Every finding on record at Morgantown Care & Rehabilitation Center

Based on interview, record review, and review of facility policy, the facility failed to inform the resident or resident representative and/or provide written information to all residents regarding the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive. This affected 6 of 29 sampled residents, Resident (R)8, R22, R45, R63, R110, and R123. The findings include:Review of the facility policy titled, Advance Directives, last revised [DATE], revealed the facility would ensure each resident had the right to request, refuse and/or discontinue treatment; participate in or refuse to participate in experimental research; and formulate an advance directive. Continued review revealed an advance directive was written with instruction, such as a living or durable power of attorney for healthcare, recognized under state law, relating to the provision of healthcare when the individual was incapacitated. Additional review of the facility policy titled, Advance Directives, revealed during the admission process, the facility would attempt to determine whether the resident had an advance directive, and if not, determine whether the resident wished to formulate an advance directive. Information would be provided in a manner easily understood by the resident or resident representative about the right to refuse medical or surgical treatment and formulate an advance directive. Additionally, the facility would periodically review, as part of the comprehensive care planning process, the existing care instructions and whether the residents or representative, as appropriate, wished to change or continue these instructions. The facility documented and communicated the residents' choices to the interdisciplinary team and to staff responsible for the resident's care as applicable and appropriate.Review of the Kentucky Medical Orders for Scope of Treatment (MOST form) revealed a patient was not required to complete the MOST form. A patient with capacity or their legal representative may void a form at any time by communicating that intent to the healthcare provider. Any section not completed does not invalidate the form and implies full treatment for that section. Continued review revealed once initial medical treatment began and the risks and benefits of further therapy were clear, treatment wishes may change medical care and this form can be changed to reflect new wishes at any time. Continued review revealed no form can address all the medical treatment decisions that may need to be made, and advance directives such as the Kentucky Healthcare Power of Attorney was recommended for all capable adults, regardless of their health status. Additional review of the Kentucky Medical Orders for Scope of Treatment (MOST form), revealed an advance directive allows you to document in detail your future healthcare instructions or name a surrogate to speak for you if you are unable to speak for yourself or both. If there are conflicting directions between an enforceable living will and a MOST form, the provisions of the will shall prevail. Further review revealed the MOST form must be reviewed and signed by the patient's physician. The MOST form must be reviewed and contain the original signature of the patient's physician to be valid. The signature of the patient surrogate or responsible party is required; however, if the patient surrogate or responsible party is not reasonably available to sign the original form, a copy of the completed form with the signature or electronic signature of the patient, surrogate or responsible party must be signed by the patient's physician and placed in the medical record. The MOST must be reviewed at least annually, at any time the patient or patient's representative requests, when the patient is admitted or discharged from a healthcare facility, and when there is a substantial change in the patient's health status or a change in the patient's treatment preference.Review of the Resident Legal Document Checklist, located in the admission Agreement, revealed a box indicating the document type the resident or representative provided and a box that stated check all that apply. The document types included power of attorney, healthcare proxy, healthcare surrogate guardianship order, living will, and advance directive. Further review of the checklist revealed a signature line for the person named to act on the resident's behalf as the legal authority and a signature line for the resident and/or the resident's authorized legal representative.1. Review of R8's Face Sheet located in the Electronic Medical Record (EMR), revealed the facility admitted the resident on [DATE] with diagnoses including type 2 diabetes mellitus with hyperglycemia. Review of the facility document titled Resident Legal Document Checklist, dated [DATE] and signed by R8, revealed no indication the resident had a Power of Attorney, Health Care Proxy, Health Care Surrogate, Guardian, Living Will, Advance Directive or other. The box to check all that apply was blank. Therefore, the document was incomplete.Review of R8's Kentucky Medical Orders for Scope of Treatment (MOST) form, dated [DATE], revealed the form was voluntary and could be voided at any time. Any section not completed did not invalidate the form and implied full treatment for that section. Further review of R8's MOST form revealed section A indicated Attempt Cardio-Pulmonary Resuscitation (CPR) and section B indicated full treatment. Additional review revealed section C related to antibiotics, and section D related to Intravenous fluids had not been completed. Review of R8's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE], revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) of a 15 out of 15, indicating intact cognition. Review of R8's medical record revealed no documented evidence of an advance directive.In an interview with R8, on [DATE] at 2:54 PM, he stated he did not recall being asked about nor was he provided with information about a living will or an advance directive.2. Review of R22's Face Sheet, located in the EMR, revealed the facility admitted the resident on [DATE] with diagnoses including wedge compression fracture of first lumbar vertebrae.Review of the facility document titled Resident Legal Document Checklist, dated [DATE], and signed by R22's spouse, revealed no indication R22 had a Power of Attorney, Health Care Surrogate, Guardian, Living Will, Advance Directive, or other. The box to check all that apply was blank. Therefore, the document was incomplete.Review of R22's Kentucky Medical Orders for Scope of Treatment (MOST) form, updated [DATE], signed on [DATE], revealed any section not completed did not invalidate the form and implied full treatment for that section. Further review of R22's MOST form revealed section A indicated R22 as a Do Not Resuscitate (DNR). However, sections B, Medical interventions; section C, Artificially Administered Fluids and Nutrition; and section D, Antibiotics, had not been completed and were blank. Review of R22's medical record revealed no documented evidence of an advance directive.Review of R22's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE], revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) of a three out of 15, indicating severe cognitive impairment. During a telephone interview with R22's spouse on [DATE] at 2:54 PM, he stated R22 did not have a living will or an advance directive. He stated he did not recall being asked nor was he provided with information about a living will or an advance directive.3. Review of R45's Face Sheet, located in the EMR, revealed the facility admitted the resident on [DATE], with diagnoses including myocardial infarction.Review of R45's Kentucky Medical Orders for Scope of Treatment (MOST) form, dated [DATE], revealed any section not completed did not invalidate the form and implied full treatment for that section. Further review of R45's MOST form revealed section A indicated R45 as a Do Not Resuscitate (DNR). Section B indicated limited additional intervention and comfort measures checked with error and initials KC. Section C indicated determine use or limitation of antibiotics, and section D indicated IV fluids for a defined trial period and no feeding tube. However, section E, Patient Preferences, had not been completed and was blank.Review of the facility document titled Resident Legal Document Checklist dated [DATE], and signed by R45, revealed no indication the resident had a Power of Attorney, Health Care Proxy, Health Care Surrogate, Guardian, Living Will, Advance Directive or other. The box to check all that apply was blank. Therefore, the document was incomplete. Review of R45's medical record revealed no documented evidence of an advance directive.Review of R45's Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) of a 15 out of 15, indicating intact cognition. In an interview with R45, on [DATE] at 2:30 PM, she stated she did not recall being asked about nor provided with information about a living will or an advance directive.4. Review of R63's Face Sheet, located in the EMR, revealed the facility admitted the resident on [DATE] with diagnoses including unspecified dementia without behavioral disturbance, and psychotic disturbance. Review of R63's Baseline Care Plan, dated [DATE], page six (6), revealed a question, Does Resident have an Advance Directive, and it was answered, No.Review of R63's Kentucky Medical Orders for Scope of Treatment (MOST) form, undated, revealed Cardiopulmonary resuscitation (CPR) was indicated with limited additional interventions. Additional review revealed section C, Artificially Administered Fluids and Nutrition; and section D, Antibiotics, had not been completed and were blank. Additional orders on this form included: full code, Do Not Intubate (DNI). Review of the facility document titled Resident Legal Document Checklist, dated [DATE], and signed by R63's resident representative on [DATE], revealed the resident had a Power of Attorney and a Living Will. However, these documents were not located in the medical record, nor were they submitted by the facility for review.5. Review of R110's Face Sheet located in the EMR, revealed the facility admitted the resident on [DATE] with diagnoses including Alzheimer's Disease late onset, type 2 diabetes mellitus without complications, and major depressive disorder. Review of R110's Kentucky Medical Orders for Scope of Treatment (MOST) form, dated [DATE], revealed the form was voluntary and could be voided at any time. Any section not completed did not invalidate the form and implied full treatment for that section. Further review of R110's MOST form revealed section A indicated Do Not Attempt Resuscitation and Section B indicated Comfort Measures. However, sections C, Antibiotics; D, Medically Administered Fluids and Nutrition; and E, Patient Preferences, had not been completed and was blank. Review of R110's facility document titled Advance Directives/Informed Consent, dated [DATE] and signed by R110's resident representative, revealed the resident was Do Not Resuscitate. Additional review revealed Designation of Health Care Surrogate was marked, but the date was left blank. 6. Review of R123's Face Sheet, located in the EMR, revealed the facility admitted the resident on [DATE] with diagnoses including urinary tract infection, type 2 diabetes mellitus, and chronic obstructive pulmonary disease (COPD).Review of the facility document titled Resident Legal Document Checklist, dated [DATE], and signed by R123 on [DATE], revealed no indication R123 had a Power of Attorney, Health Care Surrogate, Guardian, Living Will, Advanced Directive, or other. The box to check all that apply was blank. Therefore, the document was incomplete.Review of R123s Kentucky Medical Orders for Scope of Treatment (MOST) form signed [DATE], revealed Cardiopulmonary resuscitation (CPR) was to be attempted with full treatment.Review of R123's Baseline Care Plan, dated [DATE], revealed a question, Does Resident have an Advanced Directive, and it was answered, Yes. The next question stated, Do you wish to formulate an advanced directive? The answer was also Yes. However, there was no documented evidence of an advance directive in the medical record.During an interview on [DATE] at 9:43 AM, the Regional Nurse Consultant (RNC) stated the facility used the MOST form as the advance directive.During an interview with the Admissions Coordinator, on [DATE] at 11:09 AM, with the Administrator present, she stated she completed the admission documentation for residents. She stated she asked residents or resident representatives if they had an advance directive, a living will or a durable power of attorney (DPOA) during the admission process. She further stated she did not check the box on the form on the admission agreement called resident legal document checklist unless they had the documents and she received and copied them. Additionally, the Admissions Coordinator stated if residents or representatives asked questions, she provided verbal information. However, she stated she did not give residents/resident representatives written information related to advance directives. When questioned if the facility recognized the KY Medical Orders for Scope of Treatment (MOST) form as an advance directive, she stated she did not know.During an interview with the Social Services Director (SSD), on [DATE] at 11:24 AM, she stated she and the admitting nurse talked to the residents about a living will and Durable Power of Attorney upon the resident's admission. She further stated she and the admitting nurse talked about DNR (Do Not Resuscitate) and code status, and the nurse explained code status in detail. She stated resources were offered including living will paperwork, and how to obtain guardianship. She further stated she tried to obtain and provide to every resident and representative whatever resources needed. Further, if the resident or representative asked for information, she gave it to them. The SSD stated the facility did not use the MOST form as their advance directive. Additionally, the SSD stated advance directives were reviewed during care plan meetings.During an interview with the Director of Nursing (DON), on [DATE] at 11:48 AM, she stated the facility used the MOST form when discussing a resident's wishes, but the MOST form was not considered an advance directive. She stated the nurse, and SSD spoke with residents and their representatives to discuss their wishes during the admission process. The DON further stated advance directives were discussed during conference meetings. During an interview with the Administrator, on [DATE] at 3:53 PM, he stated advance directives were discussed with all residents and additional information was provided if requested. The Administrator stated the MOST form was not a legally binding document and the living will would be followed. He stated advance directives were discussed during care conferences to see if any changes needed to be made. He further stated if a resident or representative requested changes then a new Most form would be completed. He stated the MOST form could be used for years if no changes were made.

Based on observation, interview, record review and review of facility policy, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 sampled residents reviewed for Enhanced Barrier Precautions (EBP). Observation on 04/07/2026, revealed Certified Nursing Assistant (CNA) 6 failed to don the appropriate Personal Protective Equipment (PPE) prior to providing direct care to R44, who was on Enhanced Barrier Precautions (EBP).The findings include:Review of the facility policy titled, Infection Control, revised 01/30/2026, revealed the facility infection control policies and practices were intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. Further, the object of the infection control policies and practices were to prevent, detect, investigate, and control infections in the facility to maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the public.Review of the facility policy titled, Enhanced Barrier Precautions, dated 03/25/2024, revealed EBP were additional measures to attempt to decrease transmission of Multidrug-Resistant Organisms (MDRO). If a resident was placed on EBP, appropriate signage was placed at the room entrance so that personnel and visitors were aware of the need for and the type of precautions. The signage informed the staff of instructions for use of Personal Protective Equipment (PPE), and/or instructions to see a nurse before entering the room. EBP are indicated for residents who have chronic wounds or indwelling medical devices regardless of MDRO status.Review of R44's Resident Face Sheet, revealed the facility admitted the resident on 02/26/2025 with diagnoses including type 2 diabetes mellitus with foot ulcer, type 2 diabetes mellitus with diabetic neuropathy, and cognitive communication deficit. Review of R44's Annual Minimum Data Set (MDS) assessment with an Assessment Reference date (ARD) of 02/18/2026, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition.Review of a Physician's order dated 02/18/2026, revealed an order for Enhanced Barrier Precautions (EBP) related to a wound.Review of R44's Comprehensive Care Plan, dated 03/14/2025 and revised 02/19/2026, revealed a focus problem for Infection Control as resident required EBP related to a wound. Interventions included: attempt to maintain environmental cleanliness, disinfecting high-touch surfaces as applicable; personal protective equipment as indicated; and report any signs and symptoms of infection to the physician.Observation on 04/07/2026 at 7:34 PM, revealed room [ROOM NUMBER] had signage posted indicating bed B was on Enhanced Barrier Precautions (EBP). The signage indicated staff was required to wear gowns and gloves when providing direct care.Further observation upon entering R44's room, on 04/07/2026 at 7:34 PM, revealed CNA6 was on her knees at the bedside, leaning on R44's low bed, and there was a bedpan full of urine on the floor in front of her. CNA6 was not wearing the appropriate PPE. Although she was wearing gloves, she was not wearing a gown as required. CNA6 proceeded to the restroom and emptied the bedpan full of urine into the toilet, rinsed the bedpan and bagged it. She then performed hand hygiene prior to exiting the room.During an interview with CNA6, on 04/07/2026 at 7:36 PM, she was questioned if it was a requirement to wear a gown while providing direct care to R44. CNA6 stated, I don't know. CNA6 was questioned if she had seen signage posted at the door, and she again stated, I don't know.During an interview with R44, on 04/07/2026 at 7:40 PM, she was questioned if staff wore gowns when providing care for her. She stated No, and further stated she did not know why staff would have to wear a gown when providing care for her.During an interview with the Staff Development Coordinator/Infection Preventionist, on 04/10/2026 at 12:08 PM, she stated she expected staff to follow signage on the doorways for any precautions. She further stated CNA6 had a language barrier and probably did not understand what the Surveyor was asking. During additional interview, the Staff Development Coordinator/Infection Preventionist stated she educated staff constantly on PPE. She further stated she had educated staff just this week. During an interview with the Director of Nursing (DON), on 04/10/2026 at 11:53 AM, she stated when providing direct care to a resident on EBP, staff should wear the appropriate PPE, which would be a gown and gloves as indicated by signage on the door.During an interview with the Administrator, on 04/10/2026 at 3:50 PM, he stated he expected staff to follow the protocols for EBP, which included wearing gowns and gloves when performing direct care activities.

Based on observation, interview, record review, and review of facility policy, the facility failed to ensure that a resident has the right to a dignified existence for 1 of 29 sampled residents reviewed for dignity/resident rights. Observation of Resident (R)27 during mealtime, revealed a staff member was standing at the bedside feeding the resident.The findings include:Review of the facility policy titled, Assistance with Meals, revised 05/13/2024, revealed residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity. Additionally, it stated, Employees who provide resident assistance with meals will be trained and shall demonstrate competency in providing meal assistance.Review of the facility policy titled, Resident Rights, revised 01/31/2025, revealed, All residents have the right to be treated with respect and dignity. These rights will be promoted and protected by the facility. It further stated, The facility will make every effort to support each resident in exercising his/her right to assure that the resident is always treated with respect, kindness, and dignity.Review of R27's Resident Face Sheet revealed the facility admitted the resident on 04/25/2025 with diagnoses that included unspecified dementia, contractures of the left and right hips, and dysphagia.Review of the annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/26/2026 revealed the facility assessed R27 as having a Brief Interview for Mental Status of a 2 out of 15 indicating severe cognitive impairment. Further review revealed the facility assessed the resident as dependent on staff for eating.Review of the Comprehensive Care Plan revealed a focus of Activities of Daily Living (ADL) Function, dated 05/02/2025 and revised 04/09/2026, by the Director of Nursing (DON), which stated R27 was independent with eating after assistance with tray set-up.Observation on 04/07/2026 at 6:43 PM, revealed R27 was sitting up in bed. Certified Nursing Assistant (CNA)1 was standing beside the bed while feeding R27.During interview with CNA1, on 04/07/2026 at 6:54 PM, she stated she usually sat while feeding residents, but there wasn't a chair in R27's room at the time the resident received her tray. She further stated there was usually a chair already in the room for the residents that needed to be fed. During an interview with Unit Manager (UM)1, on 04/07/2026 at 6:55 PM, she stated the staff member feeding R27 should have been sitting down. UM1 then requested CNA1 to get a chair so she could sit at the bedside to feed R27, which CNA1 did upon request.During an interview with the Administrator, on 04/10/2026 at 3:50 PM, he stated staff should not be standing at the bedside feeding a resident unless it had been care planned as a preference.

