on 07/28/17 at 2:10 PM, with the Facility Administrator, revealed it was her expectation for staff to follow policy and procedures for safe transfers to prevent accidents and hazards. Continued interview revealed this was important to ensure the best care possible for the resident.

Based on interview, record review, review of facility Policy, and review of the Centers for Medicare and Medicaid Services (CMS), Resident Assessment Instrument (RAI) Manual 3.0, it was determined the facility failed to review and revise the Comprehensive Care Plan for one (1) of seven (7) sampled residents (Resident #3). Although Resident #3 was assessed to require the assistance of three (3) or four (4) staff or a Hoyer Lift (mechanical lift) for transfers per the Physical Therapy (PT) Discharge Summary dated 05/16/17; there was no documented evidence the Comprehensive Plan of Care or the Care Card (Nurse Aide Care Plan) was revised related to these recommendations. On 06/01/17 Resident #3 was transferred with the assistance of one (1) staff member sustaining injury to the left knee. An X-Ray dated 07/21/17, revealed the resident had a [MEDICAL CONDITION] Patella. A Magnetic Resonance Imaging (MRI) test dated 07/27/17, revealed the resident had an Left Anterior Cruciate Ligament (ACL) tear and Bilateral Meniscal tears, but no evidence of Fracture. (Refer to F-157 and F-323) The findings include: Review of the facility's Policy titled, Care Plans-Comprehensive, dated 07/01/13, revealed an individualized comprehensive care plan including measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs was to be developed for each resident. Continued review of the Policy, revealed each resident's comprehensive care plan was designed to incorporate identified problem areas and aid in preventing or reducing declines in the resident's functional status and/or functional levels. Further review of the Policy, revealed assessments of residents were ongoing and care plans were to be revised as information about the resident and the resident's condition changed. The Policy stated the Interdisciplinary Team (IDT) was responsible for the review and updating of the care plan when there was a significant change in the resident's condition and when desired outcomes were not met. Review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, dated October 2016, revealed the care plan must be reviewed and revised periodically, and the services provided or arranged should be consistent with each resident's written plan of care. Continued review of the Manual, revealed the care plan was driven not only by identified resident issues and/or conditions, but also by a resident's unique characteristics, strengths, and needs. Furthermore, a care plan based on a thorough assessment and effective clinical decision making, was compatible with current standards of clinical practice that provide a strong basis for optimal approaches to quality of care and quality of life needs of individual residents. A well developed and executed assessment and care plan: re-evaluates the resident's status at prescribed intervals (quarterly, annually, or if a significant change in status occurs) using the RAI and then modifies the individualized care plan as appropriate and necessary. Review of Resident #3's medical record revealed the facility admitted the resident on 08/21/14 and readmitted the resident on 04/18/17, with [DIAGNOSES REDACTED]. Review of the Comprehensive Plan of Care initiated 03/06/17, revealed Resident #3 was at risk for injuries related to falls due to overall poor health status and weakness. The goal revealed the resident's risk for falls would be evaluated and therapeutic interventions would be implemented as noted and as tolerated. There were numerous interventions which included: call light in reach when the resident was in his/her room; remind the resident to call for assistance before attempting to transfer/stand unassisted; encourage the resident to stay in common areas when he/she was awake; ensure the resident was wearing non-slip, well-fitting footwear; and assist the resident with transfers and ambulation as needed. However, the Comprehensive Care Plan was not specific in stating how the resident was to be transferred or how many staff were to transfer the resident. Interview, on 07/27/17 at 4:47 PM, with the Minimum Data Set (MDS) Nurse, revealed the Care Plan for Resident #3, with the initiated date of 03/06/17, was the care plan in place on 06/01/17. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #3 as having a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15) indicating the resident was cognitively intact. Further review revealed the facility assessed the resident to require extensive assistance of two (2) persons for transfers to or from the bed, chair, wheelchair and standing position. Review of the Physical Therapy Discharge Summary dated 05/16/17, revealed Resident #3 had a therapy goal to safely transfer to and from the bed and wheelchair, requiring the use of a Sara Steady (mechanical lift), with maximum assistance of two (2) staff persons. Further review of the Notes, revealed the resident did not meet his/her goal and was only able to safely transfer with the maximum assistance of three (3) to four (4) staff persons or transferred per the Hoyer lift (mechanical lift). Per the Notes, Resident #3 had a long term goal for daily life that required maximum assistance of two (2) staff persons with the use of Hoyer lift. Continued review of Resident #3's Comprehensive Care Plan, revealed no documented evidence of a revision to reflect the needed assistance of three (3) to four (4) staff persons or the use of a Hoyer lift as per the Physical Therapy Discharge Progress Notes dated 05/16/17. Review of the Care Card, (reference for the SRNAs to use as a guide for providing care) undated, revealed Resident #3 was to be assisted by two (2) staff persons with PRN (as needed) use of the Hoyer lift. Further review revealed no documented evidence the Care Card had been revised to reflect the needed assistance of three (3) to four (4) staff persons or the use of a Hoyer lift as per the Physical Therapy Discharge Progress Notes dated 05/16/17. Review of Resident #3's Nurse's Progress Notes, dated 06/01/17 at 6:30 PM, signed by completed by Licensed Practical Nurse (LPN) #3, revealed Resident #3's left knee was twisted during a transfer with a gait belt from the shower chair to the bed. Further review revealed the resident complained of severe pain and was medicated with two (2) [MEDICATION NAME] Tablets (narcotic pain medication) and the resident's knee was propped on a pillow. Resident #3's Radiology Report, dated 07/21/17, revealed Resident #3 had a Fracture involving the Left Upper Patella. Resident #3's Magnetic Resonance Imaging (MRI) results and Orthopedic Consult Notes, dated 07/27/17, revealed the resident had a Anterior Cruciate Ligament (ACL) (ligament of the knee that attaches the from of the tibia with the back of the femur) tear and Bilateral Meniscal tears (disc that cushions the knee and keeps the knee steady by balancing the weight across the knee). Additional review revealed no evidence of Fracture. Post Survey Phone interview, on 08/04/17 at 10:02 AM, with the consulting Orthopedic Surgeon, revealed Resident #3's x-ray results for the mobile x-ray completed on 07/21/17 was a misreading and the resident at no point had a fractured left patella. Continued interview revealed the resident's injuries of the ACL tear and of the bilateral Meniscus tears were consistent with the transfer accident explained by Resident #3. Interview, on 07/26/17 at 9:26 AM, with Resident #3, revealed he/she was a retired Registered Nurse (RN) and he/she wanted to voice a concern. The resident stated he/she was injured at the facility due to State Registered Nurse Aide (SRNA) #2's negligence during a transfer from the chair to his/her bed. Resident #3 further stated on or around 06/01/17, SRNA #2, who was a large male staff member, was lifting him/her from the shower chair to the bed, by himself. Further interview revealed the SRNA told the resident to put his/her arms around the SRNA's neck, and then lifted him/her and swung my bottom on the bed. Per interview, when the SRNA transferred him/her to the bed, his/her left knee twisted, he/she heard and felt it pop, and he/she screamed out in pain. Resident #3 stated at the time of the incident he/she was supposed to be transferred with a Hoyer lift. Resident #3 stated a few days ago (07/21/17), the doctor ordered an X-Ray that came back showing his/her left knee was fractured. Interview, with SRNA #1 on 07/26/17 at 1:45 PM, revealed she and another SRNA transferred Resident #3 on 06/01/17 to the shower chair per the Hoyer Lift. She further verified on 06/01/17, Resident #3 required extensive assistance of two (2) staff for transfers and sometimes required the use of a Hoyer lift for transfers. SRNA #1 stated after the resident's shower, she and the other SRNA rolled the resident in the shower chair to his/her bedside, and lowered the bed. SRNA #1 further stated a gait belt was placed around the resident's waist in order to transfer the resident, but the resident was feeling weak and fatigued that day, so she did not feel comfortable with a two (2) person transfer for the resident with another female. Further interview with SRNA #1, revealed she went to another unit to get SRNA #2 to assist. Per interview, SRNA #2 came to Resident #3's room and instructed the resident to put his/her arms around his neck, lifted the resident to stand up using the gait belt, and performed a one (1) person pivot transfer setting the resident's buttocks on the bed. SRNA #1 stated during the pivot transfer, Resident #3 started screaming my knee, my knee. SRNA #1 further stated Resident #3 then complained of his/her knee hurting, and Licensed Practical Nurse (LPN) #3 who was in the room during the transfer administered medication due to the resident's complaints of knee pain. SRNA #1 confirmed SRNA #2 transferred the resident independently with no assist or support from other staff. SRNA #1 stated she told SRNA #2 that the resident required two (2) person transfer prior to the transfer and offered to get another male SRNA to assist him, but SRNA #2 did not wait and transferred the resident alone with no help. Interview, on 07/26/17 at 2:21 PM, with LPN #3, revealed she was assigned to Resident #3 on 06/01/17, when the resident was assisted with a shower by two (2) female SRNAs. She stated after the shower, the SRNAs rolled the resident in the shower chair to the bed. Further interview revealed the SRNAs then went to another unit to ask SRNA #2 to assist them with transferring the resident from the shower chair to the bed. LPN #3 stated she saw SRNA #2 come over to assist, and she went into Resident #3's room to see if they needed any more assistance. She further stated that was when she saw SRNA #2 transferring Resident #3 from the shower chair to the bed by himself using only a gait belt with no assistance or support from other staff. Per interview, Resident #3 screamed out My Knee. LPN #3 stated after staff finished assisting the resident in the bed, she assessed the resident's knee, and was able to move the resident's knee without the resident screaming; however, the resident did complain his/her knee was hurting. Per interview, she offered and administered [MEDICATION NAME] for pain. Continued interview revealed after the incident she told SRNA #2 that Resident #3 could not be transferred by only one (1) person; however, did not document the education. LPN #3 stated it was important for staff to provide residents with the correct transfer technique and assistance to keep the residents and the staff safe. Interview, on 07/26/17 at 3:20 PM, with State Registered Nurse Aid (SRNA) #2, revealed on 06/01/17 he was asked by two (2) female SRNAs to come to their unit and help transfer Resident #3. He stated the resident was dressed and sitting in a shower chair in the bathroom, and he assisted by rolling the resident to the bedside in the shower chair. SRNA #2 stated he was in front of Resident #3, and stood the resident up with the resident's arms on his shoulders, while another SRNA got behind the resident to help support the resident. He further stated he completed a quick twist for a pivot transfer and was using a gait belt for the transfer to the bed, sitting the resident down on his/her buttocks, on the bed. Per interview, during the transfer, Resident #3 screamed out because of his/her leg. SRNA #2 stated when he completed the quick twist transfer, the resident's legs stayed put. Further interview with SRNA #2, revealed LPN #3 was present during the transfer, and later told him something happened to the resident's leg during the transfer, but she understood he was not familiar with the resident's leg issues. SRNA #2 stated he was unaware the resident required two (2) persons to assist with transfers as he was not familiar with the resident. Per interview he relied on the resident's assigned staff that day to let him know how the resident was to be transferred and did not review the resident's Care Card which was located on the inside of the resident's closet door. Continued interview revealed it was very important for Resident #3 to be transferred with the amount of staff and the transfer technique in which the facility had assessed the resident to need. Per interview, he did not know the resident and was not familiar with his/her care, and he caused injury to Resident #3's knee that day. Interview, on 07/27/17 at 10:55 AM, with Resident #3's daughter, revealed she was in Resident #3's room on 06/01/17 when the injury occurred. Per interview, the female SRNAs gave the resident a shower, and the SRNAs used a Hoyer lift to transfer him/her into the shower chair. She stated when the resident was finished with his/her shower, he/she was tired and weak, so SRNA #1 did not feel safe for her and the other female SRNA to transfer the resident. Further interview revealed SRNA #1 requested SRNA #2 to assist with the resident's transfer, and SRNA #2 entered the Resident #3's room stating he could transfer the resident himself. Resident #3's daughter stated SRNA #2 instructed the resident to put his/her arms around his neck and with the use of the gait belt stood the resident up, twisted {him/her}to the bed real fast, and the resident screamed out my leg, my leg. Resident #3's daughter stated the resident was crying, and LPN #3, who was present during the transfer, gave the resident two (2) pain pills and propped his/her leg up. Per interview, the resident had increased leg pain ever since the incident. Interview on 07/27/17 at 4:22 PM, with the facility's Therapy Manager, revealed on 05/16/17, Resident #3 was discharged from therapy. She stated when the resident was discharged from therapy, the therapy staff was utilizing three (3) to four (4) staff persons to manually transfer the resident or were using the Hoyer lift, which was what the therapy department recommended for bed to wheelchair and wheelchair to bed transfers. The Therapy Manager stated if the resident was in a shower chair, this would have been equivalent to being in a wheelchair, and the same practice for transfers should have been used. She further stated she would never have recommended for a staff person to attempt a one (1) person transfer for Resident #3. Additional interview with the Therapy Manager, revealed the communication process between therapy and nursing when a resident was discharged from therapy was for the therapist to speak with the nurse on the resident's unit, and let them know therapy's recommendation. Per interview, the the Physical Therapist who completed the Discharge Summary and communicated with the nurse on 05/16/17 was no longer employed by the facility, and there was no documentation of the communication. The Therapy Manager stated it was important that the recommendations from Therapy related to transfers be followed for resident safety and staff safety. The Therapy Manager further stated if a transfer was done incorrectly, it could cause injury to the resident. Interview on 07/27/17 at 4:47 PM, with the MDS Nurse as she was reviewing Resident #3's Therapy Discharge Summary dated 05/16/17, revealed the resident's Comprehensive Care Plan should have been revised by the nursing department or herself to indicate the use of a Hoyer lift for transfers. The MDS Nurse further stated the resident was discharged from Therapy on 05/16/17 and she was on medical leave from 05/17/17 until the middle of June 2017. Continued interview with the MDS Nurse revealed it was important for the Care Plans to be revised related to the Therapy Discharge recommendations for the resident's safety. Interview on 07/28/17 at 12:40 PM, with the Director of Nursing (DON), revealed Therapy recommendations should be followed for transfers because this would be the safest technique to prevent accidents. Further interview revealed it was her expectation Resident #3's Care Plan would have been revised with therapy's recommendation for three (3) to four (4) staff or use of the Hoyer lift to protect the resident and the staff from harm. She stated she was not aware the staff member transferred Resident #3 on 06/01/17 by himself until yesterday (07/27/17). The DON stated it was important for residents to be transferred correctly to protect them from harm. Post Survey Phone interview, on 08/10/17 at 12:11 PM with the DON, revealed after a resident was discharged from therapy, the Discharge Summary was to be reviewed during morning clinical meeting the following day, and the MDS Nurse was to update the Comprehensive Care Plan with the therapy recommendations at that time. The DON stated she did not recall Resident #3's Therapy Discharge Summary being discussed in the morning meeting. Further interview revealed the facility had no system related to revising the Care Cards which was the reference the SRNAs used to provide care. Interview, on 07/28/17 at 2:10 PM, with the Facility Administrator, revealed Resident #3's Care Plan should have been revised to reflect the Therapy departments recommendations. Continued interview revealed it was important the Care Plan was revised to make sure the appropriate level of care was provided for the resident's safety.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure the resident's physician was immediately notified when there was an accident involving the resident which results in injury and has the potential for requiring physician intervention for one (1) of seven (7) sampled residents (Resident #3). Although Resident #3 was assessed to require the assistance of three (3) or four (4) staff or a Hoyer Lift (mechanical lift) for transfers per the Physical Therapy (PT) Discharge Summary dated 05/16/17, the resident was transferred with the assistance of one (1) person sustaining injury to the left knee on 06/01/17. The X-Ray dated 07/21/17 revealed the resident had a [MEDICAL CONDITION] Patella. Additionally, the Magnetic Resonance Imaging (MRI) test dated 07/27/17 revealed the resident had an Left Anterior Cruciate Ligament (ACL) tear and Bilateral Meniscal tears, but no evidence of Fracture. There was no documented evidence the Physician/or Advanced Registered Nurse Practitioner (ARNP) was immediately notified of the improper transfer or injury on 06/01/17 in order to treat the resident even though the resident immediately complained of left knee pain with the transfer. In addition, although the resident continued to complain of increased knee pain and was unable to continue with usual activities due to pain such as riding his/her scooter, the Providers were not made aware of the resident's condition change and new orders were not obtained related to the pain until 07/21/17 when the X-Ray of the knee was ordered. (Refer to F-280 and F-323) The findings include: Review of the facility's Policy titled, Change in a Resident's Condition or Status, dated 07/01/13, revealed the facility should promptly notify the Attending Physician of changes in the resident's medical/mental condition and/or status. Continued review of the Policy revealed the nurse supervisor/charge nurse would notify the resident's Attending Physician or on-call Physician when there had been an accident or incident involving the resident. Review of Resident #3's clinical record revealed the facility admitted the resident on 08/21/14 and readmitted the resident on 04/18/17, with [DIAGNOSES REDACTED]. Review of the Comprehensive Care Plan initiated 03/06/17, revealed the resident was at risk for injuries related to falls due to overall poor health status and weakness. The goal stated the resident's risk for falls would be evaluated and therapeutic interventions implemented as noted and as tolerated. There were several interventions including call light in reach when the resident was in his/her room; remind the resident to call for assistance before attempting to transfer/stand unassisted; encourage the resident to stay in common areas when he/she was awake; ensure the resident was wearing non-slip, well-fitting footwear; and assist the resident with transfers and ambulation as needed. However, further review revealed the Care Plan was not specific in stating how the resident was to be transferred or how many staff were to transfer the resident. Interview, on 07/27/17 at 4:47 PM, with the MDS Nurse, revealed this Care Plan with the initiated date of 03/06/17, was the care plan in place on 06/01/17. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15) indicating the resident was cognitively intact. Further review revealed the facility assessed the resident as requiring extensive assistance of two (2) persons for transfers to or from the bed, chair, wheelchair and standing position. Continued review revealed the facility assessed the resident as requiring extensive assistance of two (2) persons for bed mobility. Per the MDS, the activity of walking did not occur. Review of the Physical Therapy Discharge Summary dated 05/16/17, revealed Resident #3 had a therapy goal of being able to safely transfer to and from the bed and wheelchair, requiring the use of a Sara Steady (mechanical lift), with maximum assistance of two (2) staff persons. Continued review of the Notes, revealed the resident did not meet his/her goal and was only able to safely transfer with the maximum assistance of three (3) to four (4) staff persons or transferred per the Hoyer lift (mechanical lift). Further review of the Notes, revealed Resident #3 had a long term goal for daily life that required maximum assistance of two (2) staff persons with the use of Hoyer lift. Continued review of Resident #3's Comprehensive Care Plan, revealed it was not reviewed or revised to reflect the needed assistance of three (3) to four (4) staff persons or the use of a Hoyer lift as per the Physical Therapy Discharge Summary dated 05/16/17. Review of the Care Card, (reference for the SRNAs to use as a guide for providing care) undated, revealed Resident #3 was to be assisted by two (2) staff persons with PRN (as needed) use of a Hoyer lift, indicating the Care Card had not been reviewed and revised as per the recommendations on the Physical Therapy Discharge Summary dated 05/16/17. Review of the Nurse's Progress Notes dated 06/01/17 at 6:30 PM, competed by Licensed Practical Nurse (LPN) #3, revealed Resident #3's left knee was twisted during a transfer with a gait belt from the shower chair to the bed. Per the Notes, the resident complained of severe pain and was medicated with two (2) [MEDICATION NAME] Tablets (narcotic pain medication) and the resident's knee was propped on a pillow. Additional review of the Nurse's Progress Notes, dated 06/01/17 through 07/25/17, revealed Resident #3 received narcotic pain medication due to left leg pain and at times it was documented the resident received the pain medication specifically for left knee pain with the highest pain being a ten (10), on a pain scale of one (1) to ten (10), with ten (10) being the worse possible pain. Review of the ARNP Progress Notes, dated 06/02/17, revealed Resident #3's Chief Complaint was [MEDICAL CONDITION] and knee pain. Per the Notes, the resident had increased left leg [MEDICAL CONDITION], and chronic pain to the left knee that was worse since a recent transfer. Additional review revealed pain medication was recently increased by Hospice. The Notes revealed, indicates good passive range of motion (PROM) with an assessment/plan for left knee pain: acute on chronic, [MEDICATION NAME], and ace wrap PRN (as needed). Review of the Attending Physician Notes, dated 07/21/17, revealed the Physician saw the resident on this date with the resident's Chief Complaint of Knee Pain and the resident had been having left knee pain with some swelling. Additional review of the Notes, revealed it was acute on chronic; however, pain was the limiting factor at the present time. Per the Notes, assessment/plan was: residents left knee pain was likely arthritic, no signs of septic joint, and an X-Ray was ordered. Review of the Radiology Report, dated 07/21/17, revealed a Fracture involving the Left Upper Patella. Interview, on 07/26/17 at 9:26 AM, with Resident #3, revealed he/she was a retired Registered Nurse (RN) and had a concern. Per interview, he/she was injured at the facility due to State Registered Nurse Aide (SRNA) #2's negligence during a transfer from the chair to the bed on or around 06/01/17. Resident #3 stated SRNA #2, who was a large male staff member, had lifted him/her from the shower chair to the bed by himself. Resident #3 further stated the SRNA told the resident to put his/her arms around the SRNA's neck, and then lifted him/her and swung my bottom on the bed. Per interview when the SRNA transferred him/her to the bed, his/her left knee twisted, he/she heard and felt it pop, and he/she screamed out in pain. Resident #3 stated at the time of the incident he/she was supposed to be transferred with a Hoyer lift. Further interview with Resident #3, on 07/27/17, at 10:19 AM, revealed there were days when he/she preferred to stay in bed all day due to the knee pain with movement and the injury to his/her left knee had affected his/her life more than just having pain. The resident stated since his/her left knee injury, he/she had not been able to use his/her motorized scooter because he/she could not straighten his/her left leg out without having pain. Resident #3 further stated when he/she was able to use the motorized scooter, he/she was able to go all around the facility, and would also go on outings off the facility grounds to events such as plays, or shopping with his/her daughter. Per interview, he/she hadn't had been off the facility grounds since the injury and now had to sit in a Geri chair. Continued interview with Resident #3, revealed when staff moved his/her left knee, it caused excruciating pain that was unbearable; so when he/she got into a position that was comfortable he/she stayed in the position for hours and only allowed staff to move him/her if absolutely necessary. Resident #3 further stated since the knee injury on 06/01/17, he/she had taken an increased amount of narcotic pain medication, although he/she did not like to take narcotics. Per interview, he/she told the aides and nurses how bad the pain was in his/her left knee every day since the incident. However, further interviewed revealed he/she never received any treatment for [REDACTED]. Resident #3 further stated he/she had not seen a doctor or a nurse practitioner since he/she learned of the fractured knee, but would like to speak to a Physician because he/she wanted to know if he/she was going to have to live in this pain for the rest of his/her life. Interview, on 07/26/17 at 1:45 PM, with SRNA #1, stated she and another SRNA transferred Resident #3 on 06/01/17 to the shower chair using the Hoyer Lift. She further stated on 06/01/17, Resident #3 required extensive assistance of two (2) staff for transfers and at times required the use of a Hoyer lift for transfers. Per interview, after the resident's shower she and the other SRNA pushed the resident in the shower chair to the bedside, and lowered the bed. SRNA #1 stated a gait belt was placed around the resident's waist in order to transfer the resident, but the resident was feeling weak and fatigued that day, so she did not feel comfortable with a two (2) person transfer for the resident with another female. Further interview with SRNA #1 revealed she went to Unit C to get SRNA #2 to assist her. Per interview SRNA #2 came to Resident #3's room, instructed the resident to put his/her arms around his neck, lifted the resident to stand up using the gait belt, and performed a one (1) person pivot transfer setting the resident's buttocks on the bed. The SRNA stated during the pivot transfer, Resident #3 screamed my knee, my knee, and continued to complained of his/her knee hurting. She stated Licensed Practical Nurse (LPN) #3 who was in the room during the transfer, administered medication due to the resident's complaints of knee pain. SRNA#1 stated Resident #3 continued to complain of knee pain the rest of the evening. SRNA#1 stated she told SRNA #2 that the resident was a two person transfer, but SRNA #2 transferred the resident alone with no assistance or support by other staff. Additional interview with SRNA #1, revealed she was always assigned to Resident #3 and the resident continued to complain every shift she worked since 06/01/17 of knee pain. SRNA #1 revealed she had seen Resident #3 cry and have facial grimaces because of the pain in his/her left knee. She stated Resident #3 used to use an electric scooter and was all over the facility doing activities and visiting with friends at the facility, but after the injury, he/she was no longer able to use the scooter because his/her knee would hurt too bad because of how he/she had to sit on the scooter. SRNA #1 further stated Resident #3 used the Geri-chair, but now stayed in bed more than he/she was out of bed. Interview, on 07/26/17 at 2:21 PM, with LPN #3, revealed she was assigned to Resident #3 on 06/01/17, and on that date the resident was assisted with a shower by two (2) female SRNAs. She revealed after the shower, the aides rolled the resident in the shower chair to his/her bed. Per interview the SRNAs then went to another unit to ask SRNA #2 to assist them with transferring the resident from the shower chair to the bed. LPN #3 stated she saw SRNA #2 come over to assist, so she went into Resident #3's room to see if they needed her help and that was when she saw SRNA #2 transfer Resident #3 from the shower chair to the bed by himself using only a gait belt. LPN stated SRNA #2 transferred the resident without any assistance or support from other staff and she heard Resident #3 scream out My Knee. Per interview after staff finished assisting the resident in the bed, she checked the resident's knee and was able to move the resident's knee without the resident screaming. However, she stated the resident did complain that his/her knee was hurting. LPN #3 stated she administered [MEDICATION NAME] for pain. Additional interview with LPN #3, revealed she did not remember notifying the resident's physician or ARNP of the resident's complaint of knee pain on 06/01/17. Per interview, she thought she had notified one of the Physician's about the resident's knee pain on a later date, and requested an X-Ray to be done; however, she was not given an order for [REDACTED]. LPN #3 reviewed the Nurse's Progress Notes and could find no documentation related to her notification of the Physician or ARNP of the resident's condition on any date on or since the incident. LPN #3 revealed to her knowledge, the first time Resident #3 was seen by a Physician for an assessment of his/her left knee was on 07/21/17, when the Physician ordered an X-Ray. Interview, on 07/26/17 at 3:20 PM, with SRNA #2, revealed on 06/01/17 he was asked by two (2) female SRNAs to come to their assigned unit and help transfer Resident #3. Per interview, the resident was dressed and sitting in a shower chair in the bathroom, and he pushed the resident to the bedside in the shower chair. SRNA #2 stated he was in front of Resident #3, and stood the resident up with the resident's arms on his shoulders, while another SRNA got behind the resident to help support the resident. He further stated he completed a quick twist for a pivot transfer and was using a gait belt for the transfer to the bed, sitting the resident down on his/her buttocks, on the bed. Further interview with SRNA #2, revealed during the transfer, Resident #3 screamed out because of his/her leg. Per interview when SRNA #2 completed the quick twist, the resident's legs stayed put. He stated LPN #3 was present during the transfer, and later told him something happened to the resident's leg during the transfer, but she understood he was not familiar with the resident's leg issues. SRNA #2 stated he did not know the resident required the assistance of two (2) persons for transfers as he was not familiar with the resident. SRNA #2 stated he relied on the resident's assigned staff that day to let him know how the resident was to be transferred and did not check the resident's Care Card which was located on the inside of the resident's closet door. Interview, on 07/27/17 at 10:55 AM, with Resident #3's daughter, revealed she was in Resident #3's room on 06/01/17 at the time the injury occurred. She stated the resident had just had a shower and was tired and weak, so SRNA #1 did not feel safe for her and the other SRNA to transfer the resident. She further stated SRNA #1 requested SRNA #2 to assist with the resident's transfer. Per interview, SRNA #2 came to Resident #3's room and stated he could do it by himself and instructed the resident to put his/her arms around his neck. She stated SRNA #2 then using the gait belt stood the resident up, twisted {him/her}to the bed real fast, and the resident screamed out my leg, my leg. The daughter stated the resident was crying, and LPN #3, who was present during the transfer, gave the resident pain medication and propped his/her leg up. Continued interview with Resident #3's daughter, revealed the resident had increased leg pain ever since the incident, and could not straighten his/her leg out all the way in order to ride the scooter without horrible pain. She further stated the resident used to ride the scooter around all the time, but now didn't do much but stay in bed because of the knee injury. Resident #3's daughter further stated she used to take the resident shopping, but the resident had not left the grounds that she could remember since the injury occurred. Interview on 07/27/17 at 4:22 PM, with the facility's Therapy Manager, revealed Resident #3 was discharged from therapy services on 05/16/17. She stated when the resident was discharged from therapy, the therapy staff was utilizing three (3) to four (4) staff persons to manually transfer the resident or were using the Hoyer lift, which was what the therapy department recommended for bed to wheelchair and wheelchair to bed transfers. The Therapy Manager further stated if the resident was in a shower chair, it would have been equivalent to being in a wheelchair, and the same practice for transfers should have been used. Per interview, the communication process between therapy and nursing when a resident was discharged from therapy was for the therapist to speak with the nurse on the resident's unit, and let them know therapy's recommendation. The Therapy Manager revealed the Physical Therapist who completed the discharge summary and who communicated with the nurse was no longer employed by the facility. Further interview revealed it was important that the recommendations from Therapy related to transfers be used for resident safety and staff safety. Interview, on 07/27/17 at 12:40 PM, with the ARNP, revealed per her Progress Note, on 06/02/17, she examined Resident #3's left knee and documented the resident had good Passive Range Of Motion (PROM). The ARNP further stated based on her assessment notes on 06/02/17, she did not think the resident's knee was fractured; however, the resident was taking chronic pain medication which could have masked the symptoms during the exam. The ARNP stated Resident #3 had always had chronic leg pain below the knee due to [MEDICAL CONDITION]; however, she was not informed after her exam of the resident on 06/02/17, that the resident had increased pain or continued problems with his/her left knee. Per interview, if she or another Provider within their practice had examined the resident and had knowledge of the increased left knee pain, it would have been documented either by paper form, or if electronically documented, it would have been faxed to the facility for the medical record. However, the ARNP stated she could find no documentation that a Provider in her practice had been notified. The ARNP further stated the nurse should have notified her or someone on the resident's primary care team on 06/01/17, of the incident related to the resident's improper transfer and the new problem of concern related to the knee pain. She further stated if the resident had a continuing knee problem which had caused him/her to have debility such as not being able to continue to use his/her scooter, the resident's primary care team should have been notified so the resident could have been assessed and treated. Further interview with the ARNP, revealed she came to the facility this week and happened to see an Resident #3's X-Ray report on the nursing counter that revealed the resident had a Patella Fracture. She stated although she was Resident #3's ARNP, she had no idea what was going on, so she asked a Hospice Nurse about the report and was informed the resident's Attending Physician/Medical Director was at the facility last week and ordered an X-Ray due to the resident being injured from a transfer. The ARNP stated she had always known Resident #3 to require a Hoyer lift for transfers since the resident had moved from the rehabilitation unit, and the facility did not notify her of the resident being incorrectly transferred. Per interview, she had not seen Resident #3 since the X-Ray results and was unaware the resident wanted to see a Provider until the State Agency Representative informed her. Interview, on 07/28/17 at 9:43 AM, with the facility's Attending Physician, revealed she was not notified by the facility that Resident #3 had twisted his/her knee on 06/01/17. Continued interview revealed when she was at the facility approximately ten (10) days ago, the resident was complaining of left knee pain and told her he/she had the left knee pain since a recent transfer, but it had been worse for the past ten (10) days. Further interview revealed she examined the resident's left knee which was tender and ordered an X-Ray. The Attending Physician stated it was her expectation the facility would have notified her or someone on her team at the time of the improper transfer, especially if the resident had an increase in pain or change of status. The Attending Physician further stated if the resident had continued knee pain since the injury, there should have been some sort of communication from the nursing staff to the resident's primary care team so the resident could have been examined and treated. Review of the Hospital Emergency Department (ED) Notes dated 07/27/17, revealed the resident presented for evaluation of the left knee and ankle pain and reported in June the resident was being lifted and was not ambulatory, and felt a crack and twisted the knee. Per the Notes, the resident stated he/she was receiving pain medication but felt symptoms were getting worse and was having increased pain in the knee and ankle with movement and swelling of the ankle and knee. Review of the Hospital History and Physical dated 07/27/17, revealed Resident #3 was admitted on [DATE] with knee and ankle pain which started after transfer. Per the Note, the State Inspector was at the facility today and heard what happened, so the facility sent the patient for Magnetic Resonance Imaging (MRI) and orthopedic evaluation. Review of the MRI results and Orthopedic Consult Notes, dated 07/27/17, revealed a Anterior Cruciate Ligament (ACL) (ligament of the knee that attaches the from of the tibia with the back of the femur) tear and Bilateral Meniscal tears (disc that cushions the knee and keeps the knee steady by balancing the weight across the knee). Further review revealed no evidence of Fracture. Post survey interview, on 08/04/17 at 10:02 AM, with the consulting Orthopedic Surgeon, revealed Resident #3's X-Ray results for the mobile X-Ray completed on 07/21/17 was a misreading and the resident at no point had a fractured left patella. Continued interview revealed the ACL tear and the bilateral Meniscus tears were consistent with the transfer accident explained by Resident #3. Interview on 07/28/17 at 12:40 PM, with the Director of Nursing (DON), revealed the incident involving Resident #3 on 06/01/17 should have been reported to the Physician on that date, and also the Physician should have been notified when the resident continued to have pain in the left knee and was unable to participate in usual activities. Per interview, the DON was unaware the resident was improperly transferred and sustained injury until yesterday. (07/27/17). Interview, on 07/28/17 at 2:10 PM, with the Facility Administrator, revealed Resident #3's Physician would have been notified right away of the accident from the transfer on 06/01/17, and should have been notified also of the resident's change of condition after the accident so the resident could have received the appropriate treatment.

Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to ensure the services provided were in accordance with the written plan of care, for one (1) of three (3) sampled residents (Resident #1). The facility failed to ensure the Care Plan was implemented for Resident #1, who was to have two (2) person assist and the use of a gait belt with transfers. On 01/30/13, the resident was transferred with the assistance of one (1) person, and sustained a fractured right arm. (Refer to F-323). The findings include: Review of the policy titled "Care Plans - Comprehensive", revised October 2010, revealed the comprehensive care plan was based on a thorough assessment that included the Minimum Data Set (MDS) assessment. Continued review revealed care plan interventions were developed based on the resident's problem areas identified on the MDS assessment. Review of the clinical record revealed the facility admitted Resident #1 on 12/28/12 with [DIAGNOSES REDACTED]. Review of the Admission MDS Assessment, dated 01/03/13, revealed the facility assessed Resident #1 to require the extensive assistance of two (2) persons for bed mobility and transfers to or from bed, chair, wheelchair and standing position. Resident #1 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident was cognitively intact. Review of the Care Area Assessment (CAA) Summary revealed Resident#1 triggered for falls which would be addressed in the care plan. Review of the Comprehensive Care Plan, dated 01/10/13, revealed the problem, Functional Deficit was identified with interventions initiated which included "resident requires extensive assist of two with bed mobility, transfers and toileting....". Continued review of the Care Plan revealed Resident #1 was at risk for fractures due to [MEDICAL CONDITION] and Osteopenia (conditions associated with weak or brittle bones). Interventions for this risk included "use a gait belt with transfers". Review of the Resident Care Card, which were utilized by the Certified Nursing Assistants (CNAs) to guide the residents' care, revealed Resident #1 was to be transferred with the assist of two (2) persons and the use of a gait belt. Observation, on 02/13/13 at 11:25 AM, revealed the Resident Care Card was posted inside the resident's closet on the back of the closet door. Review of the Nursing Progress Notes, dated 01/31/13 at 12:47 AM, revealed Licensed Practical Nurse (LPN) #2 documented Resident #1 was transferred at 6:00 PM on 01/30/13 when a "crackle noise" was heard, and the resident stated, "you broke my arm". Continued review revealed the nurse reassured the resident, and assessed the arm to have full range of motion, no swelling, no redness, and no pain. Continued review revealed the "nurse aide and nurse transferred patient properly". However, review of a statement written by Certified Nursing Assistant (CNA) #1, dated 01/30/13, revealed she transferred Resident #1 from the chair to the bed, by herself and interview with Resident #1, on 02/12/13 at 2:55 PM, revealed he/she thought there was only one person in the room when the transfer occurred. Interview with CNA #1, on 02/13/13 at 3:25 PM, revealed she used a gait belt and a walker to assist the resident with a transfer from the chair to the bed on 01/30/13. During follow up interview, on 02/14/13 at 4:40 PM, the CNA stated she was in the room by herself initially, but LPN #2 came into the room and observed the procedure. She further stated she was told Resident #1 was a one (1) person assist. She stated that's the way she always transferred Resident #1. Interview with CNA #2, on 02/14/13, at 3:15 PM, revealed she was coming out of another resident's room on 01/30/13 when she heard CNA #1 call her name. She stated she went into the room of Resident #1 and the resident was sitting on the bed. She further stated she saw the resident's wheelchair by the bed, but she did not see a walker or gait belt. Continued interview revealed the resident was complaining of right arm pain and CNA #1 reported she was lifting the resident into the bed and heard the resident's arm crack. CNA #2 stated she did not know what CNA #1 meant when she said she lifted the resident into bed. Interview with LPN #2, on 02/13/13 at 3:40 PM, revealed Resident #1 was a one (1) person assist at the time of the incident. She stated CNA #1 was using a gait belt and had the resident standing when LPN #2 entered the room. She further stated she observed the transfer. Continued interview revealed LPN #2 heard both arms crack, like cracking knuckles. She stated the resident's right arm did hit the walker. During follow up interview, on 02/14/13 at 5:00 PM, LPN #2 stated CNA #1 used a gait belt and a walker to transfer the resident. The LPN stated she was on one side of the bed and the CNA was on the other side. Review of the Nursing Progress Note, dated 01/31/13 at 7:49 AM, revealed LPN #1 discovered Resident #1 to have pain in the right arm. Continued review revealed the resident stated, "I can't move my right arm at all". When the nurse attempted to assess the arm, the resident refused and stated, "It hurts too bad". Interview with LPN #1, on 02/13/13 at 3:25 PM, revealed she saw Resident #1 at the beginning of the day shift on 01/31/13. She stated Resident #1 reported the arm was hurt when she was being transferred the night before. The LPN stated Resident #1 was a two (2) person assist for transfers. During interview with the Director of Nursing (DON), on 02/15/13 at 3:15 PM, she stated Resident #1 required the assist of two (2) persons for transfers at the time of the incident, based on the comprehensive Care Plan and according to the Resident Care Card. Continued interview revealed the Resident Care Cards were posted in the resident rooms, so all staff could determine at a glance what was required for each resident's care. However, observation, on 02/13/13 at 11:25 AM revealed the Resident Care Card was not visible "at a glance" in the resident's room, but was posted inside the closet on the back of the closet door. Further interview with the DON revealed she did not know why CNA #1 and LPN #2 thought the resident only required one (1) person assist.

Based on observation, interview and record review, it was determined the facility failed to ensure each resident received adequate supervision and assistance to prevent accidents, for one (1) of three (3) sampled residents (Resident #1). Resident #1 was assessed to require the assistance of two (2) persons for transfers; however, the resident was transferred with the assistance of one (1) person and sustained a fracture to the right upper arm. The findings include: Interview with the Director of Nursing (DON), on 02/15/15 at 3:15 PM, revealed she considered it a standard of care that a gait belt be used for all transfers, although the facility did not have a written policy related to transfers and gait belts. Review of the clinical record revealed the facility admitted Resident #1 on 12/28/12 with [DIAGNOSES REDACTED]. Review of Section G of the Admission Minimum Data Set (MDS) Assessment, dated 01/03/13, revealed the facility assessed Resident #1 to require extensive assistance of two persons for bed mobility and transfers to or from the bed, chair, wheelchair and standing position. Resident #1 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident was cognitively intact. Review of the Comprehensive Care Plan, dated 01/10/13, revealed the problem Functional Deficit was identified with interventions initiated which included "resident requires extensive assist of two with bed mobility, transfers and toileting....". Continued review of the Care Plan revealed Resident #1 was at risk for fractures due to Osteoporosis and Osteopenia (conditions associated with weak or brittle bones). Interventions for this risk included "use a gait belt with transfers". Review of the Resident Care Card, posted inside the resident's closet on the back of the closet door, revealed Resident #1 was to be transferred with the assist of two (2) persons and the use of a gait belt. Review of the Nursing Progress Note, dated 01/31/13 at 12:47 AM, revealed Licensed Practical Nurse (LPN) #2 documented Resident #1 was transferred at 6:00 PM on 01/30/13 when a "crackle noise" was heard, and the resident stated, "you broke my arm". Continued review revealed the nurse reassured the resident, and assessed the arm to have full range of motion, no swelling, no redness, and no pain. Continued review revealed the nurse documented the "nurse aide and nurse transferred patient properly". Review of the Nursing Progress Note, dated 01/31/13 at 7:49 AM, revealed Licensed Practical Nurse (LPN) #1 discovered Resident #1 to have pain in the right arm. Continued review revealed the resident stated, "I can't move my right arm at all". When the nurse attempted to assess the arm, the resident refused and stated, "It hurts too bad". Interview with Resident #1, on 02/12/13 at 2:55 PM, revealed he/she thought there was only one person in the room when the transfer occurred. The resident did not know the staff member's name. The resident stated, "I heard the bone crack". Continued interview revealed the resident reported he/she "almost passed out it hurt so bad". The resident stated all kinds of people came in and the resident told them, "just leave me alone, get out and stay out". (At this point in the interview, Resident #1 stated "I'm tired of talking about it" and turned his/her head away from the surveyor.) Review of the Physical Therapy (PT) Daily Note, dated 01/31/13 at 4:46 PM, revealed Resident #1 reported being in a great amount of pain in the right shoulder. Continued review revealed the PT Assistant was told by a nursing aide the resident had been transferred the previous evening by staff pulling under his/her arms, which resulted in a popping sound. Interview with the Physical Therapy Assistant (PTA), on 02/13/13 at 11:40 AM, revealed Resident #1 was a "maximum assist of two" prior to the incident. She stated she saw Resident #1 on 01/31/13 and he/she was extremely guarded and in a lot of pain. She verified her written statement, noted above, that it was reported to her an aide had transferred the resident by lifting under the resident's arms, and had heard a popping sound. The PTA could not identify the aide who transferred the resident, or the aide who gave the account to the PTA. Continued interview revealed therapy staff had given an in-service on transfers approximately one week before the incident, but she did not know how many staff had attended. Interview with the Occupational Therapy Assistant (OTA), on 02/13/13 at 11:00 AM, revealed she had seen Resident #1 in the afternoon of 01/31/13. She stated the resident complained of pain in the right arm and did not want to move it. She stated the resident was very protective of the right arm, which was swollen approximately twice its normal size. Continued interview revealed the resident reported to the OTA the resident's arm was injured the night before when "the girl" was putting the resident to bed. The resident told the girl she was not doing it the way therapy did it (put the resident to bed) but the girl didn't listen. The OTA stated Resident #1 required two (2) people for transfers. Interview with CNA #3, on 02/13/13 at 3:00 PM, revealed Resident #1 required the assistance of two (2) staff for transfers. She stated she took care of the resident on 01/31/13 on the day shift. CNA #3 reported Resident #1 complained of her right arm hurting and stated staff picked her up wrong the evening before. Resident #1 did not know the staff member's name. Review of a statement written by Certified Nursing Assistant (CNA) #1, dated 01/30/13 during the initial investigation of the incident, revealed she transferred Resident #1 from the chair to the bed, by herself. Review of a subsequent (undated) written statement by CNA #1, she reported LPN #2 came into the room and performed an assessment after the resident was in bed. Interview with CNA #1, on 02/13/13 at 3:25 PM, revealed she used a gait belt and a walker to assist the resident with a transfer from the chair to the bed on 01/30/13. She stated LPN #2 was in the room during the transfer. Continued interview revealed CNA #1 had the walker in front of the resident and the resident pivoted around from the chair to the bed. She reported as the resident moved to sit on the bed, his/her right elbow hit the handle of the walker and made a popping sound, "like a joint popping". She stated it was "very scary". On further interview, CNA #1 stated she had been trained on proper transfers during CNA training and at another facility but had not received any training at this facility. Per interview, she started working at the facility in January, 2013. During follow-up interview, on 02/14/13 at 4:40 PM, CNA #1 stated she was in the room by herself initially, but LPN #2 came into the room and observed the procedure. She further stated she had been told Resident #1 was a one (1) person assist. She stated that was the way she always transferred Resident #1. Interview with CNA #2, on 02/14/13, at 3:15 PM, revealed she was coming out of another resident's room on 01/30/13 when she heard CNA #1 call her name. She stated she went into the room of Resident #1 and the resident was sitting on the bed. She further stated she saw the resident's wheelchair by the bed, but she did not see a walker or gait belt. Continued interview revealed the resident was complaining of right arm pain and CNA #1 reported she was lifting the resident into the bed and heard the resident's arm crack. CNA #2 stated she did not know what CNA #1 meant when she said she lifted the resident into bed. On further interview, CNA #2 stated she stayed with the resident while CNA #1 went to get LPN #2. CNA #2 described Resident #1 as being fairly calm, was holding his/her right arm next to the body, and supported the right hand across the abdomen with the left hand. CNA #2 stated she had been trained on transfers at another facility, but had not received training since coming to work at this facility. Per interview she had been at the facility since December 2012. Interview with LPN #2, on 02/13/13 at 3:40 PM, revealed Resident #1 was a one (1) person assist at the time of the incident. She stated CNA #1 was using a gait belt and had the resident standing when LPN #2 entered the room. She further stated she observed the transfer. Continued interview revealed she heard "cracks" like cracking knuckles when CNA #1 pulled on the gait belt. During follow up interview, on 02/14/13 at 5:00 PM, LPN #2 stated Resident #1 was in the bed and was uncomfortable and wanted to get up. On reflection, the LPN stated "I forget", and stated the resident was either in the chair and wanted to go to bed, or was in the bed and wanted to get in the chair. The LPN stated she was on one side of the bed and the CNA was on the other side, and began to recount how CNA #1 was putting the resident to bed. She reported Resident #1's arm hit the walker and she heard both arms "crack". Further interview with LPN #2, and review of the incident report completed on 01/30/13, revealed the LPN notified the on-call Physician. She stated since the resident denied pain, and the nurse found no abnormalities on her assessment of the resident's arm, the Physician stated to just monitor the resident. Interview with LPN #1, on 02/13/13 at 3:25 PM, revealed she saw Resident #1 at the beginning of the day shift on 01/31/13. She stated the resident was holding his/her right arm close to his/her side and complaining of pain. The resident was wearing long sleeves and would not allow the nurse to assess the arm; the nurse could not say if there was any swelling or bruising. Continued interview with LPN #1 revealed Resident #1 reported the arm was hurt when she was being transferred the night before. The LPN stated Resident #1 was a two (2) person assist for transfers. She further stated she notified the Physician and received an order to obtain an X-ray of the right arm and shoulder. Interview, 02/13/13 at 4:30 PM with the Physician Assistant working for the Resident #1's Physician, revealed he was called regarding the resident's arm and complaints of pain, and felt like the fracture did occur during the transfer. During interview with the Director of Nursing (DON), on 02/15/13 at 10:35 AM, she stated Resident #1 required the assist of two (2) persons for transfers at the time of the incident, based on the MDS Assessment and the comprehensive Care Plan, and as indicated on the Resident Care Card. Continued interview revealed the Resident Care Cards were posted in the residents' rooms, so all staff could determine at a glance what was required for each resident's care. However, observation, on 02/13/13 at 11:25 AM, revealed the Resident Care Card was not visible "at a glance" in the resident's room, but was posted inside the closet on the back of the closet door. Continued interview revealed the DON did not know why CNA #1 and LPN #2 thought the resident only required one (1) person assist. On further interview, the DON stated the in-service on transfers, provided by the therapy department, should have been mandatory for all nurses and CNAs. She stated it would normally be the Human Resources staff person who would ensure all staff had attended. However, she reported, they did not have anyone in the Human Resources position at the time of the in-service, and the DON was unaware that anyone had verified whether or not all staff attended the in-service. Review of the sign-in sheets revealed CNA #1 and CNA #2 had not attended the in-service. Interview with the Administrator, on 02/15/13 at 12:00 PM, revealed he felt LPN #2 was a good nurse and he trusted her. He stated he and LPN #2 had followed up with the resident's daughter after the incident, and the conversation included discussion of the use of gait belts for transfers. He further stated the facility had done audits in the past related to proper transfer techniques, but had not identified the need to continue them. He further stated the transfer in-service was mandatory, but he did not know if all staff had attended. During subsequent interview with the DON, on 02/15/15 at 3:15 PM, she stated she considered it a standard of care that a gait belt be used for all transfers, although the facility did not have a written policy related to transfers and gait belts. She further stated she had investigated the incident and interviewed all staff involved. Continued interview revealed the DON recognized inconsistencies between the resident and staff accountings of the incident involving Resident #1. She also acknowledged inconsistencies between staff descriptions of the event and had re-interviewed staff involved. She further stated it was impossible to know exactly what occurred. She agreed it appeared the resident had been transferred by CNA #1 alone, and it was not clear when LPN #2 entered the room or if she gave any hands-on assistance or simply observed.

Based on interview, record review, and review of the facility's policy 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 #2). Resident #2's Interim Care Plan, undated, stated the resident would have no falls or injuries and the interventions included a Sara lift. However, on 05/21/12, the resident was transferred with a one (1) person pivot transfer causing the resident to twist his/her ankle resulting in a right ankle sprain. (Refer to F323) The findings include: Review of the facility's policy titled, "Using the Care Plan", undated, revealed the Care Plan shall be used in developing the resident's daily care routines and will be available to staff personnel who have responsibility for providing care or services to the resident. Review of Resident #2's clinical record revealed the facility admitted the resident on 05/12/12 with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the Interim Plan of Care, undated, revealed a problem of falls with approaches included the use of the Sara lift. Review of the Admission Minimum Data Set (MDS) Assessment, dated 05/25/12, revealed the facility assessed the resident with a Brief Interview Mental Status (BIMS) of fifteen (15) which indicated no cognitive loss. Interview, on 06/28/12 at 4:30 PM, with Licensed Practical Nurse (LPN) #4 revealed the staff used a gait belt and two (2) person assistance to transfer Resident #2 on admission, and after Physical Therapy assessed the resident on 05/14/12, a Sara lift was recommended and ordered per the physician's orders [REDACTED]. Interview with Resident #2, on 06/28/12 at 11:45 AM, revealed a Certified Nursing Assistant (CNA) had lifted him/her from the wheelchair to the recliner and his/her foot got caught under the chair and he/she heard his/her foot "pop". Resident #2 stated he/she informed the CNA before the transfer, that it would take two (2) staff; however, the CNA continued with the transfer. Resident #2 stated he/she notified the nurse of pain in the foot and an x-ray was ordered. Review of the Assignment Sheet, dated 05/21/12, revealed LPN #4 and CNA #9 were assigned to Resident #2 on the evening shift. Interview, on 06/28/12 at 6:30 PM, with CNA #9, revealed she was familiar with Resident #2 and was frequently assigned to him/her. She stated she transferred Resident #2 by herself on 05/21/12 with a gait belt; the resident's legs buckled; and, the resident's foot twisted and caught under the recliner chair. She further stated the resident complained of pain in the foot and she notified the nurse, which was LPN #4 to the best of her memory. Further interview revealed she always transferred Resident #2 by herself because the resident could stand up very good on one (1) leg to transfer. CNA #9 stated the CNAs were to refer to the Care Card which was kept inside the resident's closet door for reference for any care including transfers. Per interview, at that time the Care Card did not specify which transfer technique to use for this resident or how many staff were to assist with the transfer. Interview, on 06/28/12 at 4:30 PM, with LPN #4 revealed she and CNA #9 were assigned to Resident #2 on 05/21/12 and Care Cards were in place inside the closet doors for the CNAs to use for a reference related to resident care. She indicated she did rounds and spot checked to ensure the CNAs were using the correct transfer technique as per the Care Plan and Care Cards. Further interview revealed she did not remember CNA #9 notifying her of the resident complaining of pain in the foot or having any concerns related to Resident #2 on 05/21/12. She further stated, a day or two after the incident, Resident #2 told her a CNA had transferred him/her by herself and LPN #4 was also questioned by Administration about this same time. She stated, on 05/21/12, either a Sara lift or a two (2) person pivot transfer was allowed and staff was using both techniques. Review of the Physical Therapy (PT) Notes, dated 05/22/12 at 11:45 PM, revealed Resident #2 reported that his/her right ankle twisted during a transfer the previous evening. The note indicated the resident's ankle was swollen and bruised and the resident reported pain with weight bearing. Further review revealed Therapy was holding weight bearing until results of x-ray were obtained. Review of the Comprehensive Progress Notes, dated 05/22/12 at 2:48 PM, revealed Resident #2 had two (2) plus [MEDICAL CONDITION] to the right ankle and complained of pain when standing. Further review revealed a new order was noted for an x-ray and family was aware. Further review of the physician's orders [REDACTED]. Further review of the PT Notes, dated 05/23/12 at 5:05 PM, revealed x-rays of the right ankle were negative; however, there was swelling, bruising, and pain to the right ankle indicating a probable sprain. Interview on 06/28/12 at 2:00 PM with MDS/LPN #3, revealed she investigated all falls and or/injuries immediately after they occurred. She stated she, the Director of Nursing (DON), Assistant Director of Nursing (ADON), Social Services Director, CNA team leaders, a nurse for each hall, and the Administrator attended a team meeting each morning in which each resident was discussed related to new physician's orders [REDACTED]. She was informed during a meeting on 05/22/12 by a nurse that the resident's ankle was swelled and hurting and the nurse felt it happened during a transfer. Further interview revealed she talked to Resident #2 who told her CNA #9 transferred him/her by herself causing injury to the ankle. Continued interview revealed an x-ray was ordered which was negative and a meeting was held with Physical Therapy related to transfer technique for this resident. Interview on 06/28/12 at 5:00 PM with the DON, revealed the Interim Care Plan was the care plan in use at the time of the transfer on 05/21/12 because the Comprehensive Plan of Care had not yet been developed. She stated the Interim Care Plan intervention revealed staff was to use the Sara lift; however, the care plan and interventions were not dated and it was difficult to know when this intervention was started. Per interview, she was unable to specify which intervention was in place related to the transfer on 05/21/12. Continued interview revealed the Care Card was revised by nurses as they transcribed physician's orders [REDACTED]. She stated, the current Care Card did specify two (2) persons were to assist with transfers, and on 05/21/12, CNA #9 transferred the resident by herself. Continued interview, revealed according to the most recent physician's orders [REDACTED]. She stated this meant staff would not necessarily have to use the Sara lift and could use two (2) person assist to stand and pivot the resident. However, the resident's Interim Care Plan specified the use of a Sara lift only.

Based on interview, record review, and review of the facility's policy it was determined the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for one (1) of three (3) sampled residents (Resident #2). The facility failed to ensure Resident #2 was transferred per the resident's care plan which resulted in an injury to the resident's right ankle. Review of the resident's Interim Care Plan revealed a Sara lift was to be used for transfers. On 05/21/12 staff transferred Resident #2 with only a one (1) person assistance causing the resident to twist his/her ankle causing swelling and discoloration to the right ankle, and bruising to the top of the foot and fifth toe. The incident resulted in the resident having a right ankle sprain with pain which limited the resident's participation in Physical Therapy, from 05/22/12 through 05/28/12. The findings include: Review of the facility "Falls Clinical Protocol", revised 10/08, revealed staff and physician would monitor and document the individual's response to interventions intended to reduce falling. Review of Resident #2's medical record revealed the facility admitted the resident on 05/12/12 with [DIAGNOSES REDACTED]. Review of Resident #2's Fall Risk Assessment, dated 05/12/12, revealed the resident was assessed to be at risk for falls related to requiring assistance with elimination, ambulated with problems and with devices, was not steady and was only able to stabilize with human assistance, was over [AGE] years old, health conditions, and medications. The resident's fall risk score was a fourteen (14) with a score over nine (9) indicating risk for falls. Interview, on 06/28/12 at 4:30 PM, with Licensed Practical Nurse (LPN) #4 revealed the staff used a gait belt and two (2) person assistance to transfer Resident #2 on admission; however, after Physical Therapy assessed the resident on 05/14/12, a Sara lift was recommended and ordered per the physician's orders [REDACTED]. Review of the physician's orders [REDACTED]. Review of the Interim Plan of Care, with no date, revealed a problem of falls with approaches which included the use of a Sara lift. Interview on 06/28/12 at 11:45 AM with Resident #2, whom the facility had assessed with [REDACTED]. The resident stated his/her foot got caught under the chair and he/she heard his/her foot "pop". Resident #2 stated he/she informed the nurse of pain in the foot and an x-ray was ordered. Phone interview, on 06/28/12 at 6:30 PM, with CNA #9 revealed she was familiar with Resident #2 and often was assigned to him/her. She stated she transferred the resident by herself on 05/21/12 with a gait belt. She further stated the resident's legs buckled and the resident's foot got twisted and caught under the recliner chair causing the resident to have pain in the foot. She stated she notified the nurse which was LPN #4 to the best of her memory. Continued interview revealed she always transferred Resident #2 by herself because the resident could stand up very good on one (1) leg to transfer. She stated the CNAs were to refer to the Care Card which was kept inside the resident's closet door for reference for any care including transfers; however at that time the Care Card did not specify which transfer technique to use for this resident. Interview, on 06/28/12 at 4:30 PM, with LPN #4 revealed she and CNA #9 were assigned to Resident #2 on 05/21/12 and Care Cards were in place for the CNAs to use for a reference related to resident care. She stated she did rounds and spot checked to ensure the CNAs were using the correct transfer technique. Continued interview revealed she did not remember CNA #9 notifying her of the resident complaining of pain in the foot or having any concerns related to Resident #2 on 05/21/12. She further stated a day or two after the incident Resident #2 told her a CNA had transferred him/her by herself and LPN #4 was questioned by Administration. She stated at the time of the transfer on 05/21/12, either a Sara lift or a two (2) person pivot transfer was allowed. Interview, on 06/28/12 at 2:00 PM, with MDS/LPN #3 revealed she investigated all falls and/or injuries. She stated she and the Director of Nursing (DON), Assistant Director of Nursing (ADON), Social Services Director, CNA team leaders, a nurse for each hall and the Administrator attended a team meeting each morning in which each resident was discussed for new physician's orders [REDACTED].#2's ankle was swelled and hurting and the nurse felt it happened during a transfer. Continued interview revealed she talked to Resident #2 who told her CNA #9 transferred her by herself and hurt her ankle. Review of the Physical Therapy Notes, dated 05/22/12 at 11:45 PM, revealed the patient reported that his/her right ankle twisted during transfer the evening before. The Note stated the ankle was now swollen and bruised and the resident reported pain with weight bearing. Further review of the Note revealed Therapy was holding weight bearing activities until the x-ray results were received. Review of the Progress Notes, dated 05/22/12 at 2:48 PM, revealed Resident #2 had two (2) plus edema to the right ankle and complained of pain when standing. Further review revealed a new order was noted for an x-ray and family was aware. Review of the physician's orders [REDACTED]. Review of the Physical Therapy Notes, dated 05/23/12 at 5:05 PM, revealed x-rays of the right ankle were negative. The Therapist noted there was swelling, bruising, and pain to the right ankle indicating a probable sprain. The Therapist recommended to limit weight bearing activity on the right foot with no gait today. Further review of the Progress Notes, dated 05/23/12 at 6:43 PM, revealed the x-ray was negative and new orders were received for ice as needed. Review of the physician's orders [REDACTED]. Review of the Physical Therapy Notes, dated 05/24/12 at 12:00 PM, revealed the patient continued to complain of right ankle pain especially with any weight bearing, and no standing or weight bearing was attempted that day. Review of the Progress Notes, dated 05/24/12 at 3:15 AM, revealed Resident #2 complained of discomfort of the right ankle, slight swelling was noted and the resident requested Tylenol for pain. Further review revealed the CNA notified the writer of discoloration of the fifth toe which was very dark purple in color. Review of the Skin Condition Report, dated 05/24/12 (no time), revealed blue discoloration was present on the left top of foot and a bruise was noted on the top of the fifth toe on the right foot. Review of the Physical Therapy Notes, dated 05/25/12 at 2:55 PM, revealed the patient continued with pain and swelling to the right ankle. Review of the Physical Therapy Notes, dated 05/28/12 at 5:15 PM revealed progress had been limited due to right ankle sprain and pain with weight bearing. Interview was attempted with the Physical Therapist and she was unable to be reached. Interview, on 06/28/12 at 5:00 PM, with the DON, revealed the Interim Care Plan was the care plan in use at the time of the transfer on 05/21/12 and this stated to use the Sara lift; however, the care plan and interventions were not dated and it was difficult to know when this intervention was started. Further review revealed the Care Card was updated as interventions changed and there was several interventions related to transfer technique for this resident. She was unable to specify which intervention was in place related to transfer on 05/21/12. Further interview revealed, according to the most recent physician's orders [REDACTED]. However, the resident's Interim Care Plan specified the use of a Sara lift only. The DON further stated the order for the Sara lift should have been clarified by nursing. Interview with the Attending Physician, on 06/28/12 at 7:40 PM, revealed the order written on 05/14/12 to recommend transfer with a Sara lift was "as needed". He revealed he had seen the resident's ankle after the transfer on 05/21/12 and his impression was that the resident had sustained a sprain to the ankle.