Based on observation, interview, and review of facility policy, it was determined the facility failed to store food in a safe and sanitary manner. Observation on 02/25/2025 at 8:50 AM and 02/26/25 2:49 PM, revealed the walk-in freezer had frost and ice accumulated throughout and food particles located on the freezer's floor, which had the potential to affect all residents consuming foods stored there. The findings include: Review of the facility policy titled, Food Storage: Cold Foods, revised 04/01/2018, revealed All Time and Temperature Control for Safety (TCS) foods, frozen and refrigerated, were to be appropriately stored in accordance with guidelines of the Food and Drug Administration (FDA) Food Code. Further policy review revealed all foods were to be wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. Observation of the facility's walk-in freezer on 02/25/2025 at 8:50 AM, revealed it had large piles of frost and ice accumulation throughout the freezer. Further observation revealed food particles lying on the floor of the walk-in freezer. Observation of the facility's walk-in freezer on 02/26/25 at 2:49 PM, revealed the large piles of frost and ice accumulation continued to be present throughout the freezer. Observation additionally revealed the food particles continued to be present lying on the floor of the walk-in freezer. In interview on 02/27/2025 at 8:30 AM, [NAME] 1 stated she had worked at the facility a little over a year. She said she performed other duties such as cleaning, sanitizing dishwashing, as well as, cooking and followed a cleaning schedule. [NAME] 1 reported once the schedule had been completed she turned it into her manager. She stated the cleaning of the walk-in freezer and cooler was done by the kitchen manager and she was not responsible for that task unless it was assigned to her. During interview on 02/25/2025 at 8:50 AM, the Dietary Accounts Manager stated the walk-in freezer had been malfunctioning, and a work order had been placed on Saturday, (02/22/2025). She stated there was nothing they could do to stop the accumulation of the ice in the walk-in, and she was in the process of trying to tidy things up when the State Survey Agency (SSA) Surveyor arrived to inspect the kitchen. The Dietary Accounts Manager reported the walk-in freezer and cooler were scheduled to be cleaned weekly and she was the staff member responsible for cleaning it. She further stated if she ran into a problem with her schedule she assigned the task of cleaning the walk-in freezer and cooler to someone else. During interview with the Regional Dietary Accounts Manager (RDAM) on 02/26/2025 at 2:49 PM, she stated they used a chemical cleaner to get the ice up and that cleaner was specially formulated to not freeze. She said using that chemical cleaner must be done on a regular basis to keep it from allowing ice to build up. The RDAM reported they had been trying to clean the walk-in freezer at least once a week; however, she thought the dietary manger had gotten behind because of being short staffed a couple of days. She said her expectations were for the walk-in freezer to be cleaned at a minimum of once a week for a detailed cleaning. The RDAM explained at that time the problem with the walk-in freezer was that outside air was getting inside and was causing excessive moisture to buildup. She stated a technician from a local service repair company came out and looked at it, then followed up with them on Monday regarding the freezer. The RDAM additionally said the local service repair company's technician let them know the walk-in freezer was beyond repair and the facility planned to replace the freezer. In interview with the facility's Maintenance Director on 02/26/2025 at 4:17 PM, he stated he had been informed on Friday about the walk-in freezer. He said he had someone come out that day to look at the walk-in freezer. The Maintenance Director reported they had another freezer that was next to it they could use if needed. He stated he believed they were now waiting on a part to fix the freezer's issue. The Maintenance Director said he thought air was coming in but he was not for sure. He explained the service technician was supposed to schedule a time when they would come back and fix the walk-in freezer. The Maintenance Director reported he could not recall who came out to look at the freezer. He further stated the normal protocol for was to report to the Administrator his issue before he could get someone else to come and fix freezer issues. In interview with the Registered Dietician (RD) on 02/27/2025 at 8:23 AM, she stated she came to the facility at least one to two days a week and performed a monthly sanitation audit of the kitchen. She stated she last performed the sanitation audit on Friday (02/21/2025) and found nothing unusual during her audit. The RD said the food appeared good, and the floors of the walk-in freezer were just slick and hard to get around on due to the excess moisture that was coming in. She reported the walk-in freezer issue had been an ongoing problem they had been dealing with. The RD stated the Dietary Accounts Manager had been coming in and sweeping out the excess ice and frost accumulation in the walk-in freezer from time to time; however, it just came back so fast it was hard to keep up with. She explained when she was at the facility on Friday and did the sanitary audit she had not seen any food or excess ice on the walk-in freezer floor at that time. The RD said if she had seen the freezer in its current state she would be providing ongoing education with the staff on cleaning and keeping the excess frost and ice swept up. She stated she felt there was not much else they could really do to properly address the situation with the walk-in freezer now as they could not keep the large amount of frost and ice from accumulating inside. The RD additionally stated her expectations were for dietary staff to do more frequent sweeping inside the walk-in freezer, but even then she was not still sure that would help with the issue. In interview with the Service Manager for the contracted Repair Services Company on 02/27/2025 at 9:14 AM, he stated he had been contacted and came out to the facility last week on 02/21/2025. He reported he found large amounts of ice building up because of there being a large amount of outside air coming into the freezer due to the seals and gaskets being compromised. The Service Manager said that caused water to get in between the foam panels and that those panels were most likely full of water. He stated the freezer had probably been doing that for a long time as the freezer was about [AGE] year. The Service Manager reported the seals and gaskets wore out and start going bad after about 10-[AGE] years of usage and start losing their effectiveness. He explained in his opinion the amount of ice inside the walk-in freezer had taken weeks to accumulate that much in there. The Service Manager said, unless there had been a large amount of water inside or a leak of some sort which could have caused that much ice accumulation to be observed in the freezer. He reported if it was just humidity coming in from outside air, that would take a long time for the ice to accumulate the way it had in the freezer. The Service Manager stated in his opinion he thought the ice had to have been there awhile. He also stated he had service men coming back out to the facility today to take measurements for the new freezer that was to be ordered to replace the current one. In interview with the Administrator on 02/27/2025 at 8:00 AM, he stated he would consider the ice accumulation away from the food since it was mainly on the floor and that it posed no risk to the food stored in it at that point. He explained if the ice was accumulating on the food, then he would have it removed and replaced and would use the emergency food supply in the meantime until the replacement food got here. The Administrator further stated his expectations was for the excess ice to be swept out daily, but since it was located on the floor it should be okay.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to post staffing data for 2 of the 3 days of the State Survey Agency (SSA) Survey. The findings include: Review of the facility's policy titled, Nursing Services, Staffing Policy, revised 01/31/2025, revealed the facility's intent was to ensure nursing staff supported the well-being of its residents. The policy further stated staffing would be allocated and adjusted to deliver quality care considering the number, characteristics, and acuity of the facility's resident population. Observation of the daily staffing posting on 02/26/2025 at 4:52 PM, revealed the staffing posted in a hallway where it was not visible unless a person were walking down that particular hallway. Per review, the staffing posted was dated 01/30/2025 (approximately 27 days prior to the Survey initiation date). Observation of the daily staffing posting on 02/27/2025 at 8:33 AM, revealed the staffing data was not posted. During interview on 02/27/2025 at 9:30 AM, the facility's staffing Scheduler stated she was responsible for posting the staffing data. She reported it was important for the staffing to be posted daily to allow staff to know how the facility would be staffed each day. The Scheduler additionally stated she usually put each day's posting on top of the previous one and she did not know what had happened to the postings. During interview with the Director of Nursing (DON) on 02/27/2025 at 10:00 AM, she stated the Scheduler was responsible for ensuring the staffing data was posted. The DON stated she had discussed the staffing not being posted with the Scheduler yesterday and informed her that task needed to be done daily. She reported going forward, the business office would be assisting when the Scheduler was not at the facility and she (the DON) would also be checking to ensure the staffing was posted daily. The DON further stated she expected the posting to be completed daily as required. During interview with the Administrator on 02/27/2025 at 2:13 PM, he stated the Scheduler was responsible for the daily staffing posting and he expected that to be completed daily (as required).

Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure the results of its most recent certification and complaint survey results were readily accessible to residents in an area where residents did not have to request to review the results. The facility's failure directly impacted 4 of 5 residents who attended the resident council meeting (Resident (R) 1, R13, R16, and R52) and had the potential to affect all residents residing in the facility, their family/representatives, and visitors of the facility who had the right to review the facility's survey history. The findings include: Review of the facility's policy titled, Resident Rights, revised 01/31/2025, revealed all residents had the right to be treated with respect and dignity and those rights would be promoted and protected by the facility. Per review of the policy, residents had the right to examine (the facility's) survey results. In a Resident Council Meeting conducted on 02/26/2025 at 2:01 PM, with residents who regularly attended those meetings, all the residents present (R1, R13, R16, and R52) stated they did not know where the facility's survey results book was located. 1. Review of R1's Face Sheet revealed the facility admitted the resident on 04/18/2005. (In interview on 02/25/2025 at 8:24 AM, the Administrator stated R1 was the resident council president.) Review of R1's Annual Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 01/14/2025, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. 2. Review of R13's Face Sheet revealed the facility admitted the resident on 10/28/2016. Review of R13's Annual MDS Assessment with an ARD of 01/14/2025, revealed the facility assessed the resident to have a BIMS score of 11 out of 15, which indicated the resident was moderately cognitively intact. 3. Review of R16's Face Sheet revealed the facility admitted the resident on 08/03/2022. Review of R16's Significant Change MDS Assessment with an ARD of 02/16/2025, revealed the facility assessed the resident to have a BIMS score of 14 out of 15, which indicated the resident was cognitively intact. 4. Review of R52's Face Sheet revealed the facility admitted the resident on 09/18/2023. Review of R52's Quarterly MDS Assessment with an ARD of 02/07/2025, revealed the facility assessed the resident to have a BIMS score of seven out of 15, which indicated the resident was severely cognitively impaired. Observation on 02/26/2025 at 4:59 PM, revealed the facility's survey (findings) binder was located behind the nursing station. Continued observation and review of the survey binder revealed it was not up to date with the most current facility survey results. Further review of the facility's survey binder revealed the survey results of the Recertification Survey on 09/05/2019 was present; however, the Recertification Survey results from 05/24/2024 were not located in the binder. During interview with the Director of Nursing (DON) on 02/27/2025 at 10:00 AM, she stated the Administrator was responsible for ensuring the facility's survey results binder was accessible to residents (and others) and up to date. The DON further stated she and the Administrator had started working at the facility in August of 2024, and she thought updating the binder had just been forgotten. During interview with the Administrator on 02/27/2025 at 2:13 PM, he stated he was responsible for the facility's survey binder. He stated the binder should have never been stored behind the nursing station and should have been available in a public area. The Administrator reported the facility's survey binder just wasn't up to date, but he did not provide a reason why. He further stated it had now been corrected and a sign with large font had been placed in the front lobby. The Administrator additionally said the binder had been updated and was now accessible for anyone to view.

Based on observation, interview, review of facility policy, and review of the Kentucky Food Guide 2013 Food Code guidance, it was determined the facility failed to provide foods at a safe and appetizing temperature on 05/24/2024 for the noon meal, to the residents of Serenity Hall. Observation on 05/24/2024 at 12:09 PM, revealed during kitchen tray line for Serenity Hall, the [NAME] slaw, cucumber salad and banana pudding was left out sitting on a tray, and was not placed in an ice bath. Following the completion of the tray line for Serenity Hall, at 12:25 PM, the State Surveyor requested a temperature check on all foods on the tray line and the following temperatures were observed: coleslaw, seven (7) servings at 61 degrees Fahrenheit (F); cucumber and onion salad, two (2) servings at 66 degrees F, and banana pudding 15 servings at 71 degrees F. The findings include: Review of facility policy titled Food Preparation, dated 02/2023, revealed all foods would be prepared in accordance with the Food and Drug Administration (FDA) food code. Continued review revealed all foods will be held at appropriate temperatures of less than 41 degrees Fahrenheit (F) for cold food holding. Review of the Kentucky Food Guide 2013 Food Code, revealed cold foods should be held at 41 degrees F or less. Review of the Service Line Checklist, dated 05/24/2024, revealed temperatures for all hot and cold foods should be taken prior to service and recorded. Temperature of cold food should be at or less than 41 degrees F. Continued review of the Checklist recorded temperatures for the 05/24/2024 noon meal prior to serving, revealed the coleslaw was 33 degrees F, cucumber and onion salad was 36 degrees F and the banana pudding was 35 degrees. Observation on 05/24/2024 at 12:09 PM, revealed during tray line for Serenity Hall, the [NAME] slaw, cucumber salad and banana pudding was left out sitting on a tray, and was not placed in an ice bath. Following the completion of the tray line for Serenity Hall, on 05/24/2024 at 12:25 PM, the State Surveyor requested a temperature check on all foods on the tray line and the following temperatures were observed: coleslaw, seven (7) servings at 61 degrees F; cucumber and onion salad, two (2) servings, at 66 degrees F; and banana pudding 15 servings at 71 degrees F. During an interview with the Dietary Manager on 05/24/2024 at 12:27 PM, she stated the cold foods should be held at 41 degrees F. The Dietary Manager who was assisting with tray line proceeded to replace the coleslaw, salad and pudding and placed these food items in an ice bath. In a follow up interview with the Dietary Manager, on 05/24/2024 at 5:08 PM, she stated the banana pudding was canned and was refrigerated prior to the noon meal being served. She further stated she could not speak to the food temperatures during tray line and the State Surveyor would need to speak to the cook. In an interview with the Dietary Cook, on 05/24/2024 at 5:24 PM, she stated the dining cart for Serenity Hall was the fourth cart that left the kitchen. She stated the trays of pudding, coleslaw and salad were not placed in an ice bath prior to serving. She further stated dietary staff typically used an ice bath for cold food, but they were in a rush because a staff member had to leave due to a family emergency. The Dietary [NAME] stated the banana pudding was canned and they added bananas to the regular diet. She further stated she could not recall what the tray line food temperatures were prior to serving the noon meal. The State Surveyor shared that the recorded temperature for the banana pudding was 35 degrees Fahrenheit (F), the coleslaw was 33 degrees F, and the cucumber and onion salad was 36 degrees F. The cook stated based on those temperatures she would assume the food items had been in the cooler prior to her taking the temperatures. The Dietary [NAME] stated the temperatures taken of the cold foods following the completion of the tray line for Serenity Hall were not at a safe temperature and residents could potentially become sick if foods were not kept at safe temperatures. During an interview with the Director of Nursing (DON), on 05/24/2024 at 4:32 PM, she stated she expected kitchen staff to check food temperatures before and while serving food. She stated the cold foods at the noon meal tray line maybe should have been placed in an ice bath. She further stated she could not provide an answer for potential outcomes if food was served at inappropriate temperatures as she really could not answer a hypothetical question. During an interview with the Administrator, on 05/24/24 at 4:40 PM, he stated he expected cold foods to be kept cold. He stated the food code mentioned food should be palatable and served at a safe temperature.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to ensure drugs and biologicals used in the facility were stored in accordance with the manufacturer's specifications, and accepted professional nursing principles and practices for one (1) of four (4) medication carts audited out of a total of seven (7) medication carts. Observation on 05/24/2024 at 9:40 AM, of the medication cart (Cart 1) that serviced rooms #15-27 on The City hall, revealed seven (7) cards of medications were beyond the expiration date printed on the label as well as the beyond use date identified on the affixed pharmacy-generated label. This affected Residents (R3), R23, R36 and R91. The findings include: Review of the facility's policy titled, Medication Administration, General Guidelines, dated 09/2018, revealed medications are administered as prescribed in accordance with manufacturer's specifications, good nursing principles and practices. Further review revealed the person administering the medication is to, check expiration date on package/container. No expired medications will be administered to a resident. Additional guidelines included, the beyond use dating, which only lists month/year, fall to the last day of the month. Observation on 05/24/2024 at 9:40 AM, of the medication cart (Cart 1) that serviced rooms #15-27 on The City hall, revealed seven (7) cards of medications were beyond the expiration date printed on the label as well as the beyond use date identified on the affixed pharmacy-generated label. The expired medications prescribed to R3, R23, R36 and R91 included the following: Resident (R3) Pantoprazole 20 mg tablets (medication used to treat gastroesophageal reflux disease) expired 03/15/2024 with eight (8) tablets remaining. R23 Meclizine 12.5 mg tablets (antihistamine) expired 04/18/2024 with 25 tablets remaining. Amlodipine 2.5 mg tablets (medication used to treat high blood pressure) expired 05/15/2024 with 25 tablets remaining. R36 Olanzapine 2.5 milligrams (mg) half tablets (antipsychotic) expired 03/14/2024 with 27 tablets remaining. Olanzapine 2.5 mg half tablets expired 04/24/2024 with 30 tablets remaining. R 91 Cetirizine 5 mg tablets (antihistamine) expired 02/28/2024 with 1 tablet remaining. Vitamin D3 50 microgram tablets expired 03/16/2024 with seven (7) tablets remaining. During an interview on 05/24/2024 at 9:40 AM, with Licensed Practical Nurse (LPN) 3, she stated she was not usually on this medication cart, but was assigned to it this day. LPN3 further stated the nurses assigned to the medication cart should check the expiration dates of the medications and remove them if expired. In continued interview, she stated the contracted pharmacy checked for expired medications, but she was unsure of how often pharmacy completed this audit. In an interview with the Assistant Director of Nursing (ADON), on 05/29/2024 at 4:25 PM, she stated it was her expectation medications be removed from the medication cart if expired or discontinued, by the nurses assigned to the carts. The ADON further stated she audited the medication carts as often as every two (2) weeks, monthly, and as needed. In an interview with the Director of Nursing (DON), on 05/29/2024 at 3:06 PM, she stated a representative from the pharmacy checked the medication carts and medication storage monthly. She stated the pharmacy representative tried to get to the facility early enough to check all medication carts and was at the facility just last week. The DON further stated it was her expectation the floor nurses assigned to the medication carts would pull the medication from the cart if it was discontinued or expired. Further, she stated she expected the pharmacy medication cart audits to catch any expired medications.