Based on observation, interview, record review, review of Centers for Disease Control and Prevention (CDC) guidelines, manufacturers instructions, and the facility's policy and procedure, it was determined the facility failed to establish and maintain an infection control program to ensure a safe environment and to help prevent the development and transmission of infection for two (2) of eighteen sampled (Resident #10 and #11) residents and two (2) Unsampled Residents (Unsampled A and B). The facility failure to ensure staff properly disinfected shared blood glucose monitors after each use. The facility failure to ensure staff were knowledgeable related to the facility's policy regarding blood glucose monitor cleaning. On 07/28/11, facility staff failed to disinfect the blood glucose monitor according to manufacturer's recommendations and CDC guidelines between testing the blood sugar levels of Residents #10 and #11. In addition, facility staff was observed using a blood glucose monitor to test Unsampled Resident A and Unsampled Resident B's blood sugar levels without disinfecting the device between each use. The facility identified nine (9) residents who required blood glucose monitoring and for which this failure had a likelihood to affect which included (3) of eighteen (18) sampled residents (Resident #10, #11 and #16) and six (6) unsampled residents (Unsampled Resident E, U, V, A, W and B). The facility failed to ensure proper infection control procedures were followed related to dressing changes for Resident #7. Facility staff failed to adhere to standards of practice and facility policy related to isolation precautions for Resident #7 who had a wound infection with contact isolation in place. In addition, Resident #3 had a [DIAGNOSES REDACTED]. Also, improper hand hygiene was observed during the noon meal service on 08/04/11. The facility's failure to ensure proper infection control practices were followed to disinfect multi-use blood glucose monitors, placed residents in the facility at risk for serious harm, injury, impairment or death. Immediate Jeopardy was identified on 07/28/11 and the facility was notified on 07/29/11. Observations, staff interviews, and in-service record reviews were conducted to verify removal of Immediate Jeopardy as alleged in the acceptable Allegation of Compliance (AOC). However, non compliance continued to exist at an "E" as the facility had not completed the development and implementation of the Plan of Correction (POC) to ensure the facility established and maintained an effective infection control program. The findings include: 1. Review of the Centers for Disease Control and Prevention guidelines revealed if blood glucose meters were shared, the device should be cleaned and disinfected after every use. Review of the facility policy, "New Policy Update for Cleaning our Glucometer", undated, revealed the glucometer should be cleaned after every resident with an EPA (Environmental Protection Agency) approved disinfectant that meets the 1:10 bleach solution. Review of the blood glucose monitor manufacturer's instructions revealed the blood glucose monitor should be disinfected with a 1:10 dilution of 0.5 %-0.6% sodium hypochlorite solution after each use. Observation, on 07/28/11 at 4:15 PM revealed Registered Nurse (RN) #1 entered Unsampled Resident A's room on Unit B with a caddy that contained a blood glucose monitor, alcohol preps, lancets, cotton balls, and test strips. RN #1 was observed testing the blood sugar for Unsampled Resident A. After she completed the blood sugar testing, she entered Unsampled Resident B's room and completed a blood sugar test with the same monitor. Observation revealed she did not clean the monitor between Unsampled Resident A's test and Unsampled Resident B's test. Interview with RN #1 on 07/28/11 at 4:28 PM revealed she cleaned the monitor at the end of the shift with alcohol wipes. She further stated she had received no training by the facility related to cleaning the monitor and was unaware of the manufacturer's guidelines or the facility's policy and procedure. Observation on 07/28/11 at 4:15 PM, revealed Licensed Practical Nurse (LPN) #5 entered Resident #10's room, on Unit C, with a caddy that contained a blood glucose monitor, alcohol preps, lancets, cotton balls, and test strips. LPN #5 was observed testing the blood sugar for Resident #10. After she completed the blood sugar testing, she failed to clean the blood glucose monitor and entered Resident #11's room. She placed the blood glucose monitor on the resident's bedside table, and proceeded to insert a test strip into the monitor. However, the Nurse did not proceed with testing the resident's blood sugar due to surveyor intervention. Interview with LPN #5 on 07/28/11 at 4:20 PM revealed she was hired by the facility 06/11. She stated she had received no training at the facility related to cleaning the glucometers after each use, and was unaware of the need to clean the glucometers. Continued interview revealed the nurse was unfamiliar with the manufacturer's guidelines and facility's policy related to disinfecting blood glucose monitors after each use. Observation of the caddies on the B and C Units, immediately after interviews with RN #1 and LPN #5, revealed the caddies provided by the facility for blood glucose monitoring contained no disinfectant wipes with a 1:10 bleach solution per CDC guidelines, manufacturer's guidelines, and facility policy. Interview, on 07/28/11 at 5:30 PM, with Nurse Consultant #1, who was serving in an administrative role related to the absence of a Director of Nursing (DON) since 07/14/11, revealed it was the facility's policy to clean the monitors between each resident use. She further stated she was unaware that staff was not cleaning the glucose monitors after each use. Continued interview revealed there was no system in place to monitor staff related to ensure the blood glucose monitors were disinfected between resident use. Further interview, on 07/28/11 at 6:00 PM, revealed she had checked the recent in-service records and found no documented evidence of training related to disinfecting the blood glucose monitors between residents, per facility policy. 2. Review of the policy titled Types of Isolation and PPE (Personal Protective Equipment) Required (no date) revealed contact isolation requires healthcare personnel to "wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment". Review of the clinical record revealed the facility admitted Resident #7 on 07/01/11, with [DIAGNOSES REDACTED]. Observation on 07/26/11 at 4:00 PM, revealed a "STOP" sign on the door to Resident #7's room. Interview with Certified Nursing Assistant (CNA) #20 on 07/26/11 at 4:15 PM, revealed the sign was to remind staff of isolation precautions for Resident #7. CNA #20 stated the resident "has wounds" and explained staff were to wear gloves and gowns when caring for the resident. Further observation revealed a cart in the resident's bathroom contained gloves and gowns. During interview on 07/26/11 at 4:15 PM, LPN #4 revealed Resident #7 was in contact isolation for MRSA in a wound. She stated the wound was draining and the resident had a history of [REDACTED]. Review of laboratory results dated [DATE] revealed a wound culture, site not specified, was positive for MRSA. Review of the physician's Progress note dated 06/12/11, prior to transfer to the facility, revealed "Chronic MRSA Right hip". Review of the Wound Care Progress Note, dated 08/03/11, also revealed Resident #7 had chronic MRSA of the right hip. Review of the Comprehensive Care Plan regarding skin integrity, dated 07/27/11, revealed no interventions were in place for Resident #7 related to the MRSA or the need for contact isolation precautions. Review of the Wound Report dated 06/28/11, prior to admission, revealed Resident #7 had a Stage II pressure sore on the left outer foot, 4.0 centimeters (cm) long x 2.8 cm wide by 0.8 cm deep. Review of the Wound Report, dated 06/29/11, revealed the resident had a Stage IV pressure sore on the left buttock (or ischium). The wound was measured at 6.0 cm x 7.1 cm x 4.2 cm. Review of the Weekly Skin/Wound Assessment, dated 06/29/11, revealed an unhealed surgical incision present on the right hip. Review of the Physician's Orders for the month of July 2011 revealed orders were in place for dressing changes to the three (3) open wounds. Review of the Skin Condition Report, dated 07/22/11, revealed a copious (very large) amount of drainage was noted at each of the wound sites. During observation of the dressing changes with LPN #4 on 07/27/11 at 10:50 AM revealed the following: The unhealed surgical incision at the right hip was draining at both ends. LPN #4 did not wear a gown throughout the procedure, in spite of the contact precautions and the history of MRSA at the site. In addition, CNA #23 did not wear a gown while assisting with turning and positioning the resident for the wound care although gowns were available in the isolation cart in the resident's bathroom. Observation of the Stage IV ulcer on the left buttock revealed no dressing was in place prior to the procedure. The absence of a dressing could allow any drainage to contaminate bed linens, seat of the wheelchair and sling of the mechanical lift used to transfer the resident. In addition, the resident had no barrier against bacteria entering the wound. Continued observation revealed, after application of the dressing to the left buttock, the nurse picked up the trash can and carried it to the other side of the bed. The nurse proceeded to perform the dressing change to the left foot without changing her gloves or [MEDICATION NAME] hand hygiene. Interview with LPN #4, on 07/27/11 at 11:00 AM, revealed the resident did remain under contact isolation for the history of MRSA in the right hip wound. She acknowledged the hip wound was draining heavily and stated she and CNA #23 should have worn a gown and gloves per facility policy. Continued interview revealed she should have washed her hands and applied new gloves between wound sites. Interview with the Wound Care Center consultant, an Advanced Registered Nurse Practitioner (ARNP), on 08//03/11 at 3:30 PM revealed she was familiar with Resident #7 and consulted regarding the wounds on an as needed basis when requested. She stated Resident #7's wounds were chronic, as well as the MRSA at the surgical site. When questioned further, the ARNP stated contact isolation precautions were appropriate for the resident. Interview with Nurse Consultant #2 on 08/04/11 at 5:50 PM revealed Resident #7's contact isolation status indicated staff should have worn gowns during the dressing change to the draining wounds. 3. Observation during meal service, on 08/04/11 at 12:25 PM, revealed CNA #16 assisted with seating residents at tables by pushing wheelchairs around. CNA #16 was then observed to deliver three (3) bowls of soup to three (3) different residents without changing her gloves or washing her hands between resident contact or prior to food contact. It was noted she held the bowls in such a way that her gloved fingers made contact with the soup. Observation on 08/04/11 at 12:40 PM revealed CNA #16 assisted a resident to replace his/her nasal cannula into their nose and was then noted to serve three (3) more residents their lunch time meal without changing her gloves and washing her hands. Interview with CNA #16 on 08/04/11 at 12:54 PM revealed she should have washed her hands after each resident contact before another resident contact and before handling residents' food. Interview with the Dietary Technician on 08/04/11 at 2:55 PM revealed hands should be washed and gloves changed between tasks if anything except food is touched. 4. Review of the facility's Infection Control Policy (no date) revealed staff were to implement isolation precautions as needed for specific infections. Review of the "Types of isolation and PPE (personal protective equipment) required" (no date) revealed "Healthcare personnel caring for patients on Contact Precautions should wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment". Continued review revealed Clostridium Difficile was an example of pathogens requiring contact isolation precautions. Review of Resident #3's medical record revealed the facility admitted the resident from a local hospital on [DATE] with [DIAGNOSES REDACTED]. Review of the hospital record revealed a stool culture report dated 07/16/11, indicated Resident #3 was Clostridium Difficile (C-diff) Toxin Positive. Review of the admitting physician's Progress Note dated 07/18/11 revealed a [DIAGNOSES REDACTED]. Review of the initial care plan, dated 07/20/11, revealed identified problems included Clostridium difficile. Observation on 07/21/11 at 1:45 PM, revealed no signage displayed on the door to Resident #3's room indicating contact precautions were in effect, per facility policy and procedure, and no PPE was available outside or inside the resident's room. Continued observation, on 07/21/11, between the hours of 1:45 PM and 2:15 PM revealed staff and visitors entered and exited Resident #3's room. Interview with LPN #3 on 07/21/11 at 5:10 PM revealed that per facility policy related to infection control, a sign should have been posted outside the resident's room. In addition, a cart containing PPE should have been placed at the entrance to the room or just inside the entrance. She agreed there was no sign or PPE in place. Interview with the Interim Director of Nursing on 07/21/11 at 5:42 PM revealed she was aware Resident #3 was positive for[DIAGNOSES REDACTED] when admitted on [DATE]. She stated gowns were not available at the time of the interview. Continued interview revealed she had informed staff to pass the isolation instructions along to the night shift and she would work on obtaining proper PPE first thing in the morning (07/22/11). Interview on 07/28/11 at 5:30 PM with Nurse Consultant #1 revealed she had been at the facility since 07/18/11 and was temporarily in charge of infection control. She stated there had been no infection control program in place since the previous DON, and Assistant DON left the facility mid July 2011. She further stated she was unaware of what infection control program was in place prior to her arrival at the facility. Further interview revealed the infections were not being tracked and trended at that time; however, the nurses were to indicate resident infections on the twenty-four (24) Hour Report and she was conferring with the nurse about the residents' infections and what follow up was needed related to the infection. The facility provided an Acceptable Credible Allegation of Compliance (AOC) on 08/01/11 that alleged removal of the IJ effective 08/02/11, based on the following; 1) Nurse Consultant #1 verified the manufacturer's recommendation for sanitizing the Easy Maz L blood glucose monitoring device between resident use, and verified the wipes used at the facility had the proper chemicals to disinfect the device. 2) The licensed staff identified as not correctly cleaning the monitors were interviewed to investigate the cause of not following nursing standards of practice related to cleaning the blood glucose monitors and in-services on proper cleaning of the monitors. 3) All licensed staff were re-educated by Nurse Consultant #1, Nurse Consultant #2, and Licensed Practical Nurse (LPN) #8 on sanitizing the blood glucose monitor and would be performing a return demonstration prior to working. 4) Labs were drawn on the nine (9) residents who received finger stick blood sugars at the facility to check for infectious disease on 07/29/11. 5) The above actions were discussed at the Quality Assurance Meeting on 07/29/11 and the Medical Director was in agreement with the actions taken and future plans. On 08/04/11, it was verified the immediacy of the IJ was removed and the facility implemented corrective actions as alleged in the AOC, effective 08/02/11 based on the following: Observation on 08/04/11 at 4:10 PM revealed Registered Nurse (RN) #1 cleaned the blood glucose monitor with Sani-Wipes before and after performing the fingerstick blood sugar on each resident, as per facility policy. Interview on 08/04/11 at 4:15 PM, with RN #1 revealed she had two (2) inservices related to cleaning the glucometer and it was discussed how to disinfect the monitors and what products to use for disinfecting the monitors. She further stated the monitors were to be cleaned before and after use with the Sani Wipes. She further stated the entire monitor was to be wiped off with the Sani Wipes and the monitor was to air dry for two (2) minutes. Observation, on 08/04/11 at 4:15 PM, with LPN #2 revealed she cleaned the blood glucose monitor with Sani-Wipes before and after performing the fingerstick blood sugar on each resident, as per facility policy. Interview, on 08/04/11 at 4:20 PM, revealed LPN #2 had been educated on the facility's policy related to the proper cleaning of the monitors with Sani Wipes before and after use. Observation, on 08/04/11 at 4:15 PM, revealed Licensed Practical Nurse (LPN) #10 cleaned the blood glucose monitor with Sani-Wipes before and after performing the fingerstick blood sugar on each resident, as per facility policy. Interview, on 08/04/11 at 4:15 PM, revealed LPN #10 had received a mandatory inservice, prior to 08/02/11, related to disinfecting the blood glucose monitor. She stated she been checked off three (3) times by the Administrative Nurses. Observation, on 08/05/11 at 11:30 AM, revealed RN #4 cleaned the blood glucose monitor with Sani-Wipes before and after performing the fingerstick blood sugar on each resident, as per facility policy. Interview, on 08/05/11 at 11:35 AM, revealed RN #4 was aware of the policy and had been educated on the proper cleaning of the monitor before and after each use with Sani-Wipes. Review of the residents' records revealed all the insulin dependent diabetic residents were tested for the Human Immunodeficiency Virus [MEDICATION NAME]/Antibody (HIV AG/AB) and Hepatitis B Surface [MEDICATION NAME] (HEP BS AG). Laboratory tests to check for HIV or Hepatitis B infections, were completed for all residents with Diabetes Mellitus who received blood glucose monitoring, on 07/29/11. Interview with Nurse Consultant #2, on 08/04/11 at 3:40 PM, revealed all licensed staff received in-services and had performed competency on the cleaning of the blood glucose monitors prior to 08/02/11. Record review of the Nursing Roster, the blood glucose monitoring in-services, and competencies revealed all licensed nurses had received the training and had demonstrated competency on the cleaning of the monitors, before 08/02/11. The facility remained out of compliance at a lower scope and severity of an "E", a pattern deficiency with potential for more than minimal harm in order for the facility to develop and implement the Plan of Correction (POC).

Based on observation, interview, record review and review of Centers for Disease Control and Prevention (CDC) guidelines, manufacturers instructions, and the facility's policy and procedure, it was determined the facility failed to establish and maintain an infection control program to ensure a safe environment and to help prevent the development and transmission of infection. This was evidenced by the facility's failure to ensure staff properly disinfected shared blood glucose monitors after each use. The facility failed to ensure staff were knowledgeable related to the facility's policy regarding blood glucose monitor cleaning between resident use. The failure to ensure staff were knowledgeable of the proper procedure to clean blood glucose monitors affected two (2) of eighteen (18) sampled residents and two (2) unsampled residents. Observation on 07/28/11 revealed facility staff failed to disinfect the blood glucose monitor according to manufacturer's recommendations, CDC guidelines, and facility policy, between testing the blood sugar levels of Residents #10 and #11. Additionally, facility staff was observed using a blood glucose monitor to test Unsampled Resident A and Unsampled Resident B's blood sugar levels without disinfecting the device between each use. The facility identified nine (9) residents who required the use of a blood glucose monitor for testing blood sugar for which this failure had a likelihood to affect. In addition, the facility failed to ensure proper infection control procedures were adhered to related to dressing changes for Resident #7, who had a wound infection for which he/she was in contact isolation. In addition, Resident #3 had a [DIAGNOSES REDACTED]. However, the facility failed to display signage on the resident's door and failed to follow its policy related to contact precautions. Also, improper infection control related to hand hygiene was observed during the noon meal service on 08/04/11. The failure of the facility to ensure proper infection control practices were adhered to, placed residents in the facility at risk for serious harm, injury, impairment or death. Immediate Jeopardy was identified on 07/28/11. Observations, staff interviews, and in-service record reviews were completed to verify removal of Immediate Jeopardy as alleged in the acceptable Allegation of Compliance (AOC). The facility remained out of compliance at a lower scope and severity of an "E", a pattern deficiency with potential for more than minimal harm, for all residents with a [DIAGNOSES REDACTED]. This was in order for the facility to implement monitoring and a surveillance program. In addition, based on observation, interview, and record review, it was determined the facility's Administration failed to ensure the facility provided a program of activities designed to meet, in accordance with the Comprehensive Assessment, the interest and physical, mental, and psychosocial well-being of the residents. Substandard Quality of Care (SQC) was identified at CFR 483.15 Quality of Life F-248. The Substandard Quality of Care deficient practice included a system failure in which residents were not offered activities according to their interest per the Comprehensive Assessments and the Activities Assessments. The facility failed to ensure activities were performed as scheduled, failed to ensure there was sufficient staff to perform the activities, and failed to ensure sufficient training for staff, who were designated to perform the activities. Additionally, based on interview and record review, it was determined the facility failed to ensure adequate assessment and monitoring to ensure residents maintained acceptable parameters of nutritional status for six (6) of eighteen (18) sampled residents (Resident #10, #11, #7 #8, #1 and #6) and fifteen (15) unsampled residents, Unsampled Residents B, F, H, I, J, K, L, M, N, O, P, Q, R, S and T). Resident #10 had a significant weight loss of six (6) pounds (5%) from 06/09/11 to 07/15/11. However, the facility failed to notify the Physician of the weight loss and failed to notify the Physician of the Dietician's recommendations which were written 07/15/11. In addition, the facility failed to obtain admission weights per the facility's policy for residents who were admitted on [DATE] including Residents #1, #6, #7, #8 #11 and Unsampled Residents B, F, H, I, J, K, L, M, N, O, P, Q, R, S and T . Also, there was no documented evidence of meal intakes being documented, tracked, or monitored consistently. The findings include: 1. Based on observation, interview, and record review (of Centers for Disease Control and Prevention (CDC) guidelines, manufacturer's instructions, and the facility's policy and procedure,) it was determined the facility failed to establish and maintain an infection control program to ensure a safe environment and to help prevent the development and transmission of infection as evidenced by the facility's failure to ensure staff properly disinfected shared blood glucose monitors after each use and failed to ensure staff was knowledgeable related to the facility's policy regarding blood glucose monitor cleaning. This affected two (2) sampled residents (Resident #10 and #11) and two (2) unsampled residents. On 07/28/11, facility staff was observed using a blood glucose monitor to test Residents #10 and #11's blood sugar levels without disinfecting the device between each use. Also, on 07/28/11 facility staff was observed using a blood glucose monitor to test Unsampled Resident A's and Unsampled Resident B's blood sugar levels without disinfecting the device between each use. The facility identified nine (9) residents, who require blood glucose monitoring for which this failure has a likelihood to effect. Additionally, staff failed to implement proper infection control technique related to a dressing change for Resident # 7 who was in contact isolation, failed to ensure proper signage was in place and isolation precautions were adhered to for Resident #3 related to the [DIAGNOSES REDACTED]. 2. Review of the Infection Control Policy and Infection Control Reports for the facility, revealed any infection report was sent to the front office to alert other departments of any precautions needed regarding infections. Copies were also to be sent to the Director of Nursing (DON)/Assistant DON for review and follow up. Further review revealed isolation precautions were to be implemented as needed for specific infections, i.e., contact, droplet, and provide staff with appropriate personal protective equipment. "The Director of Nursing has ultimate responsibility for review of completed infection control reports and assessing infection trends or patterns within the facility. Each charge nurse had responsibility for recognizing the signs and symptoms of infection and completing the Infection Report. Physician, family and staff should always be aware of infection and their role in management, prevention of spread and precautions which should be taken. The DON reviews all infection reports monthly and reports to the Safety Committee any trends or patterns. The Safety Committee recommends further services or other education to prevent and/or control infections disease in the facility". Interview was conducted, on 07/28/11 at 5:30 PM and on 08/03/11 at 4:30 PM, with Nurse Consultant #1, who started at the facility on 07/18/11 and was serving in an administrative role due to absence of a DON at the facility since 07/14/11. She stated there was no infection control program in place after the DON left on 07/14/11, and the Assistant DON left on 07/15/11. Further interview revealed the new infection control program was in the process of being implemented. She further stated the glucose monitors should be cleaned between each resident use with bleach wipes as per the facility's policy and the Centers for Disease Control (CDC) guidelines. Continued interview revealed she was unaware staff was not cleaning the glucose monitors after each use with bleach wipes and there was no system in place to monitor staff related to ensuring the cleaning of the blood glucose monitors between resident use. Further interview on 07/28/11 at 6:00 PM, revealed she had reviewed the recent in-services and there was no documented evidence of training related to cleaning the blood glucose monitors per facility policy. Continued interview revealed the facility was not tracking and trending infections when she arrived on 07/18/11. Interview, on 08/05/11 at 5:20 PM, with the Administrator revealed the previous Administrator resigned 07/15/11 and the previous DON left 07/15/11. He stated he had been in the building since 06/26/11 and identified fairly quickly there were clinical issues after talking with staff and receiving complaints from families. He further stated he brought in Nurse Consultant #1 and other corporate staff after identifying system problems in the facility including infection control. 3. Based on observation, interview, and record review, it was determined the facility failed to ensure an ongoing program of activities designed to meet the individual interests of each resident. Record review and interviews with staff, residents, and the Ombudsman revealed residents' individual activity interests and special needs were not met. In addition, observations and complaints from residents and staff revealed a systemic failure to provide a varied program of activities that was well-communicated to the residents. Record review and interview revealed activities were frequently cancelled or interrupted due to the floor staff having to provide resident care as well as implement the activity program. In addition, record review and interviews revealed no evidence the staff assigned to conduct resident activities had received training to plan, coordinate and conduct consistent daily recreational offerings. Interview, on 08/03/11 at 3:00 PM, with the Activities Director revealed there was no activities staff and the Certified Nursing Assistants (CNAs) were to lead the scheduled activities. However, further interview revealed the CNAs were unable to perform the activities due to being assigned to many duties including housekeeping duties and dietary duties. The Activities Director stated he realized the scheduled calender of activities were not being completed after reviewing the documentation for resident activities and interviewing the CNAs. Continued interview revealed he was to oversee the activities on the units; however, was assigned several responsibilities at the facility which did not allot him the time needed to perform his duties as Activities Director. Interview with the Vice President of Operations (Interim Administrator), on 08/05/11 at 5:20 PM, revealed he was aware of concerns related to the Activities Programs and the facility was looking at the issue, but had not yet implemented an action plan. During continued interview, he explained facility Administration was interested in "Universal Workers", staff who performed a variety of duties, across disciplines. Further interview revealed implementing such an approach was a "full culture change" and required a more systematic approach than had been applied thus far. He stated he felt there was enough staff; however, stated staffing ratios and more staff education were two issues that needed further consideration. 4. Interview, on 08/04/11 at 4:30 PM, with Nurse Consultant #1, Nurse Consultant #2 and the Interim DON, revealed they were aware the weights were not completed for the twenty-two (22) residents who were admitted [DATE]. Continued interview revealed they were aware there was an issue with the meal intakes not being documented and a recent in-service had been completed with staff related to documenting meal intakes. Further interview revealed they became aware of Resident #10's weight loss on 08/03/11, and as of that date there were no committees in place to evaluate the residents' nutritional status. However, they were in the process of instituting an interdisciplinary team meeting which would meet every week to discuss weights. Continued interview revealed the Dietitian was now tracking weights and would inform the Nurses and Nurse Management of significant weight changes. Further interview revealed they were aware there was a problem related to dietary recommendations not being followed, and the Dietitian would be writing recommendations on the physician's orders [REDACTED]. Continued interview revealed the facility failed to have a system in place to assess, plan, implement and monitor residents for nutritional status.

Based on interview and record review it was determined the facility failed to have an effective Quality Assurance (QA) Committee that was structured to identify quality issues with the potential for negatively affecting the residents. The facility failed to establish and maintain an infection control program to ensure a safe environment and to help prevent the development and transmission of infection. This was evidenced by the facility's failure to ensure staff properly disinfected shared blood glucose monitors after each use and failure to ensure staff were knowledgeable related to the facility's policy regarding blood glucose monitor cleaning. This was also evidenced by the staff failing to adhere to proper infection control technique during dressing changes, failing to ensure proper hand hygiene at meal service, and failing to follow the policy related to isolation precautions for a resident with a known infectious disease. The facility's failure to ensure proper infection control practices were followed, placed residents in the facility at risk for serious harm, injury, impairment or death. Immediate Jeopardy was identified on 07/28/11 and was removed on 08/02/11, after an acceptable credible Allegation of Compliance (AoC) was received and further observations, in-service record reviews, and staff interviews were conducted to verify removal of the Jeopardy. In addition, there was a system failure related to the facility's failure to provide a program of activities designed to meet, in accordance with the Comprehensive Assessment, the interest and physical, mental, and psychosocial well-being of each resident. Substandard Quality of Care (SQC) was identified at CFR 483.15 Quality of Life F-248. Also, based on interview and record review, it was determined the facility had a system failure related to ensuring admission weights and weekly weights were obtained and monitored, meal consumption was monitored, and Registered Dietician recommendations were implemented in order to ensure residents maintained acceptable parameters of nutritional status for six (6) of eighteen (18) sampled residents (Resident #10, #11, #7 #8, #1, and #6) and fifteen (15) unsampled residents, Unsampled Residents B, F, H, I, J, K, L, M, N, O, P, Q, R, S and T). The facility failed to notify the Physician and follow dietary recommendations which were written on 07/15/11 when the facility became aware that Resident #10 had a significant weight loss of six (6) pounds (5%) from 06/09/11 to 07/15/11. Additionally, the facility failed to obtain admission weights per the facility's policy for residents who were admitted on [DATE] including Resident #1, #6, #7, #8 #11, and Unsampled Residents B, F, H, I, J, K, L, M, N, O, P, Q, R, S and T . In addition, there was no documented evidence of meal intakes being documented consistently. The findings include: 1. Based on observation, interview, and record review, it was determined the facility failed to have an effective system to ensure blood glucose monitors were disinfected between resident use as per policy. On 07/28/11 facility staff was observed using a blood glucose monitor to test Resident #10's and Resident #11's blood sugar levels without disinfecting the monitor between each use. In addition, on 07/28/11 facility staff was observed using a blood glucose monitor to test Unstamped Resident A's and Unstamped Resident B's blood sugar levels without disinfecting the monitor between each use. Additionally, the facility failed to ensure proper infection control procedures were adhered to related to dressing changes for Resident #7 who had a wound infection for which he/she was in contact isolation. Also, Resident #3 had a [DIAGNOSES REDACTED]. However, the facility failed to display signage on the resident's door and failed to follow its policy related to contact precautions. In addition, improper infection control related to hand hygiene was observed during the noon meal service on 08/04/11. Interview with Nurse Consultant #1, on 07/18/11 at 5:30 PM, 07/28/11 at 6:00 PM, and 08/03/11 at 4:30 PM revealed she started at the facility on 07/18/11, and noted there was no infection control program in place after the previous Director of Nursing (DON) and Assistant Director of Nursing (ADON) left on 07/13/11. She stated there was no system in place to monitor staff related to ensuring the cleaning of the blood glucose monitors between resident use. Further interview revealed she had reviewed the recent in-services and there was no documented evidence of training related to cleaning the blood glucose monitors per facility policy. Continued interview revealed the facility had not been tracking and trending infections when she arrived on 07/18/11; however, she was starting to track infections from the information on the the twenty-four (24) hour report. 2. Based on observation, interview, and record review, it was determined the facility failed to have an effective system to ensure residents were offered activities according to their interest per the Comprehensive Assessment and the Activities Assessments. Also, observation and interviews from residents and staff revealed a systemic failure to provide a variety of activities which was communicated to residents. In addition, observations and interviews revealed activities were interrupted or cancelled as a result of floor staff having to coordinate and conduct daily recreational offerings, as well as provide resident care. Interview, on 08/03/11 at 3:00 PM, with the Activities Director revealed the Certified Nursing Assistants (CNAs) were to lead and participate in the scheduled activities. However, the CNAs were unable to always perform the activities due to being assigned to many duties including housekeeping duties and dietary duties. He stated the scheduled calender of activity events were not being completed after reviewing the documentation for resident activities and interviewing the CNAs. Continued interview revealed he was assigned several responsibilities at the facility which did not allot him the time needed to perform his duties as Activities Director. Interview, on 08/04/11 at 10:30 PM, with Nurse Consultant #1, who was serving in an administrative role, and Nurse Consultant #2, revealed they had a QA Meeting on 07/29/11 which was the first meeting since she had started on 07/18/11. She further stated the Medical Director attended and made suggestions to assist with getting into compliance with issues identified. She further stated the committee intended to educate staff on immediate needs and get audits in place. Continued interview revealed the facility did not currently have a process in place to ensure weekly interdisciplinary meetings were held related to infection control, activities, and other issues identified. However, they would be in the process of getting that implemented. Interview, on 08/05/11 at 5:20 PM, with the Vice President of Operations (and Interim Administrator) revealed he had been in the building since 06/26/11. Continued interview revealed the previous Administrator resigned 07/15/11 and the previous DON left 07/15/11. He stated the systems which were in place in the old facility building were not being implemented since the move to the new facility building on 07/01/11 which included infection control. He stated, after noting concerns with clinical issues, he brought in Nurse Consultant #1 and other corporate staff. Further interview revealed he was aware of concerns related to the Activities Program and the facility was examining the issue. He stated the facility Administration was interested in "Universal Workers", staff who performed a variety of duties, across disciplines. Continued interview revealed implementing such an approach was a "full culture change" and required a more systematic approach than had been applied thus far. He stated he felt there was enough staff; however, he stated staffing ratios and more staff education were two issues that needed further consideration. 4. Interview, on 08/04/11 at 4:30 PM, with Nurse Consultant #1, Nurse Consultant #2 and the Interim DON, revealed the facility was aware the weights were not completed for the residents who were admitted [DATE], and was aware there was an issue with the meal intakes not being consistently documented. Continued interview revealed a recent in-service had been completed with staff related to documenting meal intakes. Further interview revealed they became aware of Resident #10's weight loss on 08/03/11, and as of that date there were no committees in place to evaluate the residents' nutritional status. Continued interview revealed they were in the process of instituting an interdisciplinary team meeting which would meet every week to discuss weights. Also, interview revealed the Dietitian was now tracking weights and would inform the Nurses and Nurse Management of significant weight changes. Continued interview revealed they were aware there was a problem related to dietary recommendations not being followed, and the Dietitian would be writing recommendations on the physician's orders [REDACTED]. .

Based on observation, interview, and record review it was determined the facility failed to maintain a quality assessment and assurance committee that developed and implemented effective plans of action to correct identified quality deficiencies. The facility failed to ensure the plan of correction to correct regulatory violations cited on the 08/05/11 abbreviated/partial extended survey was effective. The facility failed to develop effective audits to ensure deficient practice was identified and corrected. During the onsite revisit survey, additional examples of non-compliance were identified and deficiencies continued in the following areas: F-157- physician notifications; F-281-following physician orders; F-282-following the comprehensive care plan; F-323-supervision to prevent accidents; F-514-mainenance of the medical record; and F-520-quality assurance. The findings include: 1. According to the acceptable Plan of Correction (PoC), with an alleged compliance date of 09/20/11, the facility implemented the following: a full audit for timely notifications to physicians and family was conducted; nurses were inserviced on the timeliness of notifications; all physician orders were reviewed daily, Monday through Friday by the Inter-Disciplinary Team; and nursing administration completed five (5) random audits of nurses' progress notes weekly for four (4) weeks. Audit results were reported to the monthly Quality Assurance meetings on 09/30/11 and 10/28/11. Document review revealed all corrective activities were completed as outlined in the PoC. Staff interviews revealed the nurses were inserviced on notifications as stated. However, the facility remained out of compliance for one (1) of nine (9) sampled residents during the Revisit Survey. Resident #10 was observed by his/her nurse to have a discolored foot that was cold to the touch. The physician was not notified for several hours and the resident ultimately was transferred to the hospital and amputation of the leg was required. (Refer to F-157) 2. Review of the PoC revealed all residents' orders related to lab tests, range of motion, restorative nursing, positioning, pressure sore prevention devices and safety precautions were reviewed and clarified as needed. In addition, nursing consultants and administrators reconciled the orders with the care plans, direct care guides, medication and treatment administration records, laboratory records, and sources for documentation of implementation of physician's orders. Continued review revealed the facility revised their system to ensure all orders were continued upon admission or transfer from another facility. Newly revised direct care guides were implemented. All nurses, and Certified Nursing Assistants (CNAs) as applicable, were educated on the admission process, fall policies, direct care guides, following physician orders, physician order processing, insulin orders, restorative program, medication pass, skin policy, skin assessments and weekly measurements, and the lab process. Additionally, weekly audits (times four weeks) were conducted to verify the completion of admission assessments, and for timeliness and accuracy during medication pass. Audit findings were reported to monthly QA meetings on 09/30/11 and 10/28/11. Interviews with staff revealed they had received the inservices as stated, and were knowledgeable on new policies and processes. Document review revealed the above stated action plan was implemented as alleged. However, although a number of system revisions were implemented and staff were inserviced, not every element was included in the audits. As a result, the facility remained out of compliance with this regulation. The facility failed to ensure physician's orders were followed for three (3) of nine (9) sampled residents. Residents #6 and #11 did not have weekly skin assessments as ordered. Resident #10 did not have a chair alarm as ordered. In addition, professional standards were not followed when, on 10/12/11, Resident #10's right foot was noted to be cool and discolored, and had a weak pulse. There was no documented evidence of a thorough circulation check or assessment of the affected extremity. (Refer to F-281) 3. Continued review of the PoC revealed the facility reviewed all residents with fall prevention devices to ensure their care plans had been revised as indicated. An inservice for all nurses related to the facility's fall policy and prevention strategies was conducted. In addition, the facility audited five (5) residents with fall prevention devices weekly for four (4) weeks to ensure the safety measures were being implemented as ordered. Audit findings were reported to the monthly QA meetings on 09/30/11 and 10/28/11. Review of documents related to the training and audits revealed the action plan was implemented as stated. Interviews with nurses revealed they had been inserviced on the fall policy and related prevention strategies. However, facility response did not include an audit of care plan interventions being followed. During the Revisit Survey, the care plan was not followed for three (3) of nine (9) sampled residents. Resident #10 did not have a chair alarm when observed by surveyors. In addition, Residents #6 and #11 did not have weekly skin assessments completed. (Refer to F-282) 4. Review of the PoC revealed the facility assessed all residents for fall risk, and care plans were put in place with appropriate fall prevention strategies. All licensed staff and CNAs were inserviced on the fall policy, fall prevention strategies, completion of the fall risk assessment, and appropriate care planning. In addition, the facility conducted an audit of three (3) incidents/accidents weekly for four (4) weeks to ensure compliance with the fall policy. Continued review of the PoC revealed all electrical rooms, soiled utility rooms, and laundry room doors were closed and locked immediately. Facility policy related to keeping the doors locked was included in the inservice agenda. Environmental rounds were conducted three (3) times per week for four (4) weeks. Results of the audits and environmental rounds were reported to the QA meetings on 09/30/11 and 10/28/11. Document review revealed the facility completed educational activities and audits as stated in the PoC. Interviews with staff revealed they had attended the inservices and were familiar with the fall policy and knew doors to rooms with accident hazards were to be locked at all times. However, during the Revisit Survey, the laundry room door was observed to be unlocked. An unattended housekeeping cart containing harmful chemical substances was in the room and accessible to residents. (Refer to F-323) 5. Further review of the PoC revealed the facility educated all nurses and CNAs on proper documentation related to meal consumption and bowel movements. Nursing administration audited five (5) meal consumption records and four (4) bowel records weekly for four (4) weeks. In addition, the CNA team leader was made responsible for ensuring the daily documentation was completed. Audit findings were reported to the monthly QA meetings on 09/30/11 and 10/28/11. Review of facility records revealed the inservices were provided and the audits were completed as indicated in the PoC. Interviews with staff revealed they were aware of the policy related to documenting meal consumption and bowel movements. Interview with the CNA team leader revealed she reviewed the records daily to ensure they were complete. However, the facility audits not address all elements of the Clinical Record, as evidenced by one (1) of nine (9) sampled residents whose Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Therefore, the facility remained out of compliance. (Refer to F-514) Interview with the Administrator, on 11/04/11 at 6:50 PM, revealed he had overseen corrective action activities as outlined in the PoC. Document review revealed he signed off on the completion and review of audits daily, Monday through Friday. He stated, and document review corroborated, there had been two (2) Quality Assurance (QA) meetings since the alleged date of compliance of 09/20/11. The meetings were held on 09/30/11 and 10/28/11. He admitted all instances of non-compliance had not been captured in the audits and stated the team had identified, during the 10/28/11 meeting, additional audits were needed beyond the four (4) weeks outlined in the PoC. Further interview revealed the new Director of Nursing (DON) had revised the QA program, to follow a Continuous Quality Improvement (CQI) model. The Administrator revealed more of the QA/CQI activities needed to be delegated to other team members. He stated it was not effective for the PoC to be the sole work of the Administrator and the DON. He felt the DON should be free for educational activities and nursing management. He further stated more monitoring responsibilities should be assigned to other team members. One strategy, he revealed, was to assign a specific set of residents (to include every resident) to each team member for ongoing audits. The Administrator felt the near total turnover of administrative staff had been a big factor in the failure to achieve full compliance. He felt he now had an effective team in place and expected continued improvement and ultimate total compliance. Although the DON was critical to corrective action activities, she was unavailable for interview due to a family emergency. The Assistant DON began her duties on 10/31/11, one (1) day prior to the Revisit Survey, and was still in the learning stages related to facility deficiencies and the PoC.

Based on interview, record review, and review of facility's policy, it was determined the facility failed to ensure the Physician was notified for a significant change physical status for one (1) of nine (9) sampled residents (Resident #10). On 10/12/11 at 5:30 PM the facility noted Resident #10's right foot was reddish blue in color; however there was no documented evidence of a thorough circulation check and assessment of the right lower extremity as per facility policy. In addition, there was no documented evidence the Physician was notified of the discoloration of the resident's right foot. At 10:00 PM Resident #10 was transferred to the hospital where the foot was noted to be blackish blue in color, with no palpable pedal pulse and the leg was cool to the touch from the foot to the knee. Resident #10 was admitted to the hospital on [DATE] and received an above the knee amputation to the right lower extremity. The findings include: Review of the "Lippincott Manual of Nursing Practice, Ninth Edition", revealed a physical assessment of peripheral circulation of the extremities would include: noting the temperature of the skin over the extremities, comparing one side to the other, palpate pulses (radial, femoral, posterior tibial, dorsalis pedis) comparing symmetry from side to side, palpate the skin over the tibia for [MEDICAL CONDITION] by squeezing the skin between thirty (30) to sixty (60) seconds and note indentation. Interview on 11/03/11 at 3:00 PM with the Assistant Director of Nursing (ADON) in the absence of the DON, revealed this was the was the reference the facility used as a guideline related to circulation checks. Review of the facility "Physician/Family Notification Policy", undated, revealed,"the Physician (or the designated on call Physician) is notified by telephone or by fax immediately (within 60 minutes) about any of the following circumstances,... a significant change of physical, mental, or psychosocial condition of the resident". Interview on 11/02/11 at 3:00 PM with the Director of Nursing (DON) revealed this was the current policy related to Physician notification. 1. Review of Resident #10's medical record revealed diagnoses which included Dementia, Diabetes Mellitus, and status [REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident as moderately impaired in cognitive skills for decision making. Further review revealed the facility assessed the resident as requiring total assistance with all Activities of Daily Living (ADL's). Review of the Progress Notes dated 10/12/11 at 10:00 PM written by Licensed Practical Nurse (LPN) #2, revealed at 5:30 PM a Certified Nursing Assistant (CNA) informed the writer that the resident's right foot was discolored. Further review of the Note revealed the resident's foot was a reddish blue color and the nurse asked the CNA to keep an eye on the foot and make her aware of any changes. Continued review revealed at approximately 8:30 PM the CNA informed the nurse that the right foot was turning black. According to the Note, the Director of Nursing (DON) was called and a blood pressure (130/78), pulse (99) and oxygen saturation (95%) was obtained. The resident had no complaints of pain and responded to questions and name. The nurse called the Physician and left a message. Resident #10's son was called at 9:00 PM and updated on the resident's condition and wanted the resident sent to the hospital. According to the Note, at 9:30 PM a call was placed to rural metro for transportation and at 10:00 PM the resident was transported to the hospital. Further review revealed at the time of transport the resident's third toe was darker that the rest of the foot which remained blackish blue in color. An entry at 11:22 PM revealed the resident was sent to the hospital per the son's request and the resident's foot was turning black, there was no pedal pulse noted, and the leg was cool to the touch from the foot to the knee. Review of the Hospital History and Physical dated 10/13/11 revealed the resident's right lower extremity below the knee, and the right calf and shin area felt very cool to the touch. The resident's right foot over the midfoot, distal foot and over the toes was a severe purplish discoloration and there was mottling of the skin. The resident's foot was very cold to the touch and there was no palpable pulse in the right dorsalis pedis or posterior tibial foot. The Hospital Discharge Summary was not completed by the hospital at the time of this survey. Review of the facility Readmission physician's orders [REDACTED]. Interview on 11/02/11 at 4:00 PM with Licensed Practical Nurse #2 who assessed the resident on 10/12/11 at 5:30 PM, revealed the resident's right foot was discolored which she described as reddish blue, and the foot was cool to the touch with a weak pulse on top of the foot (dorsalis pedis). She stated she assessed the pedal pulses on the top of both feet and the right foot pedal pulse was weaker than the left. She stated she did not check for a posterior tibial pulse. Continued interview revealed she was concerned there was a circulation issue; however, had never assessed the resident's feet and did not know what was normal for this resident. She stated there was no supervisor in house in which to consult with; however, stated there were other nurses she could have asked to assess the foot. Continued interview revealed she did not ask another nurse to check the resident's foot and did not call the Physician after the assessment. She stated she did not document her full assessment of the foot at 5:30 PM. Further interview, revealed when Certified Nursing Assistant (CNA) #19 assisted the resident to bed at 8:00 PM or 8:30 PM, the CNA informed her the foot "was really bad". She stated she observed the third toe on the right foot to be completely black and the foot was turning black. She further stated there was an area which she described as reddened, and warm to the touch on the front of the right shin which was about two (2) inches in diameter. Continued interview revealed the right foot was cold and there was no palpable pulse. She stated she called the Physician and left a message and then called the son who wanted the resident sent to the hospital. She further stated the Director of Nursing (DON) asked her to do a recount of all that happened that night and they talked about the resident's signs of poor circulation; however, she did not receiving teaching related to a circulation check and documentation. Interview on 11/02/11 at 4:00 PM with CNA #19 revealed she was getting the resident up for dinner on 10/12/11 before 5:00 PM when she noted the resident's toes looked bluish purplish; however, could not see the rest of the resident's foot because the resident was wearing Ted Hose. She told LPN #2 to check the residents foot and the nurse came immediately. She stated she did not stay in the room while the nurse checked the resident's foot and was unaware of the color of the rest of the foot and leg. Continued interview revealed when she was assisting the resident to bed between 7:00 PM and 8:00 PM, she removed the resident's Ted Hose and noted the resident's toes and foot were blue in color. She described the middle toe as black and the right shin as having a purplish area. She further stated the right foot and leg were cold and she notified LPN #2. Interview on 11/04/11 at 12:00 PM with CNA #16 who was assigned to the resident on the morning of 10/11/11 revealed she was assisting the resident to get out of bed that morning and noted her/his leg was noticeably a discolored white and "icy cold" from the knee to the foot and she informed Registered Nurse (RN) #20. She stated the nurse told her it was probably bad circulation and to go ahead and get the resident up. Continued interview revealed she applied the Ted Hose to the residents lower extremities and assisted the resident up for breakfast. She stated when she layed the resident down after lunch, the resident's Ted Hose were removed and there was no change noted in the lower extremities from that morning. She was unaware of the nurse assessing the resident's lower extremity. Phone interview with RN #20 on 11/04/11 at 2:15 PM revealed she had worked at the facility for two (2) weeks and was in training on 10/11/11. She stated she did not remember anyone asking her to assess the resident's lower extremity on 10/11/12. Continued interview revealed she saw the resident on the morning of 10/12/11 because she did a "general look over" of all the residents in the mornings. She stated she lifted the covers and noted the resident's foot was "a little cold to touch", as compared to the other foot but had no discoloration. She stated she did not complete a circulation check or feel for pulses. Interview on 11/04/11 at 1:45 PM with CNA #18 revealed she was assisting Resident #10 on 10/12/11 in the morning and noted the foot was discolored and purplish reddish to the ankle. She described the foot as "ice cold" and also stated the leg was cold. She further stated she was working with CNA #15 who said she would tell LPN #20. Continued interview revealed the nurse did not come into the room to assess the foot and they went ahead and applied the resident's Ted Hose and assisted the resident to the wheelchair for breakfast. Further interview revealed the resident did not complain of pain with the foot and she was unaware if the nurse assessed the resident's foot that shift. Interview with LPN #20 on 11/04/11 at 2:30 PM revealed she did not remember a CNA informing her of the resident's foot being cold and discolored. She further stated she would have assessed the foot and completed a circulation check including pedal pulses, color, warmth. Continued interview revealed she would have checked to ensure Ted Hose were in place; however, the CNA's applied Ted Hose. Interview with the Director of Nursing (DON) on 11/02/11 at 4:30 PM revealed LPN #2 should have documented the dorsalis pedal and posterior tibial pulses, temperature of the foot, assessed the resident for pain, checked for a capillary refill and checked for a Homans sign during her first assessment at 5:30 PM. She further stated she could not tell by the documentation if a circulation check was done. Continued interview revealed she had talked to the nurse related to a circulation check not being documented; however, was unsure if she had documented the "teachable moment". A copy of the education with the nurse was requested; however not provided. Interview on 11/02/11 at 5:00 PM with the Medical Director, revealed the nurse should have called the Physician if the foot was cooler and had a weaker pulse than the other foot and if the foot was discolored. He further stated it was the obligation of the nurse to immediately complete an assessment if there was a noted change in condition and notify the Physician. He further stated in this situation the resident should have been looked at by a Physician immediately and not hours later. Interview with the Attending Physician on 11/03/11 at 10:00 AM and 11:50 AM revealed the resident had no [DIAGNOSES REDACTED]. He stated it would be a judgement call for the nurse in deciding if the Physician should have been notified after the assessment of the foot at 5:30; however, felt if there was a definite difference in the color of the foot the nurse may have needed to notify the Physician. Further interview revealed he had talked to the Vascular Surgeon at the hospital who treated the resident and the Vascular Surgeon felt the circulation problem had been going on longer; however, there was no documentation of this.