Based on observation, interview, record review and facility policy review it was determined the facility failed to review and revise the Comprehensive Care Plan for one (1) of four (4) sampled residents (Resident #2). Staff was aware Resident #2 worried about his/her spouse's health and would become agitated if residents were outside or near his/her room door. However, review of Resident #2's Comprehensive Care Plan revealed there were no interventions to address Resident #2 becoming agitated if residents were outside or near his/her room. On 01/02/19, staff left Resident #1 sitting outside of Resident #2's door in a wheelchair and Resident #2 pushed the wheelchair away from his/her door, causing Resident #1 to hit the wall and the resident to fall out of the wheelchair. The resident sustained [REDACTED]. The findings include: Review of the facilities professional standards Lippincott Manual of Nursing Practice-Tenth Edition. not dated, revealed for Nursing Care Plan: A. to assign priorities to the nursing diagnoses. Highest priority is given to problems that are most urgent and critical. B. To establish goals or expected outcomes derived from the nursing diagnoses. Specify short-term, intermediate, and long-term goals as established by the nurse and patient together. Goals should be specified, measurable, and patient-focused and should include a time frame. C. Actualization of the care plan through nursing interventions or supervision of others to do the same. D. Determination of the patient's responses to the nursing interventions and of the extent to which the goals have been achieved. Record review revealed the facility admitted Resident #2 on 02/07/18 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 11/17/18 revealed the facility did not document a Brief Interview for Mental Status (BIMS) score. Interview with Resident #2 on 01/16/19 at 12:45 PM revealed he/she did not want anyone outside his/her door or around his/her room. Resident #2 stated he/she had hit a gentleman before and he/she had pushed a resident away from his/her door and got blood on his finger. Interviews on 01/16/19 with Certified Nurse Aide (CNA) #1 at 9:10 AM, CNA #2 at 1:10 PM, and Licensed Practical Nurse (LPN) #1 at 9:30 AM revealed Resident #2 would become agitated when anyone was outside of his/her door. CNA #1 and LPN #1 stated Resident #2 was afraid it would cause his/her spouse to get upset and have a [MEDICAL CONDITION]. Review of Resident #2's Comprehensive Care Plan for Active and/or at risk for behavior problems related to currently taking anti-Psychotic medication, dated 02/14/18, revealed the resident will not harm him/herself or others secondary through next review. However, further review revealed the care plan did not address Resident #2's behaviors of becoming agitated when other residents were around or outside of his/her room and there were no interventions to address what care to provide to try to prevent the resident from becoming agitated and to keep other residents safe. Review of a Fall Investigation With Injury, dated 10/01/19, revealed Resident #2 was agitated that Resident #1 was in the hallway, in his/her wheelchair by Resident #2's room. After explaining to Resident #2 that they would be taking Resident #1 to bed soon, Resident #2 pushed Resident #1's wheelchair, causing it to roll across the hall into a wall causing the resident to be thrown on to the floor on his/her left side. Resident #1 received a laceration on the left eyebrow area approximately one (1) inch in length by one half (1/2) centimeters (cm) in width and a small laceration on the left first finger, and an abrasion on his/her back. Interview with the Social Service Director revealed she had learned of the event on 01/03/19 at the morning meeting and was not aware Resident #2 had behaviors. She stated she was not aware Resident #2 did not want anyone in or around his/her room. She stated if she would have known she would have added the resident becomes anxious when other resident's wander around his/her door to the care plan Interview with the Director of Nursing (DON) on 01/16/19 at 3:30 PM revealed she was not aware that Resident #2 did not want anyone around his/her door. She stated she was not aware of Resident #2 ever becoming aggressive with other residents, and would become aggressive if a resident was outside of his/her room. She revealed she expected staff to communicate with administrative nursing and social services so the care plan could be updated with the behavior and interventions put in place to try to avoid this from happening again.

Based on observation, interview, record review and facility policy review it was determined the facility failed to ensure a resident who displays mental/psychological adjustment difficulty receives appropriate treatment and services to correct the assessed problem for one (1) of four (4) sampled residents (Resident #1 and #2). Resident #2 worries about the health of his/her spouse and becomes agitated when anyone is around his/her room and staff were aware. However, staff left Resident #1 outside of Resident #2's door, and Resident #2 pushed Resident #1 away from his/her door, causing Resident #1 to have a fall sustaining a laceration and skin tear. The findings include: Review of facility policy titled Behavioral Management Program dated (MONTH) (YEAR) revealed the intent of this facility is to identify and assess for disruptive behaviors in residents in order to develop interventions. Guideline steps: The Social Worker shall initiate a target behavior analysis and behavior management care plan when staff or the Minimum Data Set process identifies behaviors. Nursing designee will obtain written psychoactive medication consent from the resident/responsible party as needed. The original Behavior Management Care Plan will be placed in the medical record with the Comprehensive Care Plan. A copy will be maintained in the Social Services office and a designated location on the nursing unit. A. Assessment: 1. Identification of behaviors a. What behaviors are being exhibited by the resident? b. How do behaviors interfere with the residents Plan of Care? c. Does the behaviors presented affect other residents negatively? 2. Occurrence of behaviors a. Is there a pattern of behaviors related to the time of day? 3. Location of behaviors a. Is there a pattern of behaviors related to the location of this resident. B. Precipitating factors 1. What are the precipitating factors? 2. What are the [MEDICATION NAME]/extrinsic precipitating factors? 3. What factors trigger the problem behavior? C. Abuse risk 1. Does the behavior place this resident at risk for abuse or abusing others? 2. Does the resident exhibit behaviors that trigger negative responses from other residents or staff that result in this resident becoming an object of abuse? 3. Does this resident's behavior result in abuse toward another residents? Record review revealed the facility admitted Resident #2 on 02/07/18 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 11/17/18 revealed the facility did not code the Brief Interview for Mental Status (BIMS) score. Review of Resident #2's Comprehensive Care Plan for Active and/or at risk for behavior problems related to currently taking anti-Psychotic medication, dated 02/14/18, revealed the resident will not harm him/herself or others secondary through next review. Further review revealed interventions to explain care to resident in advance, in terms resident understands; administer and monitor the effectiveness and side effects of medication, as ordered; invite and encourage activity programs consistent with interest; refer to social services; and, admit to serenity unit, may leave unit accompanied for activities, doctor visit etc. Review of a Fall Investigation With Injury, dated 01/01/19, revealed Resident #2 was agitated Resident #1 was in the hallway in his/her wheelchair by Resident #2's room. After explaining to Resident #1 that they would be taking Resident #2 to bed soon. Resident #2 pushed Resident #1's wheelchair across the hall into a wall causing him/her to be thrown on to the floor on the left side. Resident #1 received a laceration on the left eyebrow area approximately one (1) inch in length by one half (1/2) centimeters (cm) in width and a small laceration on the left first finger, and an abrasion on his/her back. He/she also complained of left hip pain and that his/her head was hurting so was sent the emergency room for evaluation and treatment. An x-ray was negative. Resident #2 was placed on one on one observation. Interview with Certified Nurse Aide (CNA) #1 on 01/16/17 at 9:10 AM revealed she was in the process of taking Resident #1 to bed but left him/her sitting in the wheelchair, outside of Resident #2's room, to assist another resident. CNA #1 stated she heard a loud noise, then noticed Resident #1 by the back door, in the floor with Resident #2 standing by his/her wheelchair. She stated she noticed blood on Resident #2's finger and when the nurse asked him/her if he/she pushed Resident #1, Resident #2 became very upset. The interview further revealed she had worked that unit for over two (2) years and Resident #2 had never liked anyone outside his/her door because he/she was afraid it will cause his/her spouse to have a [MEDICAL CONDITION], so does not want him/her to become upset. The interview further revealed Resident #2 later asked if Resident #1 was going to be all right. Interview with Licensed Practical Nurse (LPN) #1 on 01/16/19 at 9:30 AM revealed she was the nurse on duty at the time of the fall. She stated she had the medication cart outside of Resident #2's door when he/she came up behind her and asked when Resident #1 was going to bed. She revealed she saw Resident #1 roll past her backwards in his/her wheelchair, hit the wall, then come out of the wheel chair onto the floor. She stated Resident #2 did not say anything but was noted going back to bed. The interview further revealed Resident #2 does not want anyone in his/her space and would become anxious and nervous when anyone was outside the door due to hi/her being very protective of his/her spouse and felt this may upset spouse. She stated when she assessed Resident #2, she noticed a small amount of blood on his/her finger, but did not remember which hand or finger. Interview with Resident #2 on 01/16/19 at 12:45 PM revealed he/she did not want anyone outside his/her door or around his/her room. Resident #2 stated he/she had hit a gentleman before and he/she had pushed a resident away from his/her door and got blood on his finger. Interview with CNA #2 on 01/16/19 at 1:10 PM revealed Resident #2 had a bad temper at times with other residents and he/she will slam the door if anyone is outside his/her door. CNA #2 stated she was told in report that Resident #2 had hit another resident several months ago. Further review of the 02/14/18 Comprehensive Care Plan for behavior problems revealed there was no documented evidence the resident had been identified as becoming agitated and aggressive when other resident around or outside his/her room door and no interventions to address this behavior prior to the incident on 01/02/19. Interview with the Social Service Director revealed she had learned of the event on 01/03/19 at the morning meeting and was not aware Resident #2 had behaviors. She stated she had not been aware of him/her not wanting anyone in or around his/her room. She stated behaviors were recorded on the EZ MAR and was how she was made aware, but this behavior was never recorded. Interview with the Director of Nursing (DON) on 01/16/19 at 3:30 PM revealed she was not aware Resident #2 did not want anyone around his/her door. She stated she was not aware of Resident #2 ever becoming aggressive with other residents, and would become aggressive if a resident was outside of his/her room. She stated no one actually saw Resident #2 push Resident #1, so was unsure of the occurrence. She revealed she expected staff to communicate any behaviors to administrative nursing and social service so the behavior could be care planned with interventions put in place to avoid this from happening again.

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety. Kitchen observation, on [DATE], revealed a kitchen staff member with no hairnet on, undated food in the walk-in refrigerator, opened/unsealed foods in the walk-in freezer, expired food in the walk-in freezer, and kitchen staff using their hands to scoop food out of the steam table trays to place on resident plates during trayline. Review of the Census and Condition, dated [DATE], revealed one-hundred seven (107) of one-hundred seven (107) residents received their food from the kitchen. The findings include: 1. Review of the facility policy titled, Food Storage, last revised [DATE], revealed all products should be inspected for safety and quality and be dated upon receipt and when they are prepared; use the 'use-by-dates' on all foods stored in refrigerators and use the dates according to the timetable in refrigerated and freezer storage; remember to cover, label and date; any expired or outdated food products should be discarded and foods should be stored in their original containers if designed for freezing; and foods to be frozen should be stored in airtight containers or wrapped in heavy duty aluminum foil or special laminated papers. Observation of the walk-in refrigerator, on [DATE] at 6:24 PM, revealed a full plastic container of tuna salad on the shelf with no dates present. 2. Review of the facility policy titled, Personal Hygiene, revised [DATE], revealed staff in the kitchen must wear a clean hat or other hair restraint and hair must be appropriately restrained or completely covered. Observation of the kitchen, on [DATE] at 6:20 PM, revealed Dietary Aide #1 was walking around in the kitchen with no hair net on. Observation of the walk-in freezer, on [DATE] at 6:29 PM, revealed two (2) boxes of corn dogs open to air and not sealed, a bag of french toast sticks open to air and not sealed, a bag of fish sticks with a use by date of [DATE] on it, and a bag of pancakes open to air not sealed and not dated or labeled. 3. Review of the facility policy titled, Trayline Setup and Service, revised [DATE], revealed portions are adhered to by following scoop sizes noted on the menus. Observation of the supper tray-line, on [DATE] at 6:37 PM, revealed Dietary Aides #1 and #2 using their gloved hands to grab food out of the food pans that were on the steam table with no utensils present and placed the food on resident trays after grabbing the food with their hands that were visibly soiled with a wet/oily appearance. Interview with Dietary Aide #1, on [DATE] at 6:39 PM, revealed he thought it was ok to use his hands to grab food and then place the food on the resident trays without the use of utensils. Interview with Dietary Aide #2, on [DATE] at 6:40 PM, revealed this was his first time doing trayline and did not know if it was acceptable or not to use his hands to dish food up for the resident trays. Interview with the Assistant Dietary Manager, on [DATE] at 6:41 PM, revealed she expected staff to have their hair net on at all times when in the kitchen. She stated it was not acceptable for staff to dish food up with their hands and they need to use utensils for dishing food up. She stated she expected all foods to be sealed completely with labeling of what the food items were and when they were opened and when they were to be discarded. Interview with the Dietary Manager, on [DATE] at 6:56 PM, revealed all foods being stored that have been opened must be labeled and dated and sealed completely. She stated she expected staff to use utensils when dishing up food for the residents' meal trays and it was unacceptable to use their hands instead of using utensils. Interview with facility's Registered/Licensed Dietician, on [DATE] at 9:33 AM, revealed she expected staff to use utensils when serving foods to ensure the appropriate right utensils were in use for appropriate portions and it was unacceptable for staff to be serving food with their hands whether they were gloved or not. She further stated she expected all foods that were being stored to be stored in a completely sealed container that was air tight and for everything to be labeled and dated.

Based on observation, interview, record review, and policy review, it was determined the facility failed to ensure residents received the appropriate care and services to prevent urinary tract infections to the extent possible for three (3) of twenty-four (24) sampled residents (Residents #22, #48 and #92), during indwelling urinary catheter care. The findings include: Review of the facility policy for Perineal Care Male or Female, dated 12/03/15, revealed to: 1. Review the resident's care plan to assess for any special needs of the resident. 2. Confirm resident's identity. Explain procedure to resident. 3. Assemble the equipment and supplies as needed. Place the equipment on bedside stand, arrange the supplies to be easily reached. 5. Wash and dry hands thoroughly. Put on gloves. 6. Help resident to supine position. For a male resident: a. Hold the shaft of the penis with one hand and wash with the other, beginning at the tip and working in a circular motion from the center to the periphery. Use a clean section of washcloth for each stroke. b. If using soap and water, wet a clean washcloth and rinse thoroughly using the same circular motion. c. For uncircumcised residents, gently retract the foreskin and cleanse beneath it. If appropriate, rinse well but don't dry, replace foreskin. d. Wash the rest of the penis, using downward [MEDICAL CONDITION] toward the scrotum. If appropriate, rinse well and pat dry with a towel. e. Clean top and sides of the scrotum; if appropriate rinse and pat dry thoroughly. Handle the scrotum gently to avoid discomfort. f. Turn resident to his side, clean the bottom of the scrotum and the anal area. If appropriate, rinse well and pat dry. g. After cleaning the perineum, apply ointment or cream as needed. h. If using bath basin, clean and disinfect it according to facility policy. i. Discard disposable equipment and supplies in designated containers. Discard towels/washcloths in soiled laundry container. j. Remove and discard gloves. Wash and dry hands thoroughly. For a female resident: a. Instruct the resident to bend her knees slightly and spread her legs. Assist as necessary. b. Separate her labia with one hand and wash with the other, using gentle downward [MEDICAL CONDITION] from front to back of the perineum. Avoid the area around the anus, and use a clean section of washcloth for each stroke. c. If using soap and water, wet a clean washcloth and rinse thoroughly from front to back. Pat area dry with bath towel. d. Turn resident on her side to Sim's position if possible. e. Clean, rinse and dry the anal area, starting at the posterior vaginal opening and wiping front to back. 1. Record review revealed the facility admitted Resident #92, on 05/04/18, with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment, dated 05/11/18, revealed the facility assessed Resident #92's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of four (4), which indicated the resident was not interviewable. On 06/06/18 10:25 AM, observation of indwelling catheter care for Resident #92 by Certified Nurse Aide (CNA) #1 revealed the CNA ran water into the bath basin and put wash cloths in the basin without cleaning the tub. She then took a washcloth, put soap on it, and proceeded to clean the catheter tube from the penis and out away from the penis, then went to the penis and retracted the foreskin and cleaned the head of penis, then returned the foreskin instead of cleaning the proximal area to distal area. She then placed the dirty washcloth into the clean water and picked up another cloth out of the dirty water, and proceeded to rinse starting at the tubing, and then going to the foreskin and head of the penis. With the dirty gloves on, she replaced his brief and shorts. According to the policy, she should have rinsed with clean water. Interview with CNA #1, on 06/06/18 at 10:30 AM, revealed she should have cleaned from the penis to tubing and not gone over it again to rinse with dirty water. Interview with Director of Nursing (DON), on 06/06/18 at 10:52 AM, revealed she expected staff to follow the policies as written regarding catheter care. 2. Record review revealed the facility admitted Resident #48 on 05/17/17 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated 04/24/18, revealed the resident had a BIMS score of ninety-nine (99), which indicated the resident was unable to complete the interview. Observation of incontinent care for Resident #48 by CNA #2 and CNA #3, on 06/05/18 at 9:41 AM, revealed CNA #2 placed a clean wash cloth on Resident #48's bed prior to putting soap on the wash cloth and using it for incontinent care. CNA #2 then placed the soiled wash cloth on the resident's bed, prior to placing it in a bag. CNA #3 cleaned brown stool matter from Resident #48's buttocks, but failed to remove the soiled gloves prior to applying a clean brief and pulling the resident's pants up. Both CNA #2 and CNA #3 failed to wash their hands after removing the soiled gloves and applying clean gloves to put the resident's shoes on. Interview with CNA #2 and CNA #3, on 06/05/18 at 4:13 PM, revealed they should have not placed clean wash cloths on the resident's bed prior to use and soiled wash cloths on the bed. Both CNA's stated they should have washed their hands after removing soiled gloves and before putting on clean gloves. Interview with the DON, on 06/06/18 at 11:37 AM, revealed she expected the aides to wash their hands and apply clean gloves prior to touching clean items and after providing incontinent care. She further stated she would have expected the aides to place soiled wash cloths in a bag and not on the resident's bed. 3. Record review revealed the facility admitted Resident #22 on 12/26/17 with the [DIAGNOSES REDACTED]. Further record review revealed he/she had a urinary catheter related to [MEDICAL CONDITION]. The facility assessed Resident #22's cognition to be impaired with a BIMS score of four (4), as indicated on his/her Quarterly MDS, dated [DATE]. Observation, on 06/07/18 at 9:34 AM, of peri/catheter care revealed CNA #4 provided catheter and peri-care, assisted with a skin assessment, repositioned the resident and adjusted the bed linen without changing gloves or washing her hands after the catheter care was provided. Further observation, at 9:40 AM, revealed Resident #22 was incontinent of stool. He/she was cleaned and changed by CNA #4 and again, she did not change gloves or wash her hands before repositioning the resident and adjusting the linen. Interview with CNA #4, on 06/07/18 at 10:00 AM, revealed she realized she had failed to wash her hands and change gloves after providing peri/catheter/incontinent care and should have done so anytime she went from doing a dirty procedure to a clean procedure. Interview with Licensed Practical Nurse (LPN #2), on 07/07/18 at 1:00 PM, revealed the CNAs were trained to always take off their dirty gloves, wash their hands, and change gloves prior to going to a clean procedure during care. Interview with the DON, on 06/07/18 at 1:30 PM, revealed she expected the aides to wash their hands and apply clean gloves prior to touching clean items and after providing incontinent care before assisting the resident with repositioning and replacing the clean bed linen.