Based on observation, interview, record review and review of facility policy, it was determined the facility failed to ensure residents who entered the facility without pressure did not develop a pressure sore and residents who developed a pressure sore received necessary care and treatment for [REDACTED].#6, #7, and #1). The facility failed to ensure a system was in place to ensure their skin assessments were completed on admission and weekly per policy. In addition, there was no evidence the resident's records were monitored for completeness and accuracy related to skin assessments and wound progression. Also, the facility failed to ensure physicians were notified immediately of new pressure areas, treatments were initiated timely, and treatments were administered accurately according to the orders. The facility also failed to ensure appropriate infection control procedures were practiced during wound care. The facility failed to ensure Resident #6, who was admitted on [DATE] with a Stage I pressure ulcer, had a skin assessment on admission and weekly per policy. In addition, the facility failed to ensure treatment orders for the Stage I ulcer were followed. The first documented skin assessment was three (3) weeks after admission, on 07/22/11. The Stage I had progressed to a Stage II ulcer. Record review revealed the facility failed to notify the physician to obtain new treatment orders was for six (6) days, and on 07/28/11, observation of the skin assessment by the surveyor revealed the area was larger. The facility failed to ensure Resident #7, who was admitted with three (3) open areas, had a skin assessment on admission or weekly per policy. In addition, dressing changes were not performed as ordered and infection control procedures during the dressing change did not meet facility policy. The facility failed to ensure Resident #1 had a skin assessment on admission and weekly per policy. The first documented skin assessment revealed a Stage II pressure area. Observation and interview revealed treatment to the area was not administered as ordered. In addition, the facility failed to ensure skin assessments were completed on admission and weekly, per facility policy, for twenty-two (22) residents admitted by the facility on 07/01/11 (Sampled Residents #1, #2, #6, #7, #8, #10 and #11; and, Unsampled Residents B, F, H, I, J, K, L, M, N, O, P, Q, R, S and T). The findings include: 1. Review of the facility's policy titled Types of Isolation and PPE (Personal Protective Equipment) Required (no date), contact isolation requires healthcare personnel to "wear a gown and gloves for all interactions that may involve contact with the patient". Review of the policy titled Skin Care: Pressure Sore Prevention, dated February 2007, revealed "the Braden Scale tool, a systematic, validated risk assessment tool, will be completed within 24 hours of admission by the admitting nurse and reviewed by the Director of Nursing." Review of the policy titled Skin Care: Wound/Pressure Sore Assessment/Documentation, dated February 2007, revealed wound documentation must include size, color of tissue, stage of the wound, drainage, odor and other pertinent information. Review of the policy titled Wound/Pressure Sore Policy/Procedure, dated 12/22/09, revealed every resident was to have a weekly skin assessment performed and documented. 1. Record review revealed the facility admitted Resident #6, on 07/01/11, from another facility with [DIAGNOSES REDACTED]. Review of the Physicians' Orders from the transferring facility, dated 06/30/11, revealed Resident #6 was to be transferred to the receiving facility with continuation of all orders. Continued review revealed the following order related to excoriation on the right buttock: "Cleanse with antimicrobial cleanser, apply [MEDICATION NAME] then [MEDICATION NAME]". ([MEDICATION NAME] is an antifungal skin cream.) Review of the physician's orders [REDACTED]. (Micro-Guard Powder is an antifungal.) Review of the Treatment Administration Record (TAR) for the month of July 2011 revealed no documented evidence the treatment was administered during the month. Interview with Licensed Practical Nurse (LPN) #5 on 07/28/11 at 2:45 PM revealed she could not explain why the treatment was administered as ordered. She stated "we just used the Baza" (a moisture barrier cream). Review of the weekly skin assessment from the transferring facility, dated 06/30/11, revealed Resident #6 had a red area on the right buttock that did not blanch. The area was classified as a Stage I wound with no measurements documented. Review of the Admission MDS Assessment revealed Section M, related to pressure ulcers, was completed on 07/07/11. Continued review revealed the resident was assessed to be at risk for pressure ulcers but had no ulcers at a Stage I or higher. Continued review of the clinical record, including the Electronic Medical Record (EMR), revealed no documented evidence a skin assessment was completed on admission. Review of the Nurses' Progress Notes revealed LPN #4 made a late entry on 07/21/11 in reference to a skin assessment completed on 07/07/11. The nurse documented "no new skin issues noted". No clarification or description of the resident's actual skin condition was given. Interview with LPN #4 on 08/03/11 at 4:30 PM revealed every admission should include completion of a head-to-toe skin assessment, per facility policy. During continued interview, she explained the phrase "no new skin issues noted" meant no new areas were identified. She further stated it could mean a previously identified area remained, or no areas were present. The nurse acknowledged the comment did not give a clear picture of the actual skin condition. Review of the Skin Condition/Wound Progression note by LPN #2, dated 07/22/11, revealed Resident #1 had an open lesion on the sacrum. The area was classified as Stage II and measured 2.0 cm x 2.0 cm. Continued review revealed the nurse documented "wound was present on admission". Interview with LPN #5 on 08/05/11 at 4:45 PM revealed she had actually done the skin assessment on 07/22/11 but had documented under LPN #2's name. Review of the Nurses' Progress Notes revealed no evidence the physician was notified of the newly identified open area on 07/22/11. Review of the Physicians' Orders revealed no orders were received for treatment of [REDACTED]. Observation of the skin assessment with LPN #5, on 07/28/11 at 2:45 PM, revealed an open area to the right buttock. LPN #5 classified the area as a Stage II wound and measured it at 3.0 cm x 1.5 cm. When questioned, the nurse stated she had been made aware of the area on the weekend. She stated it was not open at that time (although her documentation on 07/22/11, a Friday, revealed it was open). She further stated she instructed the aides to use Baza cream. Continued interview revealed LPN #5 did not notify the physician. 2. Record review revealed the facility admitted Resident #7 on 07/01/11, with [DIAGNOSES REDACTED]. Review of the Wound Report completed 06/28/11, prior to the transfer, revealed Resident #7 had a Stage II pressure area to the left outer foot, 4.0 centimeters (cm) long x 2.8 cm wide by 0.8 cm deep. Review of the Wound Report, dated 06/29/11, revealed the resident had a Stage IV pressure sore on the left buttock (or ischium). The wound was measured at 6.0 cm x 7.1 cm x 4.2 cm. In addition, review of the Weekly Skin/Wound Assessment, dated 06/29/11, revealed a surgical incision was present on the right hip. Review of the Physicians' Order Sheet from the transferring facility, dated 06/30/11, revealed the resident had multiple pressure sores and treatment orders were to be continued at the receiving facility. Review of the physician's orders [REDACTED]. The orders included: cleanse left ischium open area with Dakin's Solution, then apply [MEDICATION NAME] Powder along with Santyl once daily and as needed (PRN); apply Double Antibiotic Ointment to open area on outer left foot twice daily until healed; and apply dry gauze dressing to surgical incision daily. Record review revealed no documented evidence the facility conducted a skin assessment upon admission, per policy, to record the size and condition of the wounds. Review of the Skin Condition Report-Unhealed Daily Wound Assessment, for the period 07/01 to 08/02/11 revealed the only recorded skin/wound assessment was on 07/22/11, three (3) weeks after the resident was admitted to the facility. Observation, on 07/26/11 at 4:00 PM, revealed a STOP sign on the door to Resident #7's room. Interview with Certified Nursing Assistant (CNA) #20 on, 07/26/11 at 4:15 PM, revealed the sign was to alert staff to isolation precautions for Resident #7. The aide stated the resident "has wounds". Further interview revealed gloves and gowns were to be worn when caring for the resident. Continued observation revealed a cart in the resident's bathroom contained gloves and gowns. Interview with LPN #4, on 07/26/11 at 4:15 PM, revealed Resident #7 was in contact isolation [MEDICAL CONDITION] in a wound. She stated the wound was draining and she became concerned when she learned the resident had a history of [REDACTED]. resident on Contact Isolation precautions at that time. Observation of the dressing change conducted by LPN #4, on 07/27/11, at 10:50 AM revealed the presence of three (3) open areas. Observation revealed unhealed surgical incision at the right hip was open at both ends. Both areas were draining, serous drainage at the bottom, and thick tan secretions at the top were observed. LPN #4 did not wear a gown throughout the procedure, in spite of the contact precautions instituted per facility policy. In addition, CNA #23 failed to wear a gown while assisting with turning and positioning the resident for the wound care. Observation of the Stage IV ulcer on the left buttock revealed no dressing was in place prior to the procedure. Continued observation revealed the nurse packed the wound with dry gauze, contrary to the treatment orders. Continued observation revealed after application of the dressing, and prior to removing her gloves, the nurse picked up the trash can and carried it to the other side of the bed. Further observation revealed she performed the dressing change to the left foot without changing gloves or [MEDICATION NAME] hand hygiene. Interview with LPN #4, on 07/27/11 at 11:00 AM, revealed the resident did remain under contact isolation for the history [MEDICAL CONDITION] in the right hip wound. She stated gloves and a gown should have been worn if there was a chance of contact with wound drainage. She acknowledged the hip wound was draining heavily and stated she and the aide should have worn a gown. Continued interview revealed the nurse knew she should have washed her hands and applied new gloves between wound sites. Upon further interview regarding the Stage IV ulcer, LPN #4 stated she did not know why there was not a dressing in place prior to the procedure. She further stated "it must have fell off". When questioned about her choice of dressings, she stated the order for Santyl, used for debridement, was only to be used PRN (as needed) and she did not feel debridement was indicated. Interview with NC #2 on 08/04/11 at 5:50 PM revealed the contact isolation procedure for Resident #7 indicated staff should have worn gowns during the dressing change to the draining wounds. Interview with the Wound Care Center consultant, an Advanced Registered Nurse Practitioner (ARNP), on 08//03/11 at 3:30 PM, revealed she was familiar with Resident #7. The ARNP stated contact isolation precautions were appropriate for the resident. Review of the physician's orders [REDACTED]. Continued review revealed new treatment orders were received on 08/02/11 at 3:00 PM, prior to the observed skin assessment, related to the now open area on the right great toe and the new area on the right hip. Observation of the skin assessment by Nurse Consultant #2, on 08/02/11 at 5:05 PM, revealed two (2) additional open areas had developed since the previous observed dressing changes. A new "shearing" area, measuring 0.2 cm x 0.2 cm was noted on the left hip. In addition, a "superficial Stage II" area was observed over a bunion at the base of the right great toe. Interview with Nurse Consultant (NC) #1 and NC #2, on 08/04/11 at 4:30 PM, revealed they began duties at the facility on 07/18/11 and 07/29/11, respectively. They stated they were aware skin assessments had not been done on admission. Continued interview revealed the expectation was skin assessments would be completed on admission and weekly for every resident. 3. Review of the clinical record revealed the facility admitted Resident #1 on 07/01/11, with [DIAGNOSES REDACTED]. Continued review revealed the resident was status [REDACTED]. Review of the Weekly Skin Assessment, dated 06/22/11, (done at the facility the resident was admitted from), revealed Resident #1 had no abnormal skin conditions. Review of the Nutrition Progress Note, dated 07/04/11, revealed the dietician documented Resident #1 had "no skin issues according to nursing staff". Review of the Admission Minimum Data Set (MDS) assessment revealed section M, related to pressure ulcers, was completed on 07/05/11. Continued review revealed Resident #1 was at risk for pressure ulcers but did not have any pressure ulcers at the time of the assessment. Review of the Nursing Progress Note dated 07/05/11 revealed Licensed Practical Nurse (LPN) #5 documented, "weekly skin assessment done no new issues". Review of the Care Plan, dated 07/13/11, revealed Resident #1 was at risk for developing a pressure ulcer. Interventions were directed to preventing skin breakdown, and recognizing and reporting new abnormal areas. Review of the nurse's Progress Note, dated 07/23/11, revealed LPN #4, during a skin assessment, identified an open area on the right buttock measuring 5.6 centimeters (cm) by 3.8 cm that was "currently being treated". Continued review revealed no other description or staging of the wound was documented. Continued review of the clinical record revealed no evidence a skin assessment was completed between 07/05/11 and 07/23/11 as per facility policy. Observation of the skin assessment performed by LPN #4 on 07/27/11 at 3:30 PM revealed an open area to the right buttock measuring 6.4 cm by 3.0 cm. Interview at that time revealed the nurse was not sure if the area was present on admission to the facility. Continued interview revealed the area was being treated with Baza cream, as ordered by the physician. Further observation revealed there did not appear to be any treatment present to the wound. The nurse stated the cream had not been applied that day because she hadn't got to it yet. Interview with Nurse Consultant #1, on 08/04/11 at 4:30 PM revealed the facility admitted twenty-two (22) residents on 07/01/11. She stated she was contracted by the facility on 07/18/11 and recognized right away that admission procedures, including skin assessments, were not completed on any of the twenty-two (22) residents. 6. Record review revealed the facility admitted Unsampled Resident B on 07/01/11, with [DIAGNOSES REDACTED]. Review of the resident's admitting Physician order [REDACTED]. Continued record review revealed no skin assessment was completed upon admission to the facility. There was no documented evidence the above skin related interventions/orders were put into place until 07/21/11.

Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to ensure the Comprehensive Plans of Care were revised for two (2) of eighteen (18) sampled residents (Resident #13 and Resident #14). Resident #14 self transferred and fell on [DATE], sustaining a laceration requiring sutures above the left eye, a Hip Pinning Fracture Left Hip, and Left Radius and Ulna Fracture. A fall prevention alarm did not alert staff that the resident was up at the time of the fall. The resident's Plan of Care included bed and chair tab alarms to help prevent falls; however, interviews with staff revealed the resident was removing the tab alarms. The facility failed to revise the Plan of Care and implement new interventions prior to the fall. Also, upon re-admit to the facility after hospitalization for sutures above the left eye brow, a Hip Pinning Fracture Left Hip, and Left Radius and Ulna Fracture the facility failed to update the Plan of Care with additional interventions to prevent further falls. Resident #13 had multiple falls (on 07/13/11, 0716/11, 07/17/11 and 07/25/11) and the Comprehensive Plan of Care was not revised and updated with information or interventions related to each of these fall incidents. The findings include: Review of the facility's policy titled "FALLS" (undated) revealed if the resident experiences a fall the resident's care plan is revised and updated with information related to the fall incident within 24 hours. Interview, on 08/05/11 at 4:20 PM with Registered Nurse (RN) #5 (Nurse Consultant #2), revealed after each fall staff should investigate the cause and the care plan should be revised with interventions to prevent the cause of the fall 1. (Refer to F323) Record review revealed the facility admitted Resident #14 on 07/12/11, with [DIAGNOSES REDACTED]. Record review revealed the facility initiated a Plan of Care, dated 07/12/11, which identified falls as a problem and had fall prevention interventions which included bed and chair alarms, call light within reach at all times, refer to therapies, frequent visual observations and toileting. Review of Resident #14's Treatment Administration Record (TAR) revealed each shift staff was to document they had checked to ensure alarms were in place. Further review of the TAR revealed there was no documentation on 07/18/11 by the nurses on day/evening/night to indicate alarm placement had been checked and by the day shift nurse on 07/19/11. Interview, on 07/28/11 at 11:50 AM and 2:50 PM, with Certified Nursing Assistant (CNA) #10 revealed she has provided care to the resident and the aides were responsible for checking to make sure residents' fall prevention alarms were in place. She further revealed Resident #14 would sometimes remove his/her alarms and get up by himself/herself. However, she had not informed the nurses the resident could take off the alarms. Interview, on 07/28/11 at 12:10 PM and at 3:15 PM, with CNA #17 revealed the resident would take off his/her alarms at times and she had observed Resident #14 up ambulating by himself/herself. However, she could not remember if she had notified the nurse regarding the resident's ability to take off the alarm. While the facility staff was knowledgeable of the resident's noncompliance history with the alarms, there was no evidence that the facility had revised the care plan to implement new interventions to prevent falls. Review of the facility's 07/19/11 Incident Report (incident time 1:00 PM) revealed Resident#14 fell in the bathroom and was found sitting up on the floor with her/his walker against the wall. Record review revealed the resident was later transferred to the hospital for evaluation of mental status change and pain to his/her left wrist and leg. Interview on 07/27/11 at 3:30 PM with Registered Nurse (RN) #6, revealed she entered Resident #14's room to administer medication and found the resident on the bathroom floor with a cut above her/his left eye. RN #6 stated she did not hear an alarm sounding and could not remember if the resident had an alarm device on when she had found the resident. Interview, on 07/28/11 at 9:50 AM, with Certified Nursing Assistant (CNA) #6 revealed she had taken the resident to the toilet that morning before the fall and helped RN #6 with the resident after the fall. She stated she did not think the resident had alarms in place at that time or when she provided care earlier that day. Record review revealed the facility readmitted Resident #14 on 07/25/11 and the physician's orders [REDACTED]. There was no documented evidence the facility identified that either the alarm was not functioning, not in place or the resident may have removed the alarm. Review of the care plan after the incident revealed there was no documented evidence the facility had developed or implemented new interventions to prevent fall recurrence. Furthermore, interview with Nurse Consultant #1 on 07/27/11 at 5:30 PM, revealed the nurses could not access the care plans to refer to them or to revise them. 2. (Refer to F323) Record review revealed the facility admitted Resident #13 on 06/03/11, with [DIAGNOSES REDACTED]. Review of the care plan, dated 06/08/11, revealed the resident was care planned for being at risk for falls due to fall history, incontinence, needing assistant with activities of daily living, and taking [MEDICAL CONDITION] medications. The fall care plan interventions included chair and bed fall prevention alarms, ambulate with 1-2 person assistance, encourage resident to ask for assistance, keep room free of clutter, and monitor side effects of medication. Review of the Minimum Data Set (MDS) Assessment, dated 06/10/11, revealed the resident had a fall prior to admission and was assessed as being cognitively impaired. Review of the Care Area Assessment Summary, dated 06/10/11, identified falls as a care area trigger. Review, of the 07/13/11, Incident Report (incident time 10:00 AM) revealed Resident #13 fell trying to get to the bathroom. Further documentation noted the resident was not injured and did not have an alarm. There was no evidence the facility updated the resident's care plan with information/interventions after the fall on 07/13/11. Review, of the 07/16/11 Incident Report (incident time 7:30 PM), revealed Resident #13 was found on the floor on 07/16/11 at 7:30 PM in front of his/her wheelchair. The report documented the resident stated when attempting to get clothing from the bottom drawer, his/her wheelchair rolled backward and he/she fell . The document noted there was no injury and the corrective measures listed included the resident was instructed to call for help if items were out of reach. There was no evidence the facility updated the resident's care plan with information/interventions after the fall on 07/16/11. Review of the 07/17/11 Incident Report (incident time 10:45 PM) revealed Resident #13 was found sitting on the floor beside his/her bed and reported he/she said they needed to use the restroom and when attempting to ambulate tried to lean onto his/her wheelchair, but the wheels were not locked and it rolled away causing a loss of balance. The document noted there was no injury and the corrective measures listed included instructing the resident to call when ambulation was needed and the morning shift may wish to call the physician to order a bed alarm. There was no evidence the facility updated the resident's care plan with information/interventions after the fall on 07/17/11. Review, of the 07/25/11 Incident Report (incident time 7:30 PM), revealed Resident #13 stated he/she was going to the recliner from the wheelchair and lost his/her balance. The nurse noted that an alarm had been ordered. There was no documentation of injury. There was no evidence the facility updated the resident's care plan with information/interventions after the fall on 07/25/11. Interview, on 08/05/11 at 11:40 AM, with Licensed Practical Nurse (LPN#3), who completed the incident reports for Resident #13's falls on 07/16/11 and 07/17/11, revealed she had not been trained on the Facility's Falls Policy and what was expected after a resident's fall. Interview, on 08/03/11 at 5:05 PM with RN #3 (Nurse Consultant #1), revealed at this time she was one of the persons responsible for ensuring preventive interventions listed on incident reports were put in place. Further interview with RN #3 revealed, at this time, the care plans were not being updated, by staff, with interventions.

Based on observation, interview, and record review it was determined the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for one (1) of nine (9) sampled residents (Resident #10). Resident #10 was observed to be in the wheelchair without the chair alarm as per physician's orders [REDACTED]. In addition, the facility failed to ensure the residents environment remains as free of accident hazards as is possible. Observation of initial tour on 11/01/11 revealed the "Lost and Found" Room had a housekeeping cart stored which contained chemicals accessible to residents. The findings include: 1. Review of Resident #10's medical record revealed [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident as moderately impaired in cognitive skills for decision making and as sustaining two (2) falls without injury. Review of the physician's orders [REDACTED]. Observation, on 11/03/11 at 11:00 AM, revealed the resident was sitting in a wheelchair in the dining room area and there was no evidence of a chair alarm on the wheelchair. Interview with Certified Nursing Assistant (CNA) #19 at that time verified there was no alarm on the wheelchair. CNA #19 stated the resident had been sitting in the geri-chair recently and the alarm probably did not get moved to the wheelchair. CNA #19 further stated that CNA #20 was assigned to the resident. Interview, on 11/03/11 at 11:30 AM, with CNA #20 revealed he was assigned to Resident #10. He stated he was newly hired at the facility and had been there about six (6) days and this was his first day taking an assignment of residents alone. He stated he checked the Nurse Aide Care Plans at the beginning of the shift; however, had no reference in the resident rooms and no reference to carry with him in order to check which devices the residents needed. He stated it was hard to remember all the devices needed and all care needed for the resident as he was not familiar with the residents yet. Interview, on 11/03/11 at 2:00 PM, with Licensed Practical Nurse (LPN) #3 who was assigned to Resident #10 revealed the resident was assisted to bed daily after breakfast and the alarm may not have been placed back on the wheelchair when she/he was assisted to the wheelchair for lunch. Further interview revealed the nurses were to check for safety devices such as alarms and sign it off on the Medication Administration Record (MAR) indicating the devices were in place. 2. Observation during initial tour. on 11/01/11 at 2:15 PM, revealed the "Lost and Found" Room was unlocked and there was a housekeeping cart in the room which was unlocked containing chemicals accessible to residents. The chemicals included Diversy Glass Cleaner, Orange Glo Wood Furniture Polish, Virex, and Blue Bowl Cleaner Diamond Solution. Review of the Material Safety Data Sheet (MSDS) for Diversy Glass Cleaner revealed instructions to keep away from eyes and rinse eyes with plenty of water if eye contact. Review of the MSDS for the Orange Glo Wood Furniture Polish revealed; if ingested, seek immediate medical attention, avoid breathing vapors, avoid skin and eye contact and keep out of the reach of children. If ingested, do not induce vomiting, call a physician immediately. If inhaled, remove to fresh air and if breathing is irregular or had stopped, administer oxygen an call a physician immediately. Review of the MSDS for Virex revealed; Danger, corrosive, causes skin and eye burns, harmful or fatal if swallowed, combustible liquid and vapor. Review of the MSDS for the Diamond Solution Blue Bowl Cleaner revealed; danger, corrosive, causes skin and eye burns, may be fatal if swallowed. Avoid breathing vapors, use only in well ventilated areas. Interview, on 11/01/11 at 2:30 PM, with the housekeeper revealed she had parked the housekeeping cart in the "Lost and Found" Room just for a few minutes. She stated she normally put the housekeeping cart in the locked storage closet. Interview, on 11/01/11 at 2:35 PM, with the Director of Nursing revealed the "Lost and Found" Room did not need to be locked; however, the housekeeping cart should not have been left in there with chemicals accessible to residents.

Based on observation, interview and record review, it was determined the facility failed to ensure an effective program was in place to provide maintenance and restorative programs that would not only maintain, but improve, the residents' abilities for three (3) of eighteen (18) sampled residents (Resident #10, #6, and #7) and ten (10) unsampled residents(Unsampled Resident T, J, K, L, M, N, O, P, Q, and R). Interview with the Administrator, the Interim Director of Nursing, and Nurse Consultant #1 and #2, revealed twenty-two (22) residents were admitted from another facility on 07/01/11. Continued interview revealed the systems which were in place prior to 07/01/11 had failed, including the restorative nursing program. Resident #10 was receiving restorative ambulation and was able to ambulate fifteen (15) feet to one hundred (100) feet, and was receiving Active Range of Motion (AROM) to the upper and lower extremities in 06/11 prior to admission to the facility on [DATE]. However, there was no documented evidence the resident received restorative ambulation and range of motion (ROM) after admission to the facility on [DATE]. Resident #10 sustained a decline in functional ability as evidenced by decreased ROM in the left knee and the inability to ambulate. Resident #6 was to receive passive range of motion (PROM) to all extremities for ten (10) minutes, three (3) times per day, seven (7) days per week. However, there was no documented evidence the ROM was performed. Resident #7 was to receive PROM to the neck for five (5) minutes every day; AROM to the extremities, ten (10) to fifteen (15) repetitions, daily Monday through Friday; and PROM to bilateral knees, ten (10) repetitions, twice daily Monday through Friday. However, there was no documented evidence the range of motion was performed. Unsampled Resident T was to receive AROM, alternating upper and lower extremities, fifteen (15) minutes daily; PROM to the left ankle, ten (10) repetitions daily; and ambulate seventy-five (75) feet or more daily. However, there was no documented evidence the range of motion and ambulation was performed. In addition, Unsampled Residents J, K, L, M, N, O, P, Q, and R revealed each were to receive PROM, AROM and/or ambulation. However, there was no documented evidence the ROM and/or ambulation was performed. The findings include: Review of the facility's policy "Restorative Nursing Policy", undated, revealed all residents admitted would be screened for their physical, mental and psychosocial abilities. Further review revealed if the resident was not placed in a skilled therapy program and appeared to require assistance with range of motion (ROM) to prevent further contractures, ambulation to prevent a further decline in mobility or assistance in other areas, the resident would be evaluated and placed into a restorative program appropriate to meet their needs. The policy further stated, it would be the admitting nurse's responsibility to notify the appropriate disciplines for referrals to restorative. 1. Review of the clinical record revealed the facility admitted Resident #10 on 07/01/11 with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].#10 was to receive restorative ambulation seven (7) days a week, days and evening, with instructions to document the number of feet and use a gait belt and walker. Continued Further review revealed orders for (AROM) to upper and lower extremities each day in the evening with instructions to alternate upper and lower extremities for fifteen (15) minutes for ten (10) repetitions. The orders further stated, transfer to receiving facility with continuation of all current orders. Review of the Restorative Service Delivery Record from the previous facility dated 06/11 revealed the resident was receiving AROM to all extremities for fifteen (15) repetitions to the upper and lower extremities in the evenings through 06/30/11. Further review revealed the resident received ambulation fifteen (15) days in 06/11, with the amount of feet ambulated ranging from fifteen (15) feet to one hundred (100) feet. Interview, on 08/02/11 at 2:00 PM, with the Restorative Registered Nurse (RN) from the previous facility, revealed the staff was ambulating the resident prior to discharge. Further review of the Clinical Record revealed the facility, upon admission of the resident, initiated their own physician's orders [REDACTED]. However, continued review revealed none of the ancillary orders, including the ordered restorative ambulation and ROM, had been carried over from the previous orders and initiated at the facility. Interview, on 08/02/11 at 5:00 PM, with Licensed Practical Nurse (LPN) #8 revealed there were twenty-two (22) residents who were admitted from another facility on 07/01/11. She stated she had admitted Resident #10 and five (5) other residents on 07/01/11. Continued interview revealed the previous facility's physician's orders [REDACTED]. [REDACTED]. Review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed the facility had assessed the resident as having severe impairment in cognitive skills for daily decision making. Further review revealed the facility had assessed the resident as requiring extensive assistance with transfers and ambulation and as having no limits in ROM. Review of the Care Area Assessment Summary (CAAS) dated 07/26/11 revealed the resident required extensive assist of one staff for ambulating, was unsteady, and had balance issues. Further review revealed the residents [DIAGNOSES REDACTED]. Further review revealed there was no Comprehensive Plan of Care to review related to areas triggered from the Admission MDS. Observation of a skin assessment, on 07/27/11 at 11:45 AM, revealed two (2) staff stood the resident up from the chair with difficulty due to the resident not fully bearing weight. The staff was observed holding the resident under the arms to assist the resident to stand. Interview, on 07/27/11 at 10:30 AM, with Certified Nursing Assistant (CNA) #8, who was assigned to Resident #10, revealed she had been at the facility for three weeks and had received one (1) day in the classroom for orientation and one (1) day working on the floor with another CNA. She stated there was no reference guide for the CNA's to use related to how to provide specific care for the residents and she was unaware of any residents receiving restorative nursing. Continued interview revealed if the CNA's had a question related to a resident's care, they were to ask a nurse or another CNA. She further stated the aides did not provide range of motion or ambulation for Resident #10. She stated the resident was transferred with two staff members and a gait belt. Interview, on 07/27/11 at 3:00 PM, with CNA #20, who was assigned to Resident #10, revealed she was hired on 07/16/11. She stated she received a day of classroom orientation and worked with another aide the first week. She stated there was no nurse aide care plan to refer to and she had to remember all the care the resident was to receive. She further stated the resident was transferred with two assist and a gait belt. She stated there was no restorative program at the facility and she did not perform range of motion on the residents. Interview, on 07/27/11 at 4:25 PM, with Licensed Practical Nurse (LPN) #4, who was consistently assigned to the resident, revealed there was no reference for the aides to use to provide care and the aides had to ask questions if needed related to care provided. She further stated the aides and nurses did not provide range of motion and there was no restorative nursing program in place. Interview, on 08/05/11 at 2:15 PM, with Physical Therapist (PT) #1 and the Occupational Therapist/Director of Therapy revealed they had evaluated the resident after surveyor questioning on 08/02/11. They stated the resident had decreased range of motion in the left knee and decreased strength in the legs. Further interview revealed the resident was unable to ambulate and would benefit from physical therapy. Further interview revealed they were aware there would be approximately twenty-two (22) residents moved on 07/01/11 from another nursing home and they had gone to the other facility before the move to obtain a list of residents who were in PT at the time of transfer, however did not get a list of residents who were receiving restorative nursing. Further interview revealed prior to 07/01/11, there were restorative aides, however now the CNA's on the floor were expected to do restorative. Further interview revealed when the residents were discharged from PT, the CNA's received instruction related to the restorative program needed and the DON received a copy of the Restorative Form stating the instructions for the residents restorative program. Further interview revealed the resident had received Speech Therapy and Occupational Therapy at the facility since admission; however, had not received Physical Therapy Further interview on 08/05/11 at 4:30 PM with Physical Therapist #2 revealed as far as she knew, they had screened all residents who were admitted on [DATE] the first week of admission. She further stated, they planned to perform physical therapy on those residents who were previously receiving restorative nursing prior to admission until the restorative nursing program was in place. The surveyor asked for documented evidence Resident #10 was screened on admission; however, the information was not provided. Review of the Physical Therapy Evaluation, with an onset date of 08/03/11, revealed the resident recently moved to this facility from another nursing home and had a documented decline in physical abilities in the restorative record indicating the need for a physical therapy evaluation. Further review revealed the resident would benefit from skilled physical therapy intervention to address functional deficits and reach maximin functional independence. The goals included; sit to stand with minimum assist, ambulate five (5) feet with rolling walker, improved range of motion in the left knee, and develop and instruct patient/caregiver restorative program. Interview, on 08/04/11 at 1:00 PM, with the Attending Physician revealed all the orders from the previous facility were to have been carried over on 07/01/11 when the residents were admitted to the facility. He stated he was unaware the resident was not receiving restorative nursing and unaware there was a decline in her physical functioning. Further interview revealed he was not notified on 07/01/11 when the resident was admitted to verify the physician's orders [REDACTED]. 2. Record review revealed the facility admitted Resident #6 on 07/01/11 with [DIAGNOSES REDACTED]. Continued review revealed the resident was admitted from another facility with physician's orders [REDACTED]. Review of the physician's orders [REDACTED]. Continued review revealed Resident #6 had an order to receive passive range of motion to all extremities for ten (10) minutes, three (3) times per day, seven (7) days per week. Further review of the Clinical Record revealed the facility, upon admission of the resident, initiated their own physician's orders [REDACTED]. However, continued review revealed none of the ancillary orders, including the order for range of motion, had been initiated at the new facility. Record review revealed no evidence Resident #6 had received restorative services since admission to the facility. 3. Record review revealed the facility admitted Resident #7 on 07/01/11 with [DIAGNOSES REDACTED]. Continued review revealed the resident arrived from another facility with orders, including the following: Transfer to receiving facility with all current orders; Passive range of motion to neck for five (5) minutes every day; Active range of motion to extremities, ten (10) to fifteen (15) repetitions, daily Monday through Friday; and Passive range of motion to bilateral knees, ten (10) repetitions, twice daily Monday through Friday. Review of the physician's orders [REDACTED]. However, ancillary orders, including the orders related to range of motion, were not continued after transfer. Record review revealed no documented evidence Resident #7 had received the ROM as ordered since admission to the facility. 4. Review of the Physicians Order Sheet dated 06/30/11 for Unsampled Resident T revealed orders included the following: Transfer to receiving facility with all current orders; Active range of motion, alternating upper and lower extremities, fifteen (15) minutes daily; Passive range of motion to left ankle, ten (10) repetitions daily; and ambulate seventy-five (75) feet or more daily. Review of the active physician's orders [REDACTED]. Continued review of transfer orders, dated 06/30/11, for Unsampled Residents J, K, L, M, N, O, P, Q, and R revealed each had an order to transfer to the receiving facility with current orders. Continued review revealed orders for passive range of motion, active range of motion and/or ambulation were included. Review of the July 2011 physician's orders [REDACTED]. However, no ancillary orders, including the for range of motion and ambulation orders were carried over. Interview, on 08/04/11 at 4:30 PM, with the Interim DON, Nurse Consultant #1 and #2, revealed they were not sure if the Physicians were called to verify physician's orders [REDACTED]. Further interview revealed they had noted the ancillary orders including restorative nursing from the previous facility's physician's orders [REDACTED]. Continued interview revealed they had began to investigate the restorative program and were aware there was no range of motion or restorative nursing documented or being provided. Interview, on 08/05/11 at 5:20 PM, with the Interim Administrator revealed the residents from the old facility building and twenty-two (22) residents from another facility were moved into the new facility building on 07/01/11. He stated the previous DON did not return after 07/15/11, and the previous Assistant DON had left shortly afterward. He stated he brought in consultant nurses after noting there were system problems. Continued interview revealed the systems which were in place prior to 07/01/11 were to continue after the move to the new building; however, with the increase in resident census, new building, new staff and inadequate training, and lack of direction from the Administrative Nurses, the systems were not being utilized. He stated he was aware there were problems with the residents not receiving restorative nursing.