Based on observation, interview, record review, and review of the facility policy, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections related to improper hand hygiene for three (3) of twenty-four (24) sampled residents (Residents #22, #48 and #92) and for three (3) residents, not in the selected sample of twenty-four (24) residents (Residents #51, #80 and #307). Observation of a medication pass, on 06/04/18, revealed Licensed Practical Nurse (LPN) #3 administered medications to Residents #51, #80 and #307 after placing the medications in her bare hand. The findings include: Review of facility's Perry and Potter 8th edition of Clinical Nursing Skills and Techniques on page 488 under Pre-administration Activities under #7, revealed staff are to use good hand hygiene techniques and to avoid touching tablets and capsules. 1. Record review revealed the facility admitted Resident #80 to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #80's (MONTH) (YEAR) Medication Administration Record [REDACTED]. However, observation revealed LPN #3 administered these medications by mouth to Resident #80 on 06/04/18 at 7:25 PM after LPN #3 placed all these medications in her bare hand prior to putting the medications in a medication cup, then gave the medication cup to Resident #80 who then consumed the medication. 2. Record review revealed the facility admitted Resident #307 to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #307's (MONTH) (YEAR) MAR, revealed to administer Eliquis 2.5 mg (anticoagulant) and Prevastatin Sodium 20 mg (cholesterol) at 9:00 PM. However, observation revealed LPN #3 administered these medications by mouth to Resident #307, on 06/04/18 at 7:34 PM, after LPN #3 placed these medications in her bare hand prior to putting the medications in a medication cup, then gave the cup to Resident #307, who then consumed the medication. 3. Record review revealed the facility admitted Resident #51 to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #51's (MONTH) (YEAR) MAR, revealed to administer [MEDICATION NAME] 400 mg (nerve pain), [MEDICATION NAME] 875 -125 mg (Antibiotic), [MEDICATION NAME] 5 mg (muscle spasms), [MEDICATION NAME] 50 mg ([MEDICAL CONDITION]), [MEDICATION NAME] HCL 10 mg (nerve pain), Atorvastatin 80 mg (cholesterol) and [MEDICATION NAME] 0.25 mg (anti-anxiety) at 9:00 PM. However, observation revealed LPN #3 administered these medications by mouth to Resident #51, on 06/04/18 at 7:47 PM, after LPN #3 placed all these medications in her bare hand prior to putting the medications in a medication cup, then gave the cup to Resident #51, who then consumed the medication. Interview with LPN #3, on 06/04/18 at 7:47 PM, revealed she should not touch pills or medications with her bare hands because it was an infection control issue. She stated she knew she needed to do better. Interview with Unit Manager #1, on 06/04/18 at 7:57 PM, revealed she expected staff who passed medications to not handle medications with their bare hands. Interview with the Director of Nursing (DON), on 06/04/18 at 7:58 PM, revealed staff should not touch pills or medications with their bare hands. She stated she expected staff to follow infection control prevention. Review of the facility policy Handwashing/Hand Hygiene, dated 2001, last revised (MONTH) (YEAR) revealed the facility considers hand hygiene the primary means to prevent the spread of infections. 1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 3. Hand hygiene products and supplies (slinks, soap, towels, alcohol-based hand rub, etc.) shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies. 4. Wash hands with soap and water for the following situations: a. When hands are visibly soiled; and b. After contact with a resident with infectious diarrhea including, but not limited to infections caused by norovirus, salmonella, shigella, and [DIAGNOSES REDACTED]icile. 5. Use an alcohol based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: a. Before and after coming on duty b. Before and after direct contact with residents c. Before preparing or handling medications d. Before performing any non-surgical invasive procedures e. Before and after handling an invasive device (e.g., urinary catheters) f. Before donning sterile gloves g. Before handling clean or soiled dressings, gauze pads, etc. h. Before moving from a contaminated body site to a clean boy site during resident care. i. After contact with a resident's intact skin j. After contact with blood or bodily fluids k. After handling used dressings, contaminated equipment, etc. l. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident m. After removing gloves n. Before and after entering isolation precaution settings o. Before and after eating or handling food p. Before and after assisting a resident with meals; and q. After personal use of the toilet or conducting your personal hygiene 6. Hand hygiene is the final step after removing and disposing of personal protective equipment. 4. Record review revealed the facility admitted Resident #48 on 05/17/17 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 04/24/18, revealed the resident had a Brief Interview for Mental Status (BIMS) score of ninety-nine (99), which indicated the resident was unable to complete the interview. Observation of incontinent care for Resident #48 by Certified Nurse Aide (CNA) #2 and CNA #3, on 06/05/18 at 9:41 AM, revealed CNA #2 placed a clean wash cloth on Resident #48's bed prior to putting soap on the wash cloth and using it for incontinent care. CNA #2 then placed the soiled wash cloth on the resident's bed, prior to placing in a bag. CNA #3 cleaned brown stool matter from Resident #48's buttocks, but failed to remove the soiled gloves prior to applying a clean brief and pulling the resident's pants up. Both CNA #2 and CNA #3 failed to wash their hands after removing the soiled gloves and applying clean gloves to put the resident's shoes on. Interview with CNA #2 and CNA #3, on 06/05/18 at 4:13 PM , revealed they should have not placed clean wash cloths on the resident's bed prior to use and soiled wash cloths on the bed. Both CNA's stated they should have washed their hands after removing soiled gloves and before putting on clean gloves. Interview with the DON, on 06/06/18 at 11:37 AM, revealed she expected the aides to wash their hands and apply clean gloves prior to touching clean items and after providing incontinent care. She further stated she would have expected the aides to place soiled wash cloths in a bag and not on the resident's bed. 5. Record review revealed the facility admitted Resident #22 on 12/26/17 with [DIAGNOSES REDACTED]. Record review further revealed he/she had a urinary catheter related to [MEDICAL CONDITION]. The facility assessed Resident #22's cognition to be impaired with a BIMS score of four (4), as indicated on his/her Quarterly MDS, dated [DATE]. Observation, on 06/07/18 at 9:34 AM, of peri/catheter care revealed CNA #4 provided catheter and peri-care, assisted with a skin assessment, repositioned the resident and adjusted the bed linen without changing gloves or washing her hands after catheter care was provided. Further observation, at 9:40 AM, revealed Resident #22 was incontinent of stool, was cleaned and changed by the CNA, and again, she did not change gloves or wash her hands before repositioning the resident and adjusting the linen. Interview with CNA #4, on 06/07/18 at 10:00 AM, revealed she realized she had failed to wash her hands or change gloves after providing peri/catheter/incontinent care and should have done so anytime she went from doing a dirty procedure to a clean procedure. Interview with an LPN, on 06/07/18 at 1:00 PM, revealed the CNAs were trained to always take off their dirty gloves, wash hands, and change gloves prior to going to a clean procedure during care. Interview with the DON, on 06/07/18 at 1:30 PM, revealed she expected the aides to wash their hands and apply clean gloves prior to touching clean items and after providing incontinent care before assisting the resident with repositioning and replacing the clean bed linen. 6. Record review revealed the facility admitted Resident #92 on 05/04/18 with [DIAGNOSES REDACTED]. Review of the Admission MDS assessment, dated 05/11/18, revealed the facility assessed Resident #92's cognition as severely impaired with a BIMS score of four (4), which indicated the resident was not interviewable. Observation of indwelling catheter care for Resident #92 by CNA #1, on 06/06/18 10:25 AM, revealed CNA #1 transferred the resident from a wheelchair to bed and the CNA proceeded to undress the resident without washing her hands prior to donning gloves. The CNA proceeded to provide catheter care which included cleaning the catheter tubing, the head of the penis, and then rinsed the area she had washed. She replaced Resident #92's brief and shorts still wearing the dirty gloves. She then removed the gloves and without washing her hands and donning new gloves, she proceeded to empty the resident's catheter bag into a cylinder, rinsed it out and then placed it in a bag. She then removed her gait belt, placed it around the resident, transferred him to the wheelchair, and then moved the phone, grabber, paper and call light to the bedside table. She picked up the dirty trash and linen and opened the door, went out into the hallway to the shower room and opened the linen and trash hoppers, threw the trash and linen in and turned to the sink, all without donning gloves. She then stated Oh, I guess I need to wash my hands and proceeded to wash her hands. She stated she guessed she should have washed her hands more. She further stated she was not aware of causing any contamination, but she did not wash her hands and don gloves with resident personal care. Interview with the DON, on 06/06/18 at 10:52 AM, revealed she expected staff to follow the policies as written regarding hand washing.

Based on observation, interview, record review and facility policy review, it was determined the facility failed to ensure services provided or arranged by the facility were provided according to accepted standards of clinical practice for three (3) residents, not in the selected sample of twenty-four (24) residents (Resident #51, #80 and #307). Observation of a medication pass, on 06/04/18, revealed staff administered medications outside of the sixty (60) minutes before parameters to Residents #51, #80 and #307. The findings include: Review of the facility policy titled, Medication Administration General Guidelines, dated (MONTH) (YEAR), revealed medications are to be administered as prescribed in accordance with good nursing principles and practices. Further review of the policy, revealed medications are to be administered within sixty (60) minutes of scheduled time. 1. Record review revealed the facility admitted Resident #80 to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #80's Admission Minimum Data Set (MDS) assessment, dated 05/16/18, revealed the facility assessed Resident #80's cognition as intact with a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated the resident was interviewable. Review of Resident #80's (MONTH) (YEAR) Medication Administration Record [REDACTED]. However, observation revealed Licensed Practical Nurse (LPN) #3 administered these medications by mouth to Resident #80 on 06/04/18 at 7:25 PM, thirty-five (35) minutes prior to the sixty (60) minutes before scheduled timeframe. 2. Record review revealed the facility admitted Resident #307 to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #307's Admission MDS assessment, dated 05/23/18, revealed the facility assessed Resident #307's cognition as intact with a BIMS score of thirteen (13), which indicated the resident was interviewable. Review of Resident #307's (MONTH) (YEAR) MAR, revealed to administer Eliquis 2.5 mg (anticoagulant), Polyethylene [MEDICATION NAME] 3350 17 grams powder (laxative) and Prevastatin Sodium 20 mg (cholesterol) at 9:00 PM. However, observation revealed LPN #3 administered these medications by mouth to Resident #307 on 06/04/18 at 7:34 PM, twenty-six (26) minutes prior to the sixty (60) minutes before scheduled timeframe. 3. Record review revealed the facility admitted Resident #51 to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #51's Quarterly MDS assessment, dated 04/18/18, revealed the facility assessed Resident #51's cognition as moderately impaired with a BIMS score of eleven (11), which indicated the resident was interviewable. Review of Resident #51's (MONTH) (YEAR) MAR, revealed to administer [MEDICATION NAME] 400 milligrams (mg) (nerve pain), [MEDICATION NAME] 875 -125 mg (Antibiotic), [MEDICATION NAME] 5 mg (muscle spasms), [MEDICATION NAME] 50 mg ([MEDICAL CONDITION]), [MEDICATION NAME] HCL 10 mg (nerve pain), Atorvastatin 80 mg (cholesterol) and [MEDICATION NAME] 0.25 mg (anti-anxiety) at 9:00 PM. However, observation revealed LPN #3 administered these medications by mouth to Resident #51 on 06/04/18 at 7:47 PM, thirteen (13) minutes prior to the sixty (60) minutes before scheduled timeframe. Interview with LPN #3, on 06/04/18 at 7:47 PM, revealed she was supposed to only pass medications up to one (1) hour before they were scheduled and one (1) hour after they were scheduled and stated she did not know why she was early passing the medications. Interview with Unit Manager #1, on 06/04/18 at 7:57 PM, revealed staff were only allowed one (1) hour before and one (1) hour after they were scheduled to pass medications. She further stated it was not appropriate to pass medications before the one (1) hour or after the one (1) hour of scheduled medications. Interview with the Director of Nursing (DON), on 06/04/18 at 7:58 PM, revealed she expected staff to follow the time parameters of administering medications one (1) hour before and one (1) hour after the medication was scheduled. Interview with Advance Practice Registered Nurse (APRN) #1, on 06/07/18 at 2:13 PM, revealed he expected the staff to pass the medications at the right times per the orders and per protocol. Interview with ARNP #2, on 06/07/18 at 2:15 PM, revealed she expected staff to follow physician's orders and the appropriate time parameters when administering medications.

Based on observation, interview, record review, and policy review, it was determined the facility failed to maintain medical records according to acceptable professional standards and practices that were complete for one (1) of twenty-four sampled residents (Resident #92). On 05/16/18, staff failed to document the discontinuation and reinsertion of a urinary catheter for Resident #92. The findings include: Review of the Professional Standards of Practice on Documenting Nurses' Progress Notes from the 8th Edition of Perry Potter Clinical Nursing Skills & Techniques Copyright 2014 by Mosby, Inc., revealed accurate documentation reflected the quality of care and provided evidence of each health care team member's accountability in giving care. The purpose of a patient's record is to provide information for communication, education, assessment, research, financial billing, auditing, and legal documentation. Because the nursing process directs a nurse's approach to patient care, documentation needed to reflect this process. Nurses record assessment data, changes in a patient's condition, nursing interventions, and an evaluation of the patient's progress toward established outcomes. Prompt documentation of this data increases accuracy and promotes effective communication to all members of the health care team. The nurse caring for the patient is responsible for writing and signing each progress note, which included full name and title. Procedural Steps 1. Review assessment data, problems identified, goals and expected outcomes, nursing interventions, and patient response during contact with each patient and before documentation. 2. After each patient contact, identify information that needs to be documented. Consider: a. Abnormal findings. b. Changes in status. c. New problems identified. 3. Document in a timely fashion without leaving open spaces between notes and include the date and time. Record review revealed the facility admitted Resident #92 on 05/04/18 with [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED]. Further review of a physician's orders [REDACTED]. Monitor urinary output. Reinsert if unable to void. Observation, on 06/05/18 at 1:45 PM, 06/06/18 at 8:45 AM, and 06/07/18 at 10:25 AM, revealed Resident #92 continued to have an indwelling urinary catheter; however, there was no documentation found in the Nurse's Progress Notes about the catheter being discontinued or reinserted except for documentation on 05/16/18, which revealed the nurse had received the physician's orders [REDACTED].>Interview with Registered Nurse (RN) #1, on 06/06/18 9:40 AM, revealed she had made a note that she had received the order but did not include any information on the removal of the catheter and the results of removal. She stated she should have documented she removed the catheter and the results; however, she stated she doesn't always have time to chart what she needed to because she was too busy. She stated there was no documentation as to when she spoke to the Physician about reinserting the urinary catheter or about the daughter calling the urologist, as well as the follow-up when she called the Urologist to get an order to reinsert the catheter. Interview with the Director of Nursing (DON), on 06/07/18 at 1:24 PM, revealed she expected the licensed staff to follow the Professional Standards of Practice for documentation as outlined in the Perry Potter Clinical Nursing Skills and Techniques, and for nursing staff to follow the physician's orders [REDACTED]. Interview with the Administrator, on 06/06/18 at 9:56 AM, revealed she expected nurses to follow physician's orders [REDACTED].

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of twenty-four (24) sampled residents' right to privacy was honored (Resident #92). Observation, on 06/06/18, revealed staff failed to pull the privacy curtain to ensure the resident's privacy prior to providing urinary indwelling catheter care. The findings include: Review of the Residents' Rights Policy Statement revealed All residents have the right to be treated with respect and dignity. When providing care and services, the stakeholders will respect the resident's individuality and value their input. Residents are entitled to exercise their rights and privileges to the fullest extent possible without intimidation, coercion, discrimination, or reprisal from the facility. Record review revealed the facility admitted Resident #92 on 05/04/18 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment, dated 05/11/18, revealed the facility assessed Resident #92's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of four (4), which indicated the resident was not interviewable. Observation of indwelling catheter care by Certified Nurse Assistant (CNA) #1, on 06/06/18 at 10:25 AM, revealed CNA #1 transferred Resident #92 from his/her wheelchair to bed and proceeded to undress the resident without pulling the privacy curtain. She also pulled the resident's brief down and exposed his/her peri-area without covering him/her. She turned away and then turned back and said, Oh, I guess I need to cover you up. Interview with CNA #1, on 06/06/18 at 10:30 AM, revealed I should have pulled the curtain around the resident and provided privacy for him/her. Interview with the Director of Nursing (DON), on 06/06/18 at 10:52 AM, revealed she expected staff to provide privacy during peri-care and catheter care.

Based on interview, record review, and review of the Resident Assessment Instrument (RAI) Version 3.0 User Manual, it was determined the facility failed to ensure one (1) of twenty-four (24) sampled residents received an accurate assessment, reflective of the resident's status at the time of the assessment (Resident #57). Resident #57 required extensive assistance of two (2) staff for toileting from 04/20/18 through 04/26/18; however, review of the Minimum Data Set (MDS) revealed staff inaccurately coded the 04/26/18 Annual MDS Assessment, as the resident only required supervision of two (2) staff for toileting assistance. The findings include: Review of the RAI Version 3.0 User Manual on Coding instructions for G0110, Activities of Daily Living (ADL) Self Performance, revealed a code of 1 which indicated supervision if oversight, encouragement, or cueing was provided three (3) or more times during the last seven (7) days. Record review revealed the facility admitted Resident #57, on 02/01/17, with [DIAGNOSES REDACTED]. Review of Resident #57's Standard ADL Report for the seven (7) day look back period from 04/20/18 through 04/26/18, revealed staff coded the resident as totally dependent with assistance of two (2). However, review of the Annual MDS Section G, Toilet Use, Column 1, Self-Performance, revealed a code of 1 which indicated the resident required supervision with assistance of two (2). Interview with the MDS Coordinator, on 06/07/18 at 11:35 AM, revealed she made an error when coding Resident #57's self-performance for toileting and it should have been coded as four (4) and not as one (1). She further stated she used the RAI manual for instructions on completing the MDS assessments for residents. Interview with the Director of Nursing (DON), on 06/07/18 at 11:37 AM, revealed she expected the MDS Coordinator to code ADLs correctly to reflect the residents' status and need for assistance.

Based on interview, record review, review of the hospital History and Physical (H&P), and facility policy, the facility failed to ensure that services were provided according to the resident's written plan of care for one (1) of three (3) sampled residents (Resident #1). Resident #1 was care planned to receive antipsychotic medication [MEDICATION NAME] 50 milligrams (mg) by mouth (PO) twice daily (BID); however, the medication was unavailable for administration and the resident missed thirteen (13) doses from the time the medication ran out on [DATE] until [DATE]. On [DATE], Resident #1 was sent to the emergency room (ER) and admitted to the hospital with [REDACTED]. The findings include: Review of the policy Care Plans-Comprehensive, not dated, revealed a person-centered comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. The care plan will include how the facility will assist the resident to meet their needs, goals and preferences. The Nurse/Interdisciplinary Team develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. The comprehensive care plan will be developed with participation from the resident, resident's family or resident representative as indicated. Record review revealed the facility admitted Resident #1 on [DATE] with [DIAGNOSES REDACTED]. Review of the Comprehensive Care Plan for Active and/or at risk for behavior problems-Paranoia with an intervention to administer medication as ordered-see physician's orders [REDACTED]. Review of the physician's orders [REDACTED]. However, interview with Licensed Practical Nurse (LPN) #1, on [DATE] at 10:30 AM revealed there was no [MEDICATION NAME] available to administer to the resident from [DATE] through [DATE] because Pharmacy needed the Physician certification to be able to fill the prescription. She stated the physician's certification had expired, and he was out of town on vacation, leaving no one qualified to fill the prescription. LPN #1 further stated when she realized the medication had run out, and after being made aware of the expired certification, she should have made the Assistant Director of Nursing (ADON), Director of Nursing (DON), and Administrator aware of the problem. Further review of Resident #1's Progress Notes, dated [DATE] at 8:00 AM, 9:59 AM, 10:30 AM, revealed Resident #1 was vomiting, diaphoretic and pale, making the statement of I am possessed by the devil and its not a crazy idea, I know I am and crying; having involuntary movement of the face and eyes, and was crying with slow, slurred speech. The Physician was called and the resident was sent to the ER due to his/her altered mental status and [MEDICAL CONDITION] at 10:30 PM. Review of the hospital H&P dated [DATE] revealed Resident #1 was admitted to the hospital's psychiatric unit on [DATE] due to acute exacerbation of psychotic episode secondary to medication abstinence for a week. Interview with LPN #2 on [DATE] at 9:30 AM revealed she went to LPN #1 and told her something was wrong with Resident #1. She stated LPN #1 then made her aware that Resident #1 had been without his/her [MEDICATION NAME] for seven (7) days. Interview with the Unit Manager/Assistant Director of Nursing (ADON) on [DATE] at 2:40 PM revealed she was not made aware of the problem with the medication until the day Resident #1 was sent out to the hospital. The ADON stated she expected staff to always follow the resident's Plan of Care Interview with the DON on [DATE] at 4:00 PM revealed she was not aware of the event until [DATE], the day the resident was sent out to the hospital. She stated the care plan should have been followed related to administering medication per physician's orders [REDACTED]. Interview with the Administrator on [DATE] at 4:00 PM and on [DATE] at 12:37 PM revealed she was not aware of the drug omissions until she spoke with the resident's family on Monday, [DATE]. She stated she expected all residents to receive their medication as ordered by the physician and as care planned. **The facility implemented the following actions to correct the deficient practice: 1. On return from vacation, the physician was made aware of the expired certification and as the Medical Director, met with the Quality Assurance Performance Improvement (QAPI) team on [DATE] to discuss possible citations of deficient practice. Resident #1 is now a patient of a different doctor who has his Physician certification along with one (1) Physician Assistant (PA) and one (1) Nurse Practitioner (NPRN) in his office. Resident #1 received his/her medication on [DATE]. 2. The facility completed body audits on all resident's with a Brief Interview of Mental Statux (BIMS) score less than eight (8), and a verbal interview was conducted with residents with a BIMS score of eight (8) or above related to missed medication on [DATE]. No concerns were identified. 3. All residents were assessed by the DON to ensure quality of care is being delivered, no change of conditions are noted, resident's care plans are being followed and medications are available and being administered as ordered by the Physician starting on [DATE]. No concerns were identified. 4. All licensed staff and Certified Medication Technicians (CMT's) were inserviced on Physician Orders, Medication Discrepancies/omissions, Charting and Documentation, Comprehensive Care Plans, Change of Condition, Medication Administration-General Guidelines, and Physician and Administrative nursing notification on [DATE], [DATE], and [DATE]. Any staff not present for the inservicing will not be allowed to work until education is competed. Post testing was also conducted with 100% accuracy required. 5. A post-test, with a score of 100%, which includes questions from the education provided, is being administered daily by the Staff Development Coordinator (STC), Nursing Supervisors, and Minimum Data Set (MDS) Coordinator, starting on [DATE] to five (5) different staff members on different shifts daily for one (1) week to include weekends, then two (2) different staff members on different shifts daily for one (1) week to include weekends. 6. The DON, ADON, or Nursing Supervisor will review omission reports from the EZMAR system, along with the 24 hour reports, which includes all new orders, admission orders [REDACTED]. 7. A nurse from the regional team or cooperate office has been onsite since [DATE] and remained in contact with the facility for two (2) weeks, onsite or by phone to review on-going post-test, daily reviews during clinical white board meetings, and staff questionnaires. Then weekly for 1 (one) month. 8. Quality improvement (QI) will meet monthly to evaluate the plan and make adjustments as needed. **The State Survey Agency validated the facility's plan of action was carried out by: 1. Interview with the Medical Assistant to Resident #1's current Physician, on [DATE] at 11:45 AM, revealed he was aware of the [MEDICATION NAME] certification, and was working in the office where one (1) Physician, one (1) Physician Assistant (PA) and one (1) Nurse Practitioner (NPRN) all had completed their certification to be able to fill [MEDICATION NAME]. Review of the Progress Note revealed Resident #1's medication was received on [DATE] from the back up pharmacy and administered at 6:26 PM. 2. Review of the Facility Room Census form revealed all interviewable residents were asked if they had missed any medications with all residents stating no except for three (3) that stated they did not know on [DATE]. Review of Skin Assessment Tools, revealed all residents with a BIMS less than eight (8) had body audit completed to identify any change of condition on [DATE]. No concerns were identified. 3. Review of the Facility Room Census form revealed all residents (total of 99) were assessed to ensure quality of care is being delivered, no change of conditions were noted, care plans were being followed and medications were available and are being administered as ordered by the Physician. The DON started the assessments on [DATE] and completed them on [DATE]. 4. Review of an Inservice Report revealed all staff were inserviced on [DATE] through [DATE]. Review of Post tests revealed all staff had completed a post test with results of 100% accuracy. Interviews on [DATE] with LPN #1 at 10:30 AM, LPN #3 at 2:45 PM, LPN #4 at 2:55 PM and RN #1 at 3:10 PM, revealed they were educated on what action they were supposed to take when a medication was not available for administration. They stated they are supposed to call the pharmacy and if unable to obtain they should call the physician for an order to hold the medication. In addition, they revealed they should report the medication was not available to the DON, ADON, Administrator and family member. They also stated they should document on the 24 hour report, monitor the resident due to the resident not receiving medications, and on how to document on the MAR and to document in the progress notes. In addition, they stated a Post Test was administered after the inservicing and they had to score 100%. Interview with the DON and the Administrator [DATE] at 3:10 PM revealed they had educated all licensed staff on Notification, what to do if out of a medication, what to document if out of a medication, and documentation. They stated the DON was educated by the Corporate Nurse on [DATE] to include Policy and procedure for medication administration per physician's orders [REDACTED]. 5. Review of the Staff post-tests which included questions about the education provided was administered daily by the Staff Development Coordinator, Nursing Supervisors, MDS Coordinator to five (5) staff member on different shifts for one week to include weekend and two (2) different staff members on different shifts daily for one (1) week to include weekend. Interview with the DON and Administrator on [DATE] at 3:15 PM, revealed post testing had been administered by them and all other administrative staff as available. 6. Interview with the Administrator and DON on [DATE] at 3:15 revealed the DON, ADON, or Nursing Supervisor were reviewing omission report from the EZMAR system, along with the 24 hour reports, which includes all new orders, admission orders [REDACTED]. 7. Post survey interview with the Administrator on [DATE] at 12:15 PM revealed a nurse from the regional team or cooperate office has been onsite since [DATE] and remained in contact with the facility for two (2) weeks, onsite or by phone, to review on-going post-test, daily reviews during clinical white board meetings, and staff questionnaires. Then weekly for 1 (one) month and had been completed. 8. Review of the facility Plan of Correction revealed a Quality Assurance Performance Improvement (QAPI) meeting was held with the Medical Director on [DATE] to review and discuss possible citations of deficient practice, a plan was discussed to address possible citations of deficient practice, and a formulated Plan of Correction (P(NAME)) was reviewed. Interview with the Administrator on [DATE] at 9:00 AM revealed the facility continues to have monthly QAPI meetings.

Based on interview, record review, review of the Hospital History and Physical (H&P), review of facility Root Cause investigation and facility policy review, it was determined the facility failed to ensure there system to ensure one (1) of three (3) sampled residents was free of any significant medication error was effective (Resident #1). Resident #1 had a [DIAGNOSES REDACTED]. Resident #1's Physician's Certification to prescribe [MEDICATION NAME] expired while he was on vacation; which resulted in the facility not having the medication to administer. Licensed Practical Nurse (LPN) #1 failed to notify the Director of Nursing (DON), the resident's responsible party and the Performance Improvement Committee per policy. In addition, LPN documented on the MAR she administered the medication from [DATE] through [DATE] (thirteen {13} doses), even though the medication was not available. LPN #1 also failed to document on the shift change report and resident's progress notes; failed to complete an incident report, and failed to implement increased monitoring to identify if the resident showed any adverse effects from not receiving the medication per facility policy. On [DATE], Resident #1 was admitted to the hospital due to acute psychotic decompensation related to omission of his/her anti-psychotic for seven (7) days. Refer to F646, F659, F726, and F760. The findings include: Review of the facility's policies Medication Discrepancies dated [DATE], revealed the guidelines include: 1. In the event of a medication discrepancy, immediate action is taken, as necessary, to protect the resident's safety and welfare. 2. The attending physician is notified promptly of the error or significant medication discrepancy. 3. The physician's orders [REDACTED]. 4. The following information is documented in the resident's medical record: a. Factual description of the discrepancy in the case of errors. b. Name of physician and time notified. c. Physician's subsequent orders. d. Resident's condition for 24 to 72 hours or as directed. 5. A medication discrepancy/error/incident report is completed. 6. The incident is included on the shift change report. 7. Medication/error/incident reports and follow-up reports are reviewed on a regular basis by the Performance Improvement Committee and acted upon as appropriate. Review of the Food and Drug Administration (FDA) website revealed [MEDICATION NAME] is an anti-psychotic medicine used to treat [MEDICAL CONDITION] in patients whose symptoms are not controlled with standard anti-psychotic drugs. [MEDICATION NAME] is also used in patients with recurrent suicidal behavior associated with [MEDICAL CONDITION]. It further stated while [MEDICATION NAME] is beneficial for some patients, there are risk associated with this drug. Specifically, [MEDICATION NAME] can decrease the number of [DIAGNOSES REDACTED]s, a type of white blood cell, that function in the body to fight off infections resulting in severe [DIAGNOSES REDACTED]. For this reason, patients taking [MEDICATION NAME] need to have their absolute [DIAGNOSES REDACTED] count (ANC) monitored on a regular basis. This monitoring requirements serves as the basis for the [MEDICATION NAME] Risk Evaluation and Mitigation Strategy (REMS). The [MEDICATION NAME] REMS Program was approved in [DATE] and is a shared-system program, meaning that it includes all [MEDICATION NAME] medicines approved by the FDA. The [MEDICATION NAME] REMS Program ensures optimal patient monitoring for the management of [MEDICATION NAME]-induced severe [DIAGNOSES REDACTED], providing a centralized system for prescribers and pharmacists in managing patient risk. Record review revealed the facility admitted Resident #1 on [DATE] with [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set (MDS) assessment, dated [DATE], revealed the facility assessed Resident #1's cognition as intact with a Brief Interview for Mental Status (BIMS) score of fifteen (15) which indicated the resident was interviewable. Further review of the MDS assessment revealed the resident received an anti-psychotic for the seven (7) day look back period. Review of Resident #1's Comprehensive Care Plan for Active and or at risk for behavior and Paranoia, dated [DATE], revealed an intervention to administer and monitor the effectiveness and side effects of medication as ordered. Review of the physician's orders [REDACTED]. Review of the [DATE] Medication Administration Record (MAR), revealed the [MEDICATION NAME] 50 mg have been administered at 8:00 AM and 4:00 PM and a number was to be used to indicate the administration of the medication. The numbers and what they indicated were as follows: 0-Administered, 3-Refused, 6-Dose/Treatment not due, 9-Behavior outcome, 12 Hold-MD see note , and 99-Hold see nurses note. Further review revealed a 0 was noted by the [MEDICATION NAME], indicating it was administered from [DATE] through [DATE] at 8:00 AM and 4:00 PM and [DATE] at 8:00 AM by LPN #1. Interview with LPN #1 on [DATE] at 10:30 AM revealed she did not administer the [MEDICATION NAME] from [DATE] at 8:00 AM until [DATE] at 8:00 AM because the pharmacy was unable to fill the medication until the physician's certification was up to date. She stated she had called the pharmacy and physician's office every day trying to get the medication but was told the physician had to be certified, as well as the pharmacy to be able to refill the medication. She stated she did not tell anyone about not having the medication or the need for the physician certification because the administrative nursing staff and Administrator were all on vacation; however, the DON was not on vacation during this time. She revealed she coded the MAR with 0', indicating the medication was given, because there was no other code applied to the situation. She further stated she thought she documented what was going on with Resident #1's medication on the 24 hour report and did not remember if she documented in the resident's progress notes or not. In addition, LPN #1 did not complete a medication error report or initiate increased monitoring of the resident per facility policy. Review of Resident #1's Progress Note Report, dated [DATE] through [DATE] revealed no documentation was made related to the missed doses of [MEDICATION NAME], notification to the pharmacy, notification to the physician's office, or any conversation that may have taken place between the pharmacy or physician's office per facility policy. Further review revealed there was no documentation that any nursing staff in the chain of command was notified of the missed doses or the Physician's expired certification. In addition, review of the 24 hour reports forms, dated [DATE] through [DATE] revealed there was no documentation related to the omission of Resident #1's [MEDICATION NAME], Physician Notification, Pharmacy notification, or responsible party notification per facility policy. Review of the Progress Nurse Report completed by LPN #1, dated [DATE] at 3:42 PM, revealed Resident #1 was observed crying in his/her room; and, long term care (LTC) and education was provided related to increased incontinent bowel and bladder episodes. Review of Resident #1's Progress Notes Report completed by LPN #2, dated [DATE] at 8:00 AM, revealed Resident #1 was diaphoretic and pale; was noted to have one episode of vomiting, and his/her blood glucose was 187 milligrams per deciliter (mg/dl) (normal: ,[DATE] mg/dl). The resident requested to have something to drink and only ate a minimal portion of breakfast. Review of a Progress Note, dated [DATE] at 9:59 AM revealed the resident was sitting in the hall beside room, was crying, and stated, I am possessed by the devil and its not a crazy idea, I know I am. LPN #2 noted the resident was having Extrapyramidal effects (drug-induced movement disorders that may include continuous spasms and muscle contractions, motor restlessness, rigidity, and irregular, jerky movements) of facial and eye movements. The resident was also noted to be talking slowly and slurring. The nurse attempted to notify the on call Physician with no return call. Further review revealed the Nurse notified Emergency Medical Services at 10:30 AM due to the resident's altered mental status and [MEDICAL CONDITION]. Interview with LPN #2 on [DATE] at 9:30 AM revealed Resident #1 was talking out of her head, talking about the devil, then started self propelling his/her wheelchair down the hall and continued to talk out of his/her head. She stated she was not working the hall that Resident #1 was on, on [DATE], but knew the resident's baseline so she went to LPN #1 and told her something was wrong with Resident #1. She stated LPN #1 told her that Resident #1 had been without his/her [MEDICATION NAME] for seven (7) days and had been talking out of her head that morning. She revealed she attempted to notify the on-call Physician but felt the need to call the ambulance before a return call was received from the on-call Physician. She stated she assisted LPN #1 with preparing Resident #1 for transfer to the hospital and then called the ER to give them a report and make them aware of the missed doses of [MEDICATION NAME]. Review of Progress Note, dated [DATE] at 11:48 AM revealed a call was received from the emergency room (ER) due to the resident having increased behaviors at hospital. The nurse was informed by nurse at hospital that the resident was trying to hit people, throw self off stretcher and was unable to speak. Further review revealed at 12:47 PM, the nurse called the hospital to check on Resident #1 and was informed the resident was just now getting stabilized from being combative. At 5:55 PM, the hospital was called and the hospital revealed the resident was admitted for [MEDICAL CONDITION]. Review of Resident #1's H & P, with admission date of [DATE] and date of service [DATE], revealed the resident was paranoid, agitated and aggressive. The history was obtained from the resident's sister. The resident was diagnosed with [REDACTED]. During the morning rounds the resident was aggressive, and had to be given intramuscular [MEDICATION NAME] (anti-psychotic), which calmed the resident down. Further review revealed it was documented on the H & P that the resident's last psychiatric admission was two (2) or three (3) years ago. The resident was on prescribed medication of [MEDICATION NAME] for a few years and for the past one week his/her Cocaine was not available. There were prior suicidal attempts by overdosing on multiple pills. The resident was started on [MEDICATION NAME] 50 mg and an Intramuscular (IM) [MEDICATION NAME] 10 mg every six (6) hours as needed (PRN). Further review revealed Resident #1 was admitted to the hospital's psychiatric unit on [DATE] due to acute exacerbation of psychotic episode secondary to medication abstinence for a week. Interview with Resident #1's daughter on [DATE] at 1:25 PM revealed her parent, prior to the event, to be alert and talkative, and would participate in activities but now is distant, grouchy and didn't recognize her while in the hospital because he/her had not returned to a therapeutic drug level. Further interview on [DATE] at 1:10 PM revealed she was not aware that her parent had not received his/her [MEDICATION NAME] until she was at the hospital as she was informed by the hospital staff. Interview with the Occupational Therapist/Directory of therapy on [DATE] at 10:00 AM revealed Resident #1 had been picked up by therapy after returning from the hospital related to a decline and general weakness. The interview revealed she felt like the decline was directly related to the psychotic episode, and was a significant change from her baseline. She stated she had noticed a lot of improvement in the last two (2) weeks. She revealed the resident continues to be a little sluggish but is able to answer appropriately, knows who they are and is compliant with therapy. Interview with Certified Nurse Aide (CNA) #1 on [DATE] at 11:45 AM revealed she did not know what was going on with Resident #1. She stated she had been off work a few days then returned on [DATE] and [DATE] to find him/her not acting him/herself . She stated normally Resident #1 was up, doing for him/her self, but his/her mood changed. He/she was not as witty, was forgetful, and had to be encouraged to do for him/herself. She stated the resident was then sent out to the hospital, then returned, and was placed on one-on-one supervision. Interview with CNA #2 on [DATE] at 12:00 PM revealed she worked directly with Resident #1. She stated he/she always had good days and bad days but for the first week of October, was having more bad days, physically and mentally. She stated she had noticed, in the last few weeks, he/she was coming back to how he/she was prior to being sent to the hospital. Review of the facility Root Cause Investigation related to the medication error, not dated, revealed the medication was due to be refilled and the pharmacy representative logged into the REMS website on [DATE] and noted the physician's certification status had expired. The pharmacy representative stated she first made contact with the physician's office on [DATE] via fax to inform the Physician that the physician's certification was ineligible. The Pharmacy Representative stated she received the labs from the facility on [DATE]. The Pharmacy Representative stated she spoke with the facility on [DATE] to inform them that the physician's certification had expired and that they would not be receiving the medication until it had been approved. Interview with Resident #1's Physician on [DATE] revealed he was on vacation at the time of the event and was not aware of his certification expiring, and feels he should have been notified by the pharmacy. He stated he was not sure who should have been responsible for the certification but the labs were done, as they were every month and were normal so feel the pharmacy should have given an emergency dose until he returned from vacation. He further stated the certification was a complicated process and he was not going to do it while on vacation. Interview with the Unit Manager/Assistant Director of Nursing (ADON) on [DATE] at 2:40 PM revealed she was not made aware of the problem with the medication until the day Resident #1 was sent out to the hospital. Interview with the Director of Nursing (DON) on [DATE] at 4:00 PM and on [DATE] at 12:35 PM revealed she was not aware of the event until [DATE], the day the resident was sent out to the hospital. She stated she expects nursing administration to be notified when medications cannot be obtained from pharmacy, that she considered this a medication error, and the nurse should have followed the facility policy. She stated if Nursing Administration had been aware of the omissions of medication, they could have gotten an order to send Resident #1 to the hospital. Interview with the Administrator on [DATE] at 4:00 PM and on [DATE] at 12:37 PM revealed she was not aware of the drug omissions until she spoke with the resident's family on Monday, [DATE]. She stated she expected all residents to receive their medication as ordered by the physician and in the absence of the medication, the nurse should follow the plan provided to receive the medication and appropriate notification. The interview further revealed the omission of the medication was considered a medication error and all staff had been inserviced and educated on what to do if this should happen again. She stated if they had of been aware of the situation, they could have gotten an order to send him/her to the hospital so no further doses of [MEDICATION NAME] would have been missed. **The facility implemented the following actions to correct the deficient practice: 1. On return from vacation, the physician was made aware of the expired certification and as the Medical Director, met with the Quality Assurance Performance Improvement (QAPI) team on [DATE] to discuss possible citations of deficient practice. Resident #1 is now a patient of a different doctor who has his Physician certification along with one (1) Physician Assistant (PA) and one (1) Nurse Practitioner (NPRN) in his office. Resident #1 received his/her [MEDICATION NAME] on [DATE]. 2. The facility completed body audits on all resident's with a Brief Interview of Mental Statux (BIMS) score less than eight (8), and a verbal interview was conducted with residents with a BIMS score of eight (8) or above related to missed medication on [DATE]. No concerns were identified. 3. All residents were assessed by the DON to ensure quality of care is being delivered, no change of conditions are noted, resident's care plans are being followed and medications are available and being administered as ordered by the Physician starting on [DATE]. No concerns were identified. 4. All licensed staff and Certified Medication Technicians (CMT's) were inserviced on Physician Orders, Medication Discrepancies/omissions, Charting and Documentation, Comprehensive Care Plans, Change of Condition, Medication Administration-General Guidelines, and Physician and Administrative nursing notification on [DATE], [DATE], and [DATE]. Any staff not present for the inservicing will not be allowed to work until education is competed. Post testing was also conducted with 100% accuracy required. 5. A post-test, with a score of 100%, which includes questions from the education provided, is being administered daily by the Staff Development Coordinator (STC), Nursing Supervisors, and Minimum Data Set (MDS) Coordinator, starting on [DATE] to five (5) different staff members on different shifts daily for one (1) week to include weekends, then two (2) different staff members on different shifts daily for one (1) week to include weekends. 6. The DON, ADON, or Nursing Supervisor will review omission reports from the EZMAR system, along with the 24 hour reports, which includes all new orders, admission orders [REDACTED]. 7. A nurse from the regional team or cooperate office has been onsite since [DATE] and remained in contact with the facility for two (2) weeks, onsite or by phone to review on-going post-test, daily reviews during clinical white board meetings, and staff questionnaires. Then weekly for 1 (one) month. 8. Quality improvement (QI) will meet monthly to evaluate the plan and make adjustments as needed. **The State Survey Agency validated the facility's plan of action was carried out by: 1. Interview with the Medical Assistant to Resident #1's current Physician, on [DATE] at 11:45 AM, revealed he was aware of the [MEDICATION NAME] certification, and was working in the office where one (1) Physician, one (1) Physician Assistant (PA) and one (1) Nurse Practitioner (NPRN) all had completed their certification to be able to fill [MEDICATION NAME]. Review of the Progress Note revealed Resident #1's medication was received on [DATE] from the back up pharmacy and administered at 6:26 PM. 2. Review of the Facility Room Census form revealed all interviewable residents were asked if they had missed any medications with all residents stating no except for three (3) that stated they did not know on [DATE]. Review of Skin Assessment Tools, revealed all residents with a BIMS less than eight (8) had body audit completed to identify any change of condition on [DATE]. No concerns were identified. 3. Review of the Facility Room Census form revealed all residents (total of 99) were assessed to ensure quality of care is being delivered, no change of conditions were noted, care plans were being followed and medications were available and are being administered as ordered by the Physician. The DON started the assessments on [DATE] and completed them on [DATE]. 4. Review of an Inservice Report revealed all staff were inserviced on [DATE] through [DATE]. Review of Post tests revealed all staff had completed a post test with results of 100% accuracy. Interviews on [DATE] with LPN #1 at 10:30 AM, LPN #3 at 2:45 PM, LPN #4 at 2:55 PM and RN #1 at 3:10 PM, revealed they were educated on what action they were supposed to take when a medication was not available for administration. They stated they are supposed to call the pharmacy and if unable to obtain they should call the physician for an order to hold the medication. In addition, they revealed they should report the medication was not available to the DON, ADON, Administrator and family member. They also stated they should document on the 24 hour report, monitor the resident due to the resident not receiving medications, and on how to document on the MAR and to document in the progress notes. In addition, they stated a Post Test was administered after the inservicing and they had to score 100%. Interview with the DON and the Administrator [DATE] at 3:10 PM revealed they had educated all licensed staff on Notification, what to do if out of a medication, what to document if out of a medication, and documentation. They stated the DON was educated by the Corporate Nurse on [DATE] to include Policy and procedure for medication administration per physician's orders [REDACTED]. 5. Review of the Staff post-tests which included questions about the education provided was administered daily by the Staff Development Coordinator, Nursing Supervisors, MDS Coordinator to five (5) staff member on different shifts for one week to include weekend and two (2) different staff members on different shifts daily for one (1) week to include weekend. Interview with the DON and Administrator on [DATE] at 3:15 PM, revealed post testing had been administered by them and all other administrative staff as available. 6. Interview with the Administrator and DON on [DATE] at 3:15 revealed the DON, ADON, or Nursing Supervisor were reviewing omission report from the EZMAR system, along with the 24 hour reports, which includes all new orders, admission orders [REDACTED]. 7. Post survey interview with the Administrator on [DATE] at 12:15 PM revealed a nurse from the regional team or cooperate office has been onsite since [DATE] and remained in contact with the facility for two (2) weeks, onsite or by phone, to review on-going post-test, daily reviews during clinical white board meetings, and staff questionnaires. Then weekly for 1 (one) month and had been completed. 8. Review of the facility Plan of Correction revealed a Quality Assurance Performance Improvement (QAPI) meeting was held with the Medical Director on [DATE] to review and discuss possible citations of deficient practice, a plan was discussed to address possible citations of deficient practice, and a formulated Plan of Correction (P(NAME)) was reviewed. Interview with the Administrator on [DATE] at 9:00 AM revealed the facility continues to have monthly QAPI meetings.

Based on interview, record review, and review of the facility's policy and procedure, it was determined the facility failed to maintain a complete and accurately documented medical record for one (1) of three (3) sampled residents (Resident #1). On [DATE] through [DATE], Licensed Practical Nurse (LPN) #1 documented she administered Resident #1's [MEDICATION NAME] (antipsychotic) 50 milligrams at 8:00 AM and 4:00 PM; however, the medication was not available to administer. In addition, LPN #1 failed to document in the resident's progress notes that the medication was not available to administer, why the medication was not available, physician notification, or any action she had taken to obtain the medication and inability to obtain medication. The findings include: Review of facility's policies Medication Discrepancies dated [DATE], revealed medication discrepancies and change of condition should be documented in the resident's record. Record review revealed the facility admitted Resident #1 on [DATE] with [DIAGNOSES REDACTED]. Review of the [DATE] Medication Administration Record (MAR), revealed a number was to be used to indicate what was done with medication as follows; 0-Administered, 3-Refused, 6-Dose/Treatment not due, 9-Behavior outcome, 12 Hold-Physician (MD) see note , and 99-Hold see nurses note. Further review of the MAR revealed LPN #1 coded the MAR for [MEDICATION NAME] 50 milligrams (mg) on [DATE] through [DATE] at 8:00 AM and 4:00 PM as a 0 which indicated the medication was administered. However, interview with LPN #1, on [DATE] at 10:30 AM, revealed there was no [MEDICATION NAME] available to administer to the resident from [DATE] through [DATE] because Pharmacy needed the Physician ceritification to be able to fill the prescription, and he was out of town on vacation. She stated she documentedl 0 instead of 99 which indicated -hold-see Nurse's note because she did not think any of the other codes fit the situation. Further interview with LPN #1 on [DATE] at 10:30 AM, revealed she had called the pharmacy and Physician's office every day trying to get the medication but was told the Physician that prescribes this medication had to be certified, as well as the pharmacy to be able to fill the medicine. She stated she did not remember if she documented this information in Resident #1's progress notes or not. However, review of the Progess Notes, dated [DATE] through [DATE] revealed there was no documentation regarding Resident #1 not receiving his/her [MEDICATION NAME] during this time, nor was there documentation indicating the physician or pharmacy was contacted. Interview with Pharmacist on [DATE] at 9:05 AM revealed a current prescriber certification is required to fill the medication, [MEDICATION NAME]. The Pharmacist indicated that the Physician's prescriber's certification had recently expired; therefore, the pharmacy was unable to refill the medication. Interview with the Director of Nursing (DON) on [DATE] at 1:05 PM revealed she would have expected LPN #1 to document medication omissions, and any contact with the physician's office or pharmacy, in Resident #1's progress notes. Further interview with the DON on [DATE] at 9:30 AM revealed that code 99-Hold see nurses note, should have been entered on the MAR for the medication omission instead of code 0 (indicating the medication was administered). The DON further stated Code 99 would have triggered an omission on the Omission Report that is printed daily for ADON to review Interview with the Administrator, on [DATE] at 1:25 PM, revealed LPN #1 did not document in the Progress Notes as she should have and inappropriately documented on the MAR. **The facility implemented the following actions to correct the deficient practice: 1. On return from vacation, the physician was made aware of the expired certification and as the Medical Director, met with the Quality Assurance Performance Improvement (QAPI) team on [DATE] to discuss possible citations of deficient practice. Resident #1 is now a patient of a different doctor who has his Physician certification along with one (1) Physician Assistant (PA) and one (1) Nurse Practitioner (NPRN) in his office. Resident #1 received his/her medication on [DATE]. 2. The facility completed body audits on all resident's with a Brief Interview of Mental Statux (BIMS) score less than eight (8), and a verbal interview was conducted with residents with a BIMS score of eight (8) or above related to missed medication on [DATE]. No concerns were identified. 3. All residents were assessed by the DON to ensure quality of care is being delivered, no change of conditions are noted, resident's care plans are being followed and medications are available and being administered as ordered by the Physician starting on [DATE]. No concerns were identified. 4. All licensed staff and Certified Medication Technicians (CMT's) were inserviced on Physician Orders, Medication Discrepancies/omissions, Charting and Documentation, Comprehensive Care Plans, Change of Condition, Medication Administration-General Guidelines, and Physician and Administrative nursing notification on [DATE], [DATE], and [DATE]. Any staff not present for the inservicing will not be allowed to work until education is competed. Post testing was also conducted with 100% accuracy required. 5. A post-test, with a score of 100%, which includes questions from the education provided, is being administered daily by the Staff Development Coordinator (STC), Nursing Supervisors, and Minimum Data Set (MDS) Coordinator, starting on [DATE] to five (5) different staff members on different shifts daily for one (1) week to include weekends, then two (2) different staff members on different shifts daily for one (1) week to include weekends. 6. The DON, ADON, or Nursing Supervisor will review omission reports from the EZMAR system, along with the 24 hour reports, which includes all new orders, admission orders [REDACTED]. 7. A nurse from the regional team or cooperate office has been onsite since [DATE] and remained in contact with the facility for two (2) weeks, onsite or by phone to review on-going post-test, daily reviews during clinical white board meetings, and staff questionnaires. Then weekly for 1 (one) month. 8. Quality improvement (QI) will meet monthly to evaluate the plan and make adjustments as needed. **The State Survey Agency validated the facility's plan of action was carried out by: 1. Interview with the Medical Assistant to Resident #1's current Physician, on [DATE] at 11:45 AM, revealed he was aware of the [MEDICATION NAME] certification, and was working in the office where one (1) Physician, one (1) Physician Assistant (PA) and one (1) Nurse Practitioner (NPRN) all had completed their certification to be able to fill [MEDICATION NAME]. Review of the Progress Note revealed Resident #1's medication was received on [DATE] from the back up pharmacy and administered at 6:26 PM. 2. Review of the Facility Room Census form revealed all interviewable residents were asked if they had missed any medications with all residents stating no except for three (3) that stated they did not know on [DATE]. Review of Skin Assessment Tools, revealed all residents with a BIMS less than eight (8) had body audit completed to identify any change of condition on [DATE]. No concerns were identified. 3. Review of the Facility Room Census form revealed all residents (total of 99) were assessed to ensure quality of care is being delivered, no change of conditions were noted, care plans were being followed and medications were available and are being administered as ordered by the Physician. The DON started the assessments on [DATE] and completed them on [DATE]. 4. Review of an Inservice Report revealed all staff were inserviced on [DATE] through [DATE]. Review of Post tests revealed all staff had completed a post test with results of 100% accuracy. Interviews on [DATE] with LPN #1 at 10:30 AM, LPN #3 at 2:45 PM, LPN #4 at 2:55 PM and RN #1 at 3:10 PM, revealed they were educated on what action they were supposed to take when a medication was not available for administration. They stated they are supposed to call the pharmacy and if unable to obtain they should call the physician for an order to hold the medication. In addition, they revealed they should report the medication was not available to the DON, ADON, Administrator and family member. They also stated they should document on the 24 hour report, monitor the resident due to the resident not receiving medications, and on how to document on the MAR and to document in the progress notes. In addition, they stated a Post Test was administered after the inservicing and they had to score 100%. Interview with the DON and the Administrator [DATE] at 3:10 PM revealed they had educated all licensed staff on Notification, what to do if out of a medication, what to document if out of a medication, and documentation. They stated the DON was educated by the Corporate Nurse on [DATE] to include Policy and procedure for medication administration per physician's orders [REDACTED]. 5. Review of the Staff post-tests which included questions about the education provided was administered daily by the Staff Development Coordinator, Nursing Supervisors, MDS Coordinator to five (5) staff member on different shifts for one week to include weekend and two (2) different staff members on different shifts daily for one (1) week to include weekend. Interview with the DON and Administrator on [DATE] at 3:15 PM, revealed post testing had been administered by them and all other administrative staff as available. 6. Interview with the Administrator and DON on [DATE] at 3:15 revealed the DON, ADON, or Nursing Supervisor were reviewing omission report from the EZMAR system, along with the 24 hour reports, which includes all new orders, admission orders [REDACTED]. 7. Post survey interview with the Administrator on [DATE] at 12:15 PM revealed a nurse from the regional team or cooperate office has been onsite since [DATE] and remained in contact with the facility for two (2) weeks, onsite or by phone, to review on-going post-test, daily reviews during clinical white board meetings, and staff questionnaires. Then weekly for 1 (one) month and had been completed. 8. Review of the facility Plan of Correction revealed a Quality Assurance Performance Improvement (QAPI) meeting was held with the Medical Director on [DATE] to review and discuss possible citations of deficient practice, a plan was discussed to address possible citations of deficient practice, and a formulated Plan of Correction (P(NAME)) was reviewed. Interview with the Administrator on [DATE] at 9:00 AM revealed the facility continues to have monthly QAPI meetings.

Based on interview, record review, review of the hospital History and Physical (H&P), and facility policy review it was determined the facility failed to notify a resident's family member related to the omission of a significant antipsychotic medication for one (1) of three (3) sampled residents (Resident #1). Resident #1 did not receive his/her [MEDICATION NAME] (antipsychotic) twice a day from [DATE] through [DATE] (thirteen {13} doses); however, the licensed nurse failed to notify the resident's family member, On [DATE], Resident #1 had to be sent to the emergency room due to acute exacerbation of psychotic episode secondary to medication abstinence for a week. The findings include: Review of the facility policy titled Medication Discrepancies, dated [DATE], revealed medication discrepancies are documented and reported to the resident's attending physician, Director of Nursing (DON), responsible party, and the Performance Improvement Committee. Record review revealed the facility admitted Resident #1 on [DATE] with [DIAGNOSES REDACTED]. Review of the Physician's Orders, dated [DATE] revealed to administer [MEDICATION NAME] 50 mg tablet, give one tablet by mouth daily at 8:00 AM and every night for [MEDICAL CONDITION]. Interview with Licensed Practical Nurse (LPN) #1 on [DATE] at 10:30 AM revealed she did not administer the [MEDICATION NAME] from [DATE] at 8:00 AM until [DATE] at 8:00 AM because the pharmacy was unable to fill the medication until the physician's certification was updated. However, review of the Progress Note Report for the month of [DATE] revealed there was no documented evidence the family member/responsible party was made aware of the medication omissions. Further interview with LPN #1 revealed she did not tell anyone including the family about not having the medication or the need for the physician's certification to fill the prescription. Review of Resident #1's Progress Notes Reports completed by LPN #2, revealed on [DATE] at 8:00 AM, Resident #1 was diaphoretic and pale; and was noted to have one episode of vomiting. At 9:59 AM, the resident was sitting in the hall beside room, was crying, and stated, I am possessed by the devil and its not a crazy idea, I know I am. LPN #2 documented she noted irregular jerky facial and eye movements. The resident was also noted to be talking slowly and slurring. At 10:30 AM, the Nurse notified Emergency Medical Services to send the resident to the emergency room due to the resident's altered mental status and [MEDICAL CONDITION]. Review of the hsoptail H & P revealed the resident was admitted to the the hospital with acute psychotic decompensation related to omission of his/her antipsychotic for seven (7) days on [DATE]. Interview (Post Survey) with Resident #1's daughter, on [DATE] at 3:45 PM, revealed she did not know anything about the missed medication until [DATE] when she called the emergency room (ER) to find out what had happened to her family member and was informed by the ER department about the missed doses of antipsychotic medication. She stated the facility did not notify her of anything until the resident was sent out to the hospital. Interview (Post Survey) with the Administrator, on [DATE] at 3:50 PM, revealed she expected all responsible parties to be notified of any significant issues. **The facility implemented the following actions to correct the deficient practice: 1. On return from vacation, the physician was made aware of the expired certification and as the Medical Director, met with the Quality Assurance Performance Improvement (QAPI) team on [DATE] to discuss possible citations of deficient practice. Resident #1 is now a patient of a different doctor who has his Physician certification along with one (1) Physician Assistant (PA) and one (1) Nurse Practitioner (NPRN) in his office. Resident #1 received his/her medication on [DATE]. 2. The facility completed body audits on all resident's with a Brief Interview of Mental Statux (BIMS) score less than eight (8), and a verbal interview was conducted with residents with a BIMS score of eight (8) or above related to missed medication on [DATE]. No concerns were identified. 3. All residents were assessed by the DON to ensure quality of care is being delivered, no change of conditions are noted, resident's care plans are being followed and medications are available and being administered as ordered by the Physician starting on [DATE]. No concerns were identified. 4. All licensed staff and Certified Medication Technicians (CMT's) were inserviced on Physician Orders, Medication Discrepancies/omissions, Charting and Documentation, Comprehensive Care Plans, Change of Condition, Medication Administration-General Guidelines, and Physician and Administrative nursing notification on [DATE], [DATE], and [DATE]. Any staff not present for the inservicing will not be allowed to work until education is competed. Post testing was also conducted with 100% accuracy required. 5. A post-test, with a score of 100%, which includes questions from the education provided, is being administered daily by the Staff Development Coordinator (STC), Nursing Supervisors, and Minimum Data Set (MDS) Coordinator, starting on [DATE] to five (5) different staff members on different shifts daily for one (1) week to include weekends, then two (2) different staff members on different shifts daily for one (1) week to include weekends. 6. The DON, ADON, or Nursing Supervisor will review omission reports from the EZMAR system, along with the 24 hour reports, which includes all new orders, admission orders [REDACTED]. 7. A nurse from the regional team or cooperate office has been onsite since [DATE] and remained in contact with the facility for two (2) weeks, onsite or by phone to review on-going post-test, daily reviews during clinical white board meetings, and staff questionnaires. Then weekly for 1 (one) month. 8. Quality improvement (QI) will meet monthly to evaluate the plan and make adjustments as needed. **The State Survey Agency validated the facility's plan of action was carried out by: 1. Interview with the Medical Assistant to Resident #1's current Physician, on [DATE] at 11:45 AM, revealed he was aware of the [MEDICATION NAME] certification, and was working in the office where one (1) Physician, one (1) Physician Assistant (PA) and one (1) Nurse Practitioner (NPRN) all had completed their certification to be able to fill [MEDICATION NAME]. Review of the Progress Note revealed Resident #1's medication was received on [DATE] from the back up pharmacy and administered at 6:26 PM. 2. Review of the Facility Room Census form revealed all interviewable residents were asked if they had missed any medications with all residents stating no except for three (3) that stated they did not know on [DATE]. Review of Skin Assessment Tools, revealed all residents with a BIMS less than eight (8) had body audit completed to identify any change of condition on [DATE]. No concerns were identified. 3. Review of the Facility Room Census form revealed all residents (total of 99) were assessed to ensure quality of care is being delivered, no change of conditions were noted, care plans were being followed and medications were available and are being administered as ordered by the Physician. The DON started the assessments on [DATE] and completed them on [DATE]. 4. Review of an Inservice Report revealed all staff were inserviced on [DATE] through [DATE]. Review of Post tests revealed all staff had completed a post test with results of 100% accuracy. Interviews on [DATE] with LPN #1 at 10:30 AM, LPN #3 at 2:45 PM, LPN #4 at 2:55 PM and RN #1 at 3:10 PM, revealed they were educated on what action they were supposed to take when a medication was not available for administration. They stated they are supposed to call the pharmacy and if unable to obtain they should call the physician for an order to hold the medication. In addition, they revealed they should report the medication was not available to the DON, ADON, Administrator and family member. They also stated they should document on the 24 hour report, monitor the resident due to the resident not receiving medications, and on how to document on the MAR and to document in the progress notes. In addition, they stated a Post Test was administered after the inservicing and they had to score 100%. Interview with the DON and the Administrator [DATE] at 3:10 PM revealed they had educated all licensed staff on Notification, what to do if out of a medication, what to document if out of a medication, and documentation. They stated the DON was educated by the Corporate Nurse on [DATE] to include Policy and procedure for medication administration per physician's orders, discrepancy reporting, procedure to follow to ensure medication availability, notification of MD when medications are unavailable, communication of availability of medications on the 24 hour report, omission reports, notification of on-call Administration Nurse, SBAR, and to follow the care plan. 5. Review of the Staff post-tests which included questions about the education provided was administered daily by the Staff Development Coordinator, Nursing Supervisors, MDS Coordinator to five (5) staff member on different shifts for one week to include weekend and two (2) different staff members on different shifts daily for one (1) week to include weekend. Interview with the DON and Administrator on [DATE] at 3:15 PM, revealed post testing had been administered by them and all other administrative staff as available. 6. Interview with the Administrator and DON on [DATE] at 3:15 revealed the DON, ADON, or Nursing Supervisor were reviewing omission report from the EZMAR system, along with the 24 hour reports, which includes all new orders, admission orders [REDACTED]. 7. Post survey interview with the Administrator on [DATE] at 12:15 PM revealed a nurse from the regional team or cooperate office has been onsite since [DATE] and remained in contact with the facility for two (2) weeks, onsite or by phone, to review on-going post-test, daily reviews during clinical white board meetings, and staff questionnaires. Then weekly for 1 (one) month and had been completed. 8. Review of the facility Plan of Correction revealed a Quality Assurance Performance Improvement (QAPI) meeting was held with the Medical Director on [DATE] to review and discuss possible citations of deficient practice, a plan was discussed to address possible citations of deficient practice, and a formulated Plan of Correction (P(NAME)) was reviewed. Interview with the Administrator on [DATE] at 9:00 AM revealed the facility continues to have monthly QAPI meetings.

Based on interview, record review, review of the hospital History and Physical (H&P), review of the Kentucky Board of Nursing (KBN) Advisory Opinion Statement (AOS) #27, and facility policy review, it was determined the facility failed to ensure the care provided met professional standard of quality for one (1) of three (3) sampled residents (Resident #1). On [DATE] through [DATE], Licensed Practical Nurse (LPN) #1 documented she administered Resident #1's [MEDICATION NAME] (an antipsychotic) 50 milligrams at 8:00 AM and 4:00 PM; however, the medication was not available to administer. In addition, LPN #1 failed to document in the resident's progress notes and on the 24-hour report that the medication was not available to administer, why the medication was not available, physician notification, or any action she had taken to obtain the medication and inability to obtain medication. LPN #1 did not initiate close monitoring of the resident and failed to identify the resident's increased behaviors could be related to the missed medication. Lastly, LPN #1 failed to notify the Charge Nurse, Director of Nursing (DON) or the Administrator that the medication was not available. The findings include: Review of the KBN AOS #27 LPN Practice, last revised [DATE], revealed the components of licensed practical nursing practice includes assessment, which consists of observations of appearance and behavior, measurement of physical structures and physiologic function, and observations of a resident's subjective and objective signs and symptoms; and, implementation which includes performing nursing interventions and medical orders consistent with the legal scope of practical licensed practical nursing practice and recognizing resident responses to nursing actions and modifying nursing intervention based on changes in a resident's status. In addition, Licensed Practical Nursing Practice includes reporting and recording; and documentation. Reporting and recording includes directing communication to the appropriate person(s) consistent with established policies, procedures, practices, and channels of communication; communicating in a timely manner, and determining if further communication is needed. Documentation includes documenting on the appropriate resident record, accurately describing all nursing care provided, complete within a timely manner, reflect the communication of significant information to other person(s) and verify proper administration and security of medications. Review of the facility's policies Medication Discrepancies dated [DATE], 24-Hour Report last reviewed [DATE] revealed any medication discrepancies were to be documented in the progress notes and on the 24-hour report; and, the attending physician, Director of Nursing (DON), and resident's responsible party were to be notified promptly. Further review of this policy revealed close monitoring of the resident should have been implemented with any medication error/omission. Review of the facility's policy 24-Hour Report, dated [DATE], revealed LPN #1 was to document any pertinent changes in the resident's status, medication errors, and notifications of physicians and family on the 24-Hour Report. Review of the facility's policy Change in Condition, dated [DATE], revealed LPN #1 should have evaluated any change in condition through direct observation, physical examination and vital signs at the onset of the change. Record review revealed the facility admitted Resident #1 on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's [DATE] Medication Administration Record (MAR), revealed a number was to be used to indicate what was done with medication as follows; 0-Administered, 3-Refused, 6-Dose/Treatment not due, 9-Behavior outcome, 12 Hold-Physician (MD) see note, 99-Hold see nurses note, 11 no behavior, and 13 No side effects. Further review of the MAR revealed LPN #1 coded the MAR for [MEDICATION NAME] 50 milligrams (mg) on [DATE] through [DATE] at 8:00 AM and 4:00 PM as a 0 which indicated the medication was administered. However, review of the Physicians Order Noted Report revealed LPN #1 had documented that [MEDICATION NAME] was out indicating the medication was not available from [DATE] through [DATE]. In addition, further review of the MAR revealed LPN #1 entered code 11 (no behavior) on [DATE] at 8:00 AM and Code 13 (no side effects) was entered two (2) times per day for all other times [DATE] through [DATE]. However, review of Progress Note, dated [DATE] at 3:42 PM revealed LPN #1 observed Resident #1 crying because of increased incontinence of bowel and bladder. Further review of the MAR revealed there was no documented evidence the LPN initiated close monitoring of the resident due to the resident not receiving the medication. Interview with LPN #1, on [DATE] at 10:30 AM, revealed there was no [MEDICATION NAME] available to administer to the resident from [DATE] through [DATE]. She stated she documented 0 (administered) instead of 99(hold-see Nurse's Note) because she did not think any of the other codes fit the situation. LPN #1 revealed she did not make anyone aware that the medication was not available and she did not remember documenting behaviors, or lack of, while the resident was not receiving [MEDICATION NAME]. She stated she had called the physician's office and the pharmacy each day from [DATE] until Resident #1 was sent to the hospital on [DATE]. She further stated she was informed the Physician was on vacation and pharmacy representative told her that the medication could not be refilled until the certification was completed and that no one could do anything about this but the physician. However, further review of Progress Notes and the 24-Hour Reports, dated [DATE] through [DATE] revealed LPN #1 had not documented anything about the unavailability of the medication, why the medication was not available, physician notification, or any action she took to obtain the medication and the inability to obtain medication. Review of Progress Notes, dated [DATE] at 8:00 AM, revealed LPN #2 noted Resident #1 had an episode of vomiting with diaphoresis and pallor; and at 9:59 AM, LPN #2 noted Resident #1 was crying with involuntary movement of the face and eyes, as well as slow slurred speech. In addition, it was noted Resident #1 made the comment, I am possessed by the devil and it's not a crazy idea I know I am. Further review revealed Resident #1 was sent to the hospital via ambulance at 10:54 AM. Review of the hospital H & P, dated [DATE] revealed Resident #1 was admitted to the hospital's psychiatric unit on [DATE] due to acute exacerbation of psychotic episode secondary to medication abstinence for a week. Resident #1 required [MEDICATION NAME] (anti-psychotic) 10 mg intramuscularly injection to calm her. Interview with LPN #2 on [DATE] at 9:30 AM revealed she worked on [DATE] from 6:00 AM to 6:30 PM but was not assigned to the hall Resident #1 lived on. LPN #2 stated she knew the resident and realized something was wrong with him/her that morning so she alerted the nurse who was assigned to Resident #1's care (LPN #1). She revealed LPN #1 commented the resident had been out of medication and had been talking out of her head that morning. LPN #2 stated she knew the resident needed to go to the hospital and notified the physician, Emergency Medical Services and the resident's responsible party. She stated she gave report to the emergency room (ER) nurse and informed the ER nurse of the [MEDICATION NAME] omission. Interview with the Medical Director (MD) on [DATE] at 9:00 AM, revealed he was on vacation during the week of [DATE] through [DATE]. Interview with Resident #1's responsible party on [DATE] at 11:55 AM revealed the family was not aware the resident had not received his/her anti-psychotic medication, [MEDICATION NAME], until resident was at the hospital on [DATE] with a psychotic episode. Interview with the DON on [DATE] at 1:05 and 4:00 PM, revealed she expected LPN #1 to notify the DON and/or the ADON that the [MEDICATION NAME] was not available for the resident. The DON stated she was not aware Resident #1 was not getting [MEDICATION NAME] nor that the medication was not available. Further interview with the DON on [DATE] at 9:30 AM revealed that code 99-Hold see nurses note, should have been entered on the MAR for the medication omission instead of code 0. The DON further stated Code 99 would have triggered an omission on the Omission Report that is printed daily for ADON to review. Further interview (Post Survey) with the DON on [DATE] at 9:15 AM revealed documentation should have been completed each time LPN #1 attempted to contact the physician, the pharmacy, as well as any change in behaviors noted in Resident #1. She further stated if it's not documented, it's not done. The DON stated an order should have been obtained for close behavior monitoring of Resident #1 during the week of [DATE] through [DATE] and should have been implemented and indicated on the MAR. Interview with the Administrator on [DATE] at 4:00 PM, revealed she was not aware Resident #1's [MEDICATION NAME] was not available to administer until she spoke with Resident #1's family on [DATE]. Further interview on [DATE] at 9:30 AM revealed she expected the resident to receive the medications as ordered by the physician and in the absence of medications the nurse follow facility policy. Further interview (Post Survey) with the Administrator on [DATE] at 3:50 PM revealed she expected all responsible parties to be notified of any significant issues. **The facility implemented the following actions to correct the deficient practice: 1. On return from vacation, the physician was made aware of the expired certification and as the Medical Director, met with the Quality Assurance Performance Improvement (QAPI) team on [DATE] to discuss possible citations of deficient practice. Resident #1 is now a patient of a different doctor who has his Physician certification along with one (1) Physician Assistant (PA) and one (1) Nurse Practitioner (NPRN) in his office. Resident #1 received his/her medication on [DATE]. 2. The facility completed body audits on all resident's with a Brief Interview of Mental Statux (BIMS) score less than eight (8), and a verbal interview was conducted with residents with a BIMS score of eight (8) or above related to missed medication on [DATE]. No concerns were identified. 3. All residents were assessed by the DON to ensure quality of care is being delivered, no change of conditions are noted, resident's care plans are being followed and medications are available and being administered as ordered by the Physician starting on [DATE]. No concerns were identified. 4. All licensed staff and Certified Medication Technicians (CMT's) were inserviced on Physician Orders, Medication Discrepancies/omissions, Charting and Documentation, Comprehensive Care Plans, Change of Condition, Medication Administration-General Guidelines, and Physician and Administrative nursing notification on [DATE], [DATE], and [DATE]. Any staff not present for the inservicing will not be allowed to work until education is competed. Post testing was also conducted with 100% accuracy required. 5. A post-test, with a score of 100%, which includes questions from the education provided, is being administered daily by the Staff Development Coordinator (STC), Nursing Supervisors, and Minimum Data Set (MDS) Coordinator, starting on [DATE] to five (5) different staff members on different shifts daily for one (1) week to include weekends, then two (2) different staff members on different shifts daily for one (1) week to include weekends. 6. The DON, ADON, or Nursing Supervisor will review omission reports from the EZMAR system, along with the 24 hour reports, which includes all new orders, admission orders [REDACTED]. 7. A nurse from the regional team or cooperate office has been onsite since [DATE] and remained in contact with the facility for two (2) weeks, onsite or by phone to review on-going post-test, daily reviews during clinical white board meetings, and staff questionnaires. Then weekly for 1 (one) month. 8. Quality improvement (QI) will meet monthly to evaluate the plan and make adjustments as needed. **The State Survey Agency validated the facility's plan of action was carried out by: 1. Interview with the Medical Assistant to Resident #1's current Physician, on [DATE] at 11:45 AM, revealed he was aware of the [MEDICATION NAME] certification, and was working in the office where one (1) Physician, one (1) Physician Assistant (PA) and one (1) Nurse Practitioner (NPRN) all had completed their certification to be able to fill [MEDICATION NAME]. Review of the Progress Note revealed Resident #1's medication was received on [DATE] from the back up pharmacy and administered at 6:26 PM. 2. Review of the Facility Room Census form revealed all interviewable residents were asked if they had missed any medications with all residents stating no except for three (3) that stated they did not know on [DATE]. Review of Skin Assessment Tools, revealed all residents with a BIMS less than eight (8) had body audit completed to identify any change of condition on [DATE]. No concerns were identified. 3. Review of the Facility Room Census form revealed all residents (total of 99) were assessed to ensure quality of care is being delivered, no change of conditions were noted, care plans were being followed and medications were available and are being administered as ordered by the Physician. The DON started the assessments on [DATE] and completed them on [DATE]. 4. Review of an Inservice Report revealed all staff were inserviced on [DATE] through [DATE]. Review of Post tests revealed all staff had completed a post test with results of 100% accuracy. Interviews on [DATE] with LPN #1 at 10:30 AM, LPN #3 at 2:45 PM, LPN #4 at 2:55 PM and RN #1 at 3:10 PM, revealed they were educated on what action they were supposed to take when a medication was not available for administration. They stated they are supposed to call the pharmacy and if unable to obtain they should call the physician for an order to hold the medication. In addition, they revealed they should report the medication was not available to the DON, ADON, Administrator and family member. They also stated they should document on the 24 hour report, monitor the resident due to the resident not receiving medications, and on how to document on the MAR and to document in the progress notes. In addition, they stated a Post Test was administered after the inservicing and they had to score 100%. Interview with the DON and the Administrator [DATE] at 3:10 PM revealed they had educated all licensed staff on Notification, what to do if out of a medication, what to document if out of a medication, and documentation. They stated the DON was educated by the Corporate Nurse on [DATE] to include Policy and procedure for medication administration per physician's orders [REDACTED]. 5. Review of the Staff post-tests which included questions about the education provided was administered daily by the Staff Development Coordinator, Nursing Supervisors, MDS Coordinator to five (5) staff member on different shifts for one week to include weekend and two (2) different staff members on different shifts daily for one (1) week to include weekend. Interview with the DON and Administrator on [DATE] at 3:15 PM, revealed post testing had been administered by them and all other administrative staff as available. 6. Interview with the Administrator and DON on [DATE] at 3:15 revealed the DON, ADON, or Nursing Supervisor were reviewing omission report from the EZMAR system, along with the 24 hour reports, which includes all new orders, admission orders [REDACTED]. 7. Post survey interview with the Administrator on [DATE] at 12:15 PM revealed a nurse from the regional team or cooperate office has been onsite since [DATE] and remained in contact with the facility for two (2) weeks, onsite or by phone, to review on-going post-test, daily reviews during clinical white board meetings, and staff questionnaires. Then weekly for 1 (one) month and had been completed. 8. Review of the facility Plan of Correction revealed a Quality Assurance Performance Improvement (QAPI) meeting was held with the Medical Director on [DATE] to review and discuss possible citations of deficient practice, a plan was discussed to address possible citations of deficient practice, and a formulated Plan of Correction (P(NAME)) was reviewed. Interview with the Administrator on [DATE] at 9:00 AM revealed the facility continues to have monthly QAPI meetings.

Based on interview, record review, facility policy and procedure review and review of hospital records, revealed the facility failed to provide care in accordance with one (1) of three (3) sampled residents' written plan of care (Resident #1). Resident #1, who was on [MEDICATION NAME] (blood thinner) sustained a fall on 08/06/16 at 2:00 AM which resulted in two (2) hematomas to the back of the head. However, the facility failed to notify the resident's physician and responsible party per the resident's care plan. In addition, Licensed Practical Nurse (LPN) #2 administered Resident #1 pain medication at 3:00 AM, but she failed to follow the care plan and assess the resident's head pain one (1) hour after the medication was administered to determine if it was effective. Resident #1 was found in bed unresponsive at 6:15 AM and sent to the emergency room . The resident was diagnosed with [REDACTED]. Immediate Jeopardy (IJ) was identified on 08/16/16 and was determined to exist on 08/06/16. The facility was notified of the Immediate Jeopardy (IJ) on 08/16/16. An acceptable Allegation of Compliance (AoC) was received on 08/23/16, alleging the removal of the Immediate Jeopardy (IJ) on 08/17/16. The State Survey Agency validated, on 08/26/16, that the Immediate Jeopardy (IJ) was removed on 08/17/16, as alleged. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC) and the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy and procedures Care Plans-Comprehensive, last revised 06/01/15, revealed the Nurse/Interdisciplinary Team, in coordination with the resident, his/her family or responsible party, develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. Care plan interventions are implemented and the care plan identifies the professional services that are responsible for each element of care. Record review revealed the facility admitted Resident #1 on 03/15/12 with diagnoses, which included [MEDICAL CONDITION], Chronic Back Pain, Restless Leg Syndrome, and [MEDICAL CONDITION]. Review of the Significant Change Minimum Data Set (MDS) Assessment, dated 06/09/16, revealed the facility assessed Resident #1's cognition as intact with a Brief Interview of Mental Status (BIMS) score of fifteen (15) which indicated the resident was interviewable. Review of the Comprehensive Care Plan for risk of pain and falls, last updated 06/21/16, revealed to monitor for any sign and symptoms of pain (crying, grimacing, moaning, guarding, complaints of pain, restlessness, or change in behavior), administer medication as ordered, monitor for effectiveness of pain medication and report falls to physician and responsible party. Review of the August 2016 physician's orders [REDACTED]. Review of a Nursing Assessment for Resident #1 completed by Licensed Practical Nurse (LPN) #2, revealed the resident sustained [REDACTED]. Resident #1 was observed sitting on the floor in the bathroom and had two (2) hematomas on the back of his/her head. The resident stated he/she hit his/her head on the floor. Further review of the Assessment, revealed a neurological assessment was completed, which was within normal parameters and the resident had no pain. However, interviews on 08/12/16 with LPN #2 at 10:20 AM, CNA #1 at 9:15 AM, and CNA #2 at 11:15 AM, revealed the resident complained his/her head hurt at the time of the fall. Review of Resident #1's August 2016 Electronic Medication Administration Record (EMAR) revealed there was no evidence the resident was administered pain medication per the care plan at the time of the fall. Further review of the Nursing Assessment revealed LPN #2 documented she notified the physician of the fall and documented the resident was aware of fall. However, interview with LPN #2 on 08/12/16 at 10:20 AM, revealed when she referred to notifying the physician she just placed the incident report on the resident's clipboard for him to see the next day, she did not call him. She also stated she documented self for family notification because the resident did not have a Power of Attorney for decision making. LPN #2 failed to notify the physician and family of the fall per care plan. Interview with CNA #4, on 08/12/16 at 12:10 PM, revealed when she arrived at work on 08/06/16 at 2:00 AM it was reported to her Resident #1 had fallen and had two (2) hematomas on the back of his/her head. CNA #4 stated when she was in Resident #1's room at approximately 3:00 AM, the resident complained of head pain so she made the nurse aware. She stated when she entered Resident #1's room at approximately 4:00 AM to 4:15 AM, the resident stated the nurse had given him/her a pain pill but his/her head was still hurting. CNA #4 stated the resident asked her to get a bag of ice, she wrapped the ice in a pillowcase, and the resident laid down with the ice on his/her head. CNA #4 stated she reported this to LPN #2. Interview with LPN #2, on 08/12/16 at 10:20 AM, revealed Resident #1 was found on the floor in the bathroom on 08/06/16 and had two (2) bumps on the back of his/her head down by neck and blood on neck. LPN #2 stated the resident complained of a small headache but no pain medication was administered at that time. She stated she did administer pain medication at 3:00 AM when the CNA reported the resident was complaining of head pain. LPN #2 stated she did not recall if she followed up on the pain medication per the resident's care plan. Further interview with LPN #2 on 08/16/16 at 2:10 AM revealed she was not made aware the CNA gave ice to the resident to put on his/her head and that the resident was still complaining of pain at 4:15 AM. Review of Resident #1's Narcotic Count for [MEDICATION NAME] 7.5 mg/325 mg revealed the resident was administered [MEDICATION NAME] on 08/06/16 at 3:00 AM. However, review of the August 2016 MAR and Resident #1's Pain Flow Sheet revealed there was no documented evidence LPN #2 followed the resident's care plan and monitored for the effectiveness of the pain medication. Review of a Nursing Note, dated 08/06/16 at 6:08 AM, and interviews on 08/12/16 with LPN #3 at 11:00 AM and Registered Nurse (RN) #1 at 12:40 PM, revealed LPN #3 and RN #1 were informed by CNAs that Resident #1 was unresponsive. LPN #3 and RN #1 stated Resident #1 did not respond to sternal rub and his/her pupils were fixed (did not react to light). LPN #3 called Emergency Medical Services (EMS). LPN #3 and RN #1 stated the resident's physician should have been notified of the fall at the time of the fall especially since the resident had head injuries and was on blood thinners. In addition, they stated the physician should have been notified if the pain medication was not effective. Review of the hospital emergency room Report and Discharge Summary, dated 08/06/16 revealed the resident was placed on a respirator and passed away at 11:23 PM. The resident was diagnosed with [REDACTED]. Interviews on 08/16/16 with the Assistant Director of Nursing (ADON) at 2:50 PM, and LPN #5 and LPN #6 at 2:55 PM, revealed staff were expected to follow the care plans. Interview with the Director of Nursing (DON) on 08/16/16 at 3:10 PM revealed staff should be familiar with each resident's care plan and follow the care plan for the resident. The facility implemented the following actions to remove the Immediate Jeopardy: 1. The DON conducted an investigation of Resident #1's fall and identified LPN #2 failed to notify the physician and family at the time of the fall. It was also identified that the neuro evaluations were not completed according to the facility's Neurological Assessment/Monitoring Procedure. 2. A Disciplinary Action for LPN #2 was completed by the DON on 08/08/16. On 08/09/16, LPN #2 requested Family Medical Leave. 3. On 08/08/16, the Administrator met with the Medical Director, who was the attending physician for Resident #1. A plan was formulated for Charge Nurses to notify a resident's physician immediately when a resident has an unwitnessed fall and/or has a potential head injury and is receiving anticoagulant therapy. The resident is to be sent to the emergency room for evaluation and treatment. 4. On 08/12/16, current resident charts who had falls for the past four (4) months (from May-August 2016) were audited by the ADON, reviewing falls, fall interventions, care plans, fall assessments, physician and family notifications. Corrections were completed as indicated by the ADON. 5. Immediate education was initiated with licensed nurses on 08/08/16 by the Staff Development Coordinator (SDC) regarding completion of the Event Manager, location of the BIMS score, using an appropriate intervention after each incident, notification of the physician and responsible party with every fall/incident without injury. This education was completed on 08/11/16; and, no licensed nurse worked prior to receiving this education. 6. On 08/12/16, the Regional Nurse Consultant (RNC) completed a competency, the Resident Examination and Assessment Competency, with the DON. On 08/13/16, the RNC also conducted a competency, the Resident Examination and Assessment Competency, with the SDC and two (2) ADONs. 7. The SDC and two (2) ADONs conducted education with the Licensed Nurses which included PRN, Part time and full time nurses on 08/13/16 through 08/15/16 . The education was related to the facilty's policy and procedure for falls, neurological evaluation flow sheet, Event Manager, transcription on physician's orders [REDACTED]. No licensed staff worked prior to receiving this education. In addition, the Resident Examination and Assessment Competency, was completed by the SDC and two ADONs with each licensed nurse. 8. On 08/08/16, the process was initiated to notify the physician, responsible party, and On Call Administrative Nurse with every fall/incident with or without injury. 9. Beginning 08/13/16, the Interdisciplinary Team (IDT) to include but not limited to the DON, ADONs, MDS Coordinators, Medical Records Nurse, Quality of Life Director, Chaplain, Social Service Director, Social Service Assistant, Dietary Manager, and Therapy Manager, will review in the morning clinical meeting (Monday through Friday) telephone orders, change in condition, twenty-four (24) hour report, and medical records of residents to ensure timely notification, of physician and family occurred and any changes in the resident's condition were addressed timely. The RNC has been attending the meeting since 08/12/16 assisting and providing oversight and consultation. On weekends, the Administrative Nurse will be assigned to review telephone orders, SBARS (Situation, Background, and Assessment Recommendations), twenty four (24) hour reports, and medical records of residents to ensure timely notification of physician and family and any changes in resident condition were addressed timely. 10. Beginning 08/13/16, ten (10) residents charts will be audited daily by the Nursing Administration Team (DON, Unit Mangers, SDC, and MDS Coordinators and the Restorative Nurse Manager) for timely physician and family notification, change in condition being addressed, SBARs, telephone orders, and twenty-four (24) hour reports, and documentation being present, until immediacy is lifted. Then five (5) charts per day, five (5) days a week, will be checked for two (2) weeks, and then five (5) charts per week for two (2) weeks. Any issues identified will be addressed at the time of discovery. Results of the audits will be discussed in Quality Assurance Performance Improvement (QAPI) meeting. 11. Administrative oversight will be completed by the Vice President for Operations or RNC, daily until removal of immediacy beginning 08/11/16, then weekly for four (4) weeks, then monthly for six (6) months, to ensure the above audits are completed and any concerns are addressed. Oversight includes assisting with audits, reviewing charts, reviewing audits and providing oversight and consultation. 12. A QA Meeting was held on 08/08/16 with the Medial Director by phone, and an Ad Hoc QAPI meeting was held on 08/15/16 with the Medical Director, Administrator, DOM, RNC, ADONs, SDC, Chaplain, MDS Coordinators, Social Service Director, Human Resource Director, and Medical Records Coordinator were in attendance reviewing the occurrence of Resident #1 and immediate plans put in place. 13. A QAPI meeting will be held weekly until the immediacy has been removed, then monthly for six (6) months for recommendations and further follow up regarding the above stated plan. At that time based on the evaluation, the QAPI Committee will determine at what frequency any ongoing audits will need to continue. 14. Corporate Administrative oversight of the QAPI meeting will be completed by the RNC, Director of Clinical Programs, the Regional Vice President of Operations, or member of the regional staff weekly until removal of the immediacy, then weekly for four (4) weeks, and then monthly for six (6) months. **The State Survey Agency validated the corrective actions taken by the facility as follows: 1. Review of the facility's investigation, not dated, revealed the DON determined LPN #2 failed to conduct neurochecks according to facility policy and failed to notify the physician and family after the resident's fall. Interview with the DON, on 08/26/16 at 11:55 AM revealed she conducted the investigation into Resident #1's fall. She stated she identified LPN #2 had failed to conduct the neurochecks per facility policy and failed to notify the physician and family of the resident's fall. 2. Review of a Disciplinary Action, dated 08/08/16, revealed LPN #2 was counseled by the DON related to insufficient documentation on the Event Report, notification of the physician and family after a fall, and completion of neurochecks per facility policy. Review of a letter, dated 08/09/16 revealed LPN #2 requested Family Medical Leave (FML) with the Human Resource Manager. LPN #2 was placed on FML on 08/09/16. Interview with the DON, on 08/26/16 at 11:55 AM revealed she counseled LPN #2 on her failure to complete the Event Report filling in all blanks, notification of physician and family after a fall, and conducting neurochecks at the appropriate timeframes and using accurate documentation on the form. The DON stated LPN #2 requested FML and it was granted on 08/09/16. 3. Review of a Communication Form per SDC, dated 08/08/16, revealed with every fall/incident with or without injury, the Administrative Nurse, Physician, and the resident's Power of Attorney or family member would be notified. Anytime a resident has a fall with head injury, the resident is to be sent to hospital. The staff signature sheet revealed all licensed staff read the communication sheet between 08/08/16-08/11/16. Interview with the SDC, on 08/26/16, at 11:40 AM, revealed she provided the education on 08/08/16 related to notification of the Administrative Nurse, Physician and the resident's Power of Attorney or family member when a resident had a fall with or without injury. In addition, staff were educated that anytime a resident has a fall with head injury to send the resident to the hospital for evaluation. Interviews on 08/26/16 with LPN #7 at 9:30 AM, LPN #8 at 10:40 AM, LPN #5 at 10:55 AM, RN #1 at 11:00 AM, LPN #4 at 11:25 AM and LPN #9 at 12:00 PM, revealed they were educated on 08/08/16 that when a resident had a fall the to notify the physician, family or POA, and Administrative Nurse. In addition, they stated they should send a resident who had a fall with head injury out to the hospital for evaluation. 4. Review of the Event Reports for May-August 2016 revealed they were reviewed by the ADON on 08/12/16. The ADON identified there were falls where there was no documentation the family had been notified of the falls. Further review revealed each of the families was notified of the fall on 08/12/16 by the Nursing Administrative Team. Interview with the ADON on 08/26/16 at 10:30 AM, revealed she reviewed the event reports for four (4) months (May-August 2016) to determine if the physician and family/POA had been notified of the fall. She stated she identified that some families had not been notified. The Nursing Administrative Teams notified the families on 08/12/16. 5. Review of the Communication Form, dated 08/08/16, revealed the SDC initiated education on 08/08/16 to all licensed staff regarding completion of the Event Manager, location of the BIMS score, using an appropriate intervention after each incident, notification of the physician and responsible party with every fall/incident with or without injury. This education was completed on 08/11/16 and no licensed nurse worked prior to receiving this education. Interview with the SDC, on 08/26/16, at 11:40 AM, revealed she provided education to all licensed staff on 08/08/16-08/11/16 on completion of the Event Manager, using an appropriate intervention after each incident, and notification of the physician and responsible party with every fall/incident with or without injury. Interviews on 08/26/16 with LPN #7 at 9:30 AM, LPN #8 at 10:40 AM, LPN #5 at 10:55 AM, RN #1 at 11:00 AM, LPN #4 at 11:25 AM and LPN #9 at 12:00 PM, revealed the SDC educated them on ensuring an appropriate intervention was put in place after each fall, and notification of the physician and family/POA with every fall with or without injury. 6. Review of the Resident Examination and Assessment Competencies revealed the DON completed the competency on 08/12/16 and the SDC and two (2) ADONs completed the competencies on 08/13/16 with the RNC. Interview with the RNC on 08/26/16 revealed she conducted Resident Examination and Assessment Competencies for the DON, SDC and ADONs. Interviews on 08/26/16 with the SDC at 11:40 AM, and DON at 11:55 AM, revealed they had to complete Resident Examination and Assessment Competencies with the RNC. 7. Review of the Communication Form revealed the SDC and two (2) ADONs conducted education with the Licensed Nurses on 08/13/16 through 08/15/16 regarding policy and procedure for falls, neurological evaluation flow sheet, Event Manager, transcription of Physician Orders, education on narcotic sheets, physician and family notification with every incident, fall interventions, updating the care plans, and post fall assessment. No licensed staff worked prior to receiving this education. In addition, review of the Resident Examination and Assessment Competencies revealed the licensed nurses completed the competencies with the SDC and two (2) ADONs from 08/13/16 through 08/25/16. No licensed nurse worked until their competency was completed. Interview with the SDC, on 08/26/16, at 11:40 AM, revealed she and the ADONs provided education to all licensed staff on 08/13/16-08/15/16 related to falls, neurochecks, narcotic sheets, physician and family notification, and updating care plans. She stated she had to come in over a weekend to check the licensed staff off on completing the Resident Examination and Assessment Competencies. Interviews on 08/26/16 with LPN #7 at 9:30 AM, LPN #8 at 10:40 AM, LPN #5 at 10:55 AM, RN #1 at 11:00 AM, LPN #4 at 11:25 AM and LPN #9 at 12:00 PM, revealed they were educated on how to conduct the neuro checks per the facility's policy, post fall assessments, how to complete the incident in the Event Manager, narcotic sheets, physician and family notification with every incident, updating care plan with appropriate interventions, and the policy and procedure for falls. They all stated they had to come in on the weekend to complete a Resident Examination and Assessment Competency. 8. Review of a Communication Form completed by the SDC, dated 08/08/16, revealed with every fall/incident with or without injury, the Administrative Nurse, Physician, and the resident's Power of Attorney or family member would be notified. Anytime a resident has a fall with head injury, the resident is to be sent to hospital. The staff signature sheet revealed all licensed staff read the communication sheet between 08/08/16-8/11/16. Interview with the SDC, on 08/26/16 at 11:40 AM, revealed she educated licensed staff to notify the Administrative Nurse, Physician, and resident's family/POA when a resident had a fall and sustained a head injury to send the resident to the hospital for evaluation. Interviews on 08/26/16 with LPN #7 at 9:30 AM, LPN #8 at 10:40 AM, LPN #5 at 10:55 AM, RN #1 at 11:00 AM, LPN #4 at 11:25 AM and LPN #9 at 12:00 PM, revealed they had been educated that with every fall/incident, they should notify the physician, family/POA and Administrative Nurse and anytime a resident had a fall with a head injury to send him/her out to the hospital. 9. Review