Based on observation, interview, record review, and review of the facility's policies it was determined the facility failed to ensure each resident received adequate supervision and monitoring to prevent accidents for three (3) of eighteen (18) sampled residents (Resident #14, #13 and #10). The facility failed to ensure staff was knowledgeable and trained regarding the facility's Fall's Policy and Risk Assessment Policy. The facility failed to ensure these policies were implemented. Resident #14 self transferred without staff assistance and fell on [DATE], sustaining a cut above the left eye (required sutures), a Hip Pinning Fracture Left Hip and Left Radius and Ulna Fracture. The facility failed to ensure systems for checking assistive devices were implemented. The facility failed to notify the physican at the time of the incident. The facility's investigation of the incident failed to identify that staff failed to communicate their knowledge that Resident #14 was able to remove alarming devices and would attempt to rise and ambulate without assistance. This failure prevented the facility from revising the care plan interventions to prevent falls. Resident #13 had multiple falls; however, the facility failed to evaluate and analyze the causative factors and implement interventions to prevent falls. In addition, the facility failed to ensure the Physician and responsible parties were notified of the falls as per facility policy. The facility failed to complete the Falls Risk Assessment timely, per the facility policy for Resident #10. Additionally, while the facility identified the resident at high risk for falls, the facility failed to develop a care plan to address the risk and failed to follow physician orders [REDACTED]. Additionally, the facility failed to conduct assessments for sixteen (16) residents who were admitted on [DATE] for falls risk as per facility policy (Residents #1,#6, #7, #8, #10, #11 and Unsampled Residents B, F, H, I, J, K, M, O, P, Q, R, and T). This failure to assess for fall risk of each resident resulted in the facility's failure to develop and implement safety measures through the care planning process in order to ensure an environment as free of accidental hazards as is possible for the residents. In addition, the facility failed to ensure a safe environment as evidenced by observation of the electrical room, soiled utility rooms and laundry room with unlocked doors or doors which were propped open, leaving access to harmful chemicals and electrical equipment. The findings include: Review of the facility's Falls policy, undated, revealed a Fall Assessment was to be completed on admission to assess the resident for fall related factors, a Plan of Care would be developed to address issues that could contribute to the risk for falls, and precautions related to the resident would be placed on the Nursing Assistant's Care Plans. Further review revealed the Physician and family should be notified after a fall, the resident's Care Plan should be revised and updated with information related to the fall incident within 24 hours, and a Post Fall Assessment was to be completed by the designated personnel completing the follow up/investigation. Telephone Interview, on 08/04/11 at 10:45 AM, with the previous DON, who worked at the facility until 07/15/11, revealed residents were to be assessed for fall risks on admission. She stated, if the admission nurse determined a fall alarm device would be appropriate, the nurse was to call the Physician and request an order. Further interview revealed the nurse would be expected to transcribe the monitoring of the alarms on the TAR which would include checking both the placement and function each shift. She further stated the nurses were to check each shift to ensure the alarms were in place and functional, and to sign the TAR to indicate this was done. She stated the nurses were trained on this process. Review of the policy titled Risk Assessments in the Electronic Medical Record (EMR), undated, revealed the fall risk assessment was to be completed upon admission by the charge nurse. Interview, on 08/05/11 at 4:20 PM, with Nurse Consultant #2 regarding the facility's fall policy, revealed staff should be aware they were to notify the Physician and the responsible party after each fall. She further stated, staff should investigate the cause of each fall and revise the Plan of Care with interventions to prevent further falls. 1. Record review revealed the facility admitted Resident #14 on 07/12/11 with [DIAGNOSES REDACTED]. Interview, on 08/04/11 at 1:20 PM, with RN #4 revealed she had admitted Resident #14 on 07/12/11 to the facility. She stated the resident was identified to be a fall risk on admission because he/she recently had Pneumonia and appeared to be weak. She further stated the previous Director of Nursing (DON) had also informed her the resident had a history of [REDACTED]. She further revealed she documented on the Treatment Administration Record (TAR) to check placement each shift. She stated, she informed the CNAs the resident would need assistance with transfers, but did not know if it was included on the care plan. Review of the resident's Plan of Care, dated 07/12/11, identified the facility developed a fall's prevention care plan detailing the following interventions: alarm to bed and chair, call light within reach, refer to therapies, frequent visual observation and toileting. Review of Resident #14's Treatment Administration Record (TAR) revealed the facility staff was to check to ensure alarms were in place each shift. TAR review revealed there was no documentation by the nurses on days/evenings/nights to indicate the alarm placement had been checked on 07/18/11 and by the day shift nurse on 07/19/11 for Resident #14. Review of the Nurse's Notes and the facility's Incident Report, dated 07/19/11, revealed at 1:00 PM the nurse found Resident #14 sitting up on the floor in the bathroom after falling with her/his walker against the wall. The resident was assessed to have a cut above the left eye. Interview, on 07/27/11 at 3:30 PM, with Registered Nurse (RN) #6 revealed she entered Resident #14's room on 07/19/11 to administer medication and found the resident on the bathroom floor with a cut above her/his left eye. She further stated she obtained vital signs and assessed the resident's extremities before transferring her/him to a chair. RN #6 stated she did not hear any alarm when she found the resident on the floor and could not remember if the resident had an alarm device on. She stated she had not checked for alarm placement during her shift because she was told the Certified Nursing Assistants (CNAs) were responsible for checking placement and documenting this in the TAR. Continued interview revealed she did not notify the Physician immediately after the fall because she did not note any change in the resident's condition, except for the cut above the eye. Interview, on 07/28/11 at 9:50 AM, with Certified Nursing Assistant (CNA) #6 revealed she took care of Resident #14 on 07/19/11. She stated, after being notified of the fall by RN #6, she helped assist the resident to the chair. She stated she did not think the resident had alarms in place at that time or when she provided care earlier that day. She had taken the resident to the toilet that morning. Further interview revealed she was not very familiar with the resident because she did not usually work on that hall. She further stated it was the CNA's responsibility to check alarm placement. Continued interview with RN #6 revealed the resident later complained of pain to her/his left wrist; however, she again did not notify the Physician because there was no swelling to the wrist noted. Interview, on 07/27/11 at 4:07 PM, with RN #1 revealed she observed Resident #14 at about 3:00 PM and said he/she seemed confused, complained about his/her left wrist hurting, and complained of leg pain. She stated she sent the resident out to the hospital about 4:00 PM because of concerns about a possible brain injury and complaints of wrist and leg pain. Further interview revealed she did not know why the day shift nurse had not already sent the resident out to the emergency room . She stated, after a fall the nurses were to notify the Physician right away. Further review of the Nurse's Notes and the incident report, dated 07/19/11, the facility notified the Physician at 3:00 PM (2 hours after the fall with injury) and transferred Resident #14 to a local hospital at 4:00 PM per ambulance due to mental status change and complaints of left wrist and left leg pain. Review of the physician's orders [REDACTED].#14 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. There was no documented evidence that the facility had identified through their investigation whether the alarm was alarming, malfunctioning at the time of the fall, or had been removed by the resident. However, interview on 07/28/11 at 11:50 AM and 2:50 PM, with CNA #10 assigned to the resident's unit, revealed Resident #14 was capable of taking off his/her alarms and would sometimes remove them and get up by himself/herself; however, she had not informed the nurses the resident could take off the alarms. Interview, on 07/28/11 at 12:10 PM and at 3:15 PM, with CNA #17 revealed the resident would take off his/her alarms at times and she had observed Resident #14 up ambulating by himself/herself. She stated she would remind the resident he/she needed to use the call light and the resident would say he/she could get up by himself/herself. However, she could not remember if she had notified the nurse of the resident taking off the alarm. However continued interview with RN#6 revealed she was not aware that Resident #14 was removing his/her alarms. While staff interviews revealed that several staff was aware of Resident #14's ability to remove the alarm used to alert staff to provide assistance with ambulation to prevent fall, there was no documented evidence on the care plan that the facility had revised the care plan to reflect new interventions to address the resident's ability to remove the alarm. Furthermore interview, on 08/04/11 at 1:20 PM, with RN #4 revealed she did not detail on the TAR that staff was to check the functioning of the alarms because she assumed the staff would check to ensure the alarm was functioning when placement was checked. Further interview revealed she should have included to check function of the alarms on the TAR. Further interview with RN #6 revealed the nurse had not reviewed or been trained on the facility's Falls Policy nor was she aware of the residents Care Plan on fall precautions. Interview, on 07/27/11 at 5;30 PM, with Nurse Consultant #1, who was hired on 07/18/11 and was working in an administrative role, revealed when she came to the facility the Care Plans were not accessible to the nurses and the nurses still could not access the Care Plans to refer to them or revise them. 2. Record review revealed the facility admitted Resident #13 on 06/03/11 with [DIAGNOSES REDACTED]. Review of the Comprehensive Plan of Care, dated 06/08/11, revealed the facility identified the resident was at risk for falls related to a history of falls, incontinence, needing assistance with Activities of Daily Living (ADL's), and receiving psychotropic medications. The interventions included both chair and bed fall prevention alarms. Review of the Minimum Data Set (MDS) Assessment, dated 06/10/11, revealed the facility assessed the resident as having severe impairment in cognitive status for daily decision making, and required extensive assistance with transferring, toilet use, and locomotion. Further review revealed the facility assessed the resident as having a fall prior to admission. A Care Area Assessment Summary was requested; however, only the trigger sheet was provided which revealed the resident triggered for falls. Review of the Incident Report, dated 07/13/11 and incident time 10:00 AM, revealed the resident fell while trying to get to the bathroom and did not have an alarm in place. The Power of Attorney was notified; however, there was no documented evidence detailing that the facility notified the Physician. No injury was identified on the Report. There was no documented evidence the facility had revised the Plan of Care with new interventions to prevent further falls. Review of the Incident Report, dated 07/16/11 and incident time 7:30 PM, revealed the resident was found on the floor in front of their wheelchair. According to the Report the resident fell when attempting to get clothing from the bottom drawer when his/her chair rolled backward. The corrective measures documented on the incident report revealed the resident was instructed to call for help if items were out of reach. Review of the report notification section revealed there was no documented evidence that the facility notified the family or Physician of the incident. Further review revealed the Incident Report did not indicate if the alarm was in place and/or alarming at the time of the fall. The report indicated there was no injury. Furthermore, there was no documented evidence the Plan of Care was revised with new interventions to prevent further falls after this incident. Review of the Incident Report, dated 07/17/11 and incident time 10:45 PM, revealed the resident was found sitting on the floor beside his/her bed. According to the Report the resident stated he/she attempted to ambulate to the restroom and when trying to lean onto his/her wheelchair the wheels were not locked and the chair rolled away causing a loss of balance. The corrective measures documented included instructing the resident to call when ambulation was needed. The report stated there was no injury and the nurse on the morning shift may wish to call the MD to order a bed alarm. There was no documented evidence the Plan of Care was revised with interventions to prevent further falls after this incident and no documented evidence the facility notified the Physician of the fall. The Incident Report, dated 07/25/11 and incident time 7:30 PM, documented the resident was found on the floor next to the recliner and stated she/he was transferring to the recliner from the wheelchair and lost her/his balance. The nurse documented on the Report, an alarm had been ordered. Continued review, revealed there was no injury and the Power of Attorney was notified. However, there was no documented evidence the facility notified the Physician. Additionally, there was no documented evidence the Plan of Care was revised with new interventions to prevent further fall recurrence after the incident. Observations of Resident #13, on 07/28/11 at 8:50 AM, revealed the resident was in their wheelchair in the dining room with no fall alarm observed. On 07/28/11 at 10:40 AM, the resident was observed sitting in a straight stuffed chair in her/his room; however, there was no fall alarm attached to the resident. On 07/29/11 at 1:00 PM the resident was observed in their room sitting in a straight stuffed chair and no fall alarm was present. Observation of the resident with CNA #17, on 07/28/11 at 10:40 AM, revealed the resident was seated in a straight stuffed chair and the CNA verified no fall alarm was in place. Interview with RN #1 on 07/27/11 at 6:00 PM who was assigned to the resident on the dates of the falls on 07/13/11 and 07/25/11, revealed the resident was very stubborn and tried to get up without help. She reported the resident did have a tab alarm at one time; however, would take the alarm off. Further interview revealed she did not know if the resident was care planned for alarms because she did not review the Care Plans and she was not familiar with this residents fall interventions. She stated she used the resident's Treatment Administration Record (TAR) as a reference to provide care. RN #1 further stated she ordered an alarm after the fall on 07/25/11; however, there was no documented evidence of a physician's orders [REDACTED]. Interview, on 08/05/11 at 11:40 AM, with LPN #3, who completed incident reports for Resident #13's falls on 07/16/11 and 07/17/11, revealed she had not been trained on the facility's Falls Policy and what was expected after a resident's fall. Further interview revealed she did not notify anyone regarding the falls and was told she only was supposed to notify the Physician or a family member if they observe an injury with a fall. She did not talk to any supervisor about the fall because she thought they would be aware of the fall through reporting the incident in the computer system. Interview with Nurse Consultant #1, on 07/28/11 at 10:15 AM, regarding the determination of fall prevention interventions after fall events revealed she got together with the nurses involved to come up with interventions to try to prevent further falls. When asked about what interventions were identified after Resident #13's fall on 07/25/11, she revealed there should be orders for an alarm and the resident should have an alarm put in place. Further interview, on 08/03/11 at 5:05 PM, with Nurse Consultant #1 regarding who was responsible for monitoring the follow-up interventions for incidents, revealed she was one of the persons responsible for ensuring follow-up interventions listed on incident reports were performed. When questioned about the fall prevention alarm for Resident #13, which was identified as an intervention after the 07/25/11 fall, she stated it should have been in place; however, after she had talked to staff they informed her the resident refused to use an alarm. Further interview revealed she had not spoken to the resident regarding the alarms. Further interview revealed she had verbally told staff to check on the resident more frequently, every hour, but did not remember what staff she spoke to and she had not followed up to see if this was being done. She also stated they did not have care plans in place for staff to update. 3. Review of Resident #11's medical record revealed the facility admitted the resident on 07/01/11 with [DIAGNOSES REDACTED]. The facility was unable to provide documented evidence that they had completed a Falls Risk Assessment or an Admission Plan of Care. Review of the Admission Minimum Data Set (MDS) Assessment, which was not completed until 07/26/11 (Refer to F-273), revealed the facility assessed the resident as oriented, and as requiring extensive assistance with transfers and ambulation in the room. Review of the Care Area Assessment Summary (CAAS), dated 07/26/11, revealed indicators of fall risk for this resident included impaired balance, pain, incontinence, [DIAGNOSES REDACTED], and Arthritis. Further review revealed the resident was nonambulatory, a hoyer lift was used for transfers, and the resident received Ativan (anti-anxiety medication), Lexapro (anti-depressant medication), and Ambien (Hypnotic medication) which placed the resident at a higher risk for falls. Further review revealed the CAAS triggered for falls. Review of the Comprehensive Plan of Care, dated 07/26/11, revealed the risk for falls was not an identified concern and no interventions were in place for the prevention of falls. Observation, on 07/27/11 at 12:00 PM, revealed Resident #11 was up in their wheelchair with a chair alarm in place. Further observation revealed the resident's bed had a bed alarm. However record review of the Plan of Care on 07/27/11 revealed no evidence the facility had developed a plan at that time. Record review revealed the facility had developed and implemented a Plan of Care to address falls on 08/01/11 which revealed the resident was at risk for falls due to impaired mobility and poor safety awareness related to cognitive deficit. The interventions included a chair and bed alarm, and staff to assist with transfers; however, there was no specific intervention for transfer technique. 4. Review of Resident #10's medical record revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review revealed no documented evidence the facility had completed a Falls Assessment or Falls Risk Assessment upon admission or had developed and implemented an Admission Plan of Care. Review of the Comprehensive Care Plan revealed it was initiated on 07/08/11 with new problems and interventions added on 07/14/11 and 07/15/11. Continued review revealed the risk for falls was not an identified concern and no interventions were placed for the prevention of falls. Review of the Fall Risk Assessment, dated 07/22/11, revealed the resident was assigned a score of twenty-four (24), indicating a high risk for falls. According to assessment details, a score greater than nine (9) was considered high risk. Review of the physician's orders [REDACTED]. Review of the Admission Minimum Data Set (MDS) Assessment which was not completed until 07/26/11 (Refer to F-273) revealed the facility assessed the resident as having severe impairment in cognitive skills for decision making, and as requiring extensive assistance with transfers and ambulation. Review of the Care Area Assessment Summary (CAAS), dated 07/26/11, revealed indicators of fall risk for this resident included impaired balance during transfers, diuretics, incontinence, visual impairment, Arthritis, and cognitive impairment. Further review revealed the CAAS triggered for falls. Observation of Resident #10, on 07/26/11 at 4:00 PM, revealed the resident was in a wheelchair in her/his room. The wheelchair had a Dycem seat mat (non slip material) to help keep the resident from slipping out of the seat; however, there was no chair alarm on the wheelchair. Interview, on 07/26/11 at 4:45 PM, with Certified Nursing Assistant #21, who was assigned to Resident #10, revealed she verified the resident did not have a chair alarm in place. She further stated the aides had no guide to refer to in providing care for the residents. Interview, on 07/26/11 at 6:00 PM, with Licensed Practical Nurse (LPN) #6 revealed the nurses verbally gave the aides report on any new issues with the residents; however, there was no written reference for aides to refer to when providing care such as a nurse aide care plan. She stated she tried to do rounds every hour or so to make sure the beds were in low position, and call bells were in reach as well as check for safety devices, although she had no list of safety devices in which to refer. She stated the resident probably needed a chair alarm because the resident leaned forward. She further stated she was unaware of the physician's orders [REDACTED]. Further observation of the resident, on 07/27/11 at 10:30 AM, revealed the resident was in a recliner with her/his feet elevated and no alarm was on the chair. Interview, on 07/27/11 at 5:30 PM, with Nurse Consultant #1 revealed if the Falls Risk Assessment and Interim Care Plan were not provided, the facility did not complete them. She further stated the facility was still in the process of ensuring Care Plans were up to date and revised as needed. Further interview, on 07/28/11 at 2:20 PM, with Nurse Consultant #1 revealed the physician's orders [REDACTED]. She further stated the chair alarm was only for the wheelchair and the order may need to be clarified. 5. Review of the Clinical Record revealed the facility admitted Resident #7 on 07/01/11 from another facility with [DIAGNOSES REDACTED]. Review of the Comprehensive Care Plan revealed it was initiated on 07/05/11 with new problems and interventions added on 07/07/11, 07/11/11, and 07/18/11; however, risk for falls was not an identified concern and no interventions were placed for the prevention of falls. Continued review, including review of the Electronic Medical Record (EMR), revealed a fall risk assessment was not completed until 07/22/11. Review of the Fall Risk Assessment, dated 07/22/11, revealed the resident was assigned a score of twenty-six (26), indicating a high risk for falls. According to assessment details, a score greater than nine (9) was considered high risk. Review of the Comprehensive Care Plan revealed new interventions had been added on 07/27/11; however, there was no risk for falls care plan developed and no interventions were implemented for the prevention of falls. 6. Record review of Resident #1 revealed the facility admitted the resident on 07/01/11. Record review revealed no documented evidence the residents were assessed upon admission to determine their risk for falls. Review of the 07/23/11 Fall Risk Assessments for Resident #1 revealed the facility assessed the resident as at high risk for falls. 7. Record review revealed the facility admitted Resident #6 on 07/01/11. Record review revealed no documented evidence the residents were assessed upon admission to determine their risk for falls. Review of the 07/22/11 Fall Risk Assessments for Resident #6 revealed the facility assessed the resident as at high risk for falls. 8. Record review revealed the facility admitted Resident #8 on 07/01/11. Record review revealed no documented evidence the residents were assessed upon admission to determine their risk for falls. Review of the 07/22/11 Fall Risk Assessments for Resident #8 revealed the facility assessed the resident as at high risk for falls. 9. Unsampled Residents B, F, H, I, J, K, M, O, P, Q, R, and T revealed the facility admitted the residents on 07/01/11. Record review revealed no documented evidence the residents were assessed upon admission. Review of the Fall Risk Assessments for Unsampled Residents B (on 07/23/11), F (on 07/23/11), H (on 07/23/11), I (on 07/23/11), J (on 07/22/11), K (on 07/23/11), M (on 07/23/11), O (on 07/22/11), P (on 07/23/11), Q (on 07/23/11), R (on 07/23/11) and T (on 07/23/11) revealed all were assessed as high risk for falls. Record review revealed the facility could provide no documented evidence that a falls risk assessment had been completed for Unsampled Residents L, N, and S. Interview with Licensed Practical Nurse (LPN) #8, on 07/22/11 at 10:30 AM, revealed she had been working on 07/01/11 when twenty-two (22) residents were admitted from another facility. She stated it was hard to know where to start when so many residents began arriving. Continued interview revealed she went room to room, took vital signs and looked at the residents' skin for problems. She further stated she wrote her findings on a piece of paper and gave it to the Assistant Director of Nursing (ADON) at the end of the shift. LPN #8 reported she did not know what the ADON did with the information. Further interview revealed the ADON was no longer employed at the facility. Telephone interview with the former Director of Nursing (DON), on 08/04/11 at 11:00 AM, revealed she was not aware the assessments were not done on admission. She stated she assumed everything was done per protocol. She further stated she did not monitor the admission documentation for completeness. Continued interview revealed she had no explanation for why assessments weren't done per policy or why she did not know there was a problem. Interview with Nurse Consultant #1, on 08/04/11 at 4:30 PM, revealed she was aware fall risk assessments required during the admission process had not been done. She stated it was impossible to understand why proper procedures had not been followed since she was not brought into the facility until 07/18/11. 7. Observation, on 07/26/11 at 11:40 PM, revealed the Storage Utility Room on "B" Hall was unlocked. Observation of the room revealed the following products: plastic bottle labeled Blue Bowl Cleaner, and plastic bottle of Virex 256 (disinfectant). Observation, on 07/26/11 at 11:55 AM, revealed the Soiled Utility Closet on Hall "A" was unlocked. Further observation revealed the room contained the following products: plastic bottle of Virex 256, and bottle of Blue Bowl Cleaner. Review of the Blue Bowl Cleaner Material Safety Data Sheet (MSDS) hazards identification section revealed: Skin/Eye - severe burns, Ingestion - harmful or fatal, and Inhaled - Harmful Corrosive Fumes. Review of the Virex 256 MSDS hazards identification section revealed: Eye contact- moderately irritating, Ingestion - irritating. Interview with CNA #16, on 07/26/11 at 12:10 PM, revealed she was taught to lock the soiled utility room; however, we do not have a key. I think the nurses have a key. Interview with CNA #1, on 07/26/11 at 12:15 PM, revealed the Soiled Utility Closet on Hall "A" was not locked because they don't have keys for all staff. Further interview revealed residents could get into the closet when it is unlocked. Observation, on 07/26/11 at 11:55 AM, revealed the door to electrical room (IDF #1) was unlocked. This room was just outside of the entrance to 'C' household, in the central hallway. Observation revealed IDF #1 contained the electrical junction/power panels for the facility. It was further observed that a loop of Local Area Networks (LAN) cable had been looped over the door knob and shaped in a way that extended past the door. The LAN cable prevented the door from closing and automatically locking. A key was necessary to access the lock on IDF #1's door. Interview with Nurse Consultant #1, on 07/26/11 at 3:40 PM, revealed the door to IDF #1 should be locked at all times to prevent residents from unauthorized access. Further observation, on 07/26/11 at 12:00 PM, revealed the residents' family laundry room (123 D), had no lock on the door. 123 D was located in the central hallway near the entrance to 'C' household. Room 123 D contained two (2) clothes washing machines, and two (2) clothes dryers. Two (2), one (1) gallon plastic containers of liquid bleach, three (3) one (1) gallon plastic containers of liquid soap, and a one (1) gallon plastic container of 'Gain' brand liquid laundry detergent were observed within the sink cabinet. Review of Liquid Bleach MSDS sheet health hazards revealed: Eye contact - may cause severe but temporary eye injury, and Ingestion - Nausea and vomiting. Review of Gain Liquid Laundry detergent MSDS sheet health hazards revealed: Ingestion - may result in gastrointestinal irritation with nausea, vomiting, and/or diarrhea. Interview with Nurse Consultant #1, on 07/26/11 at 3:40 PM, revealed all hazardous materials were to be securely stored. She stated, the reason room 123 D was not a secured room (lockable) was unknown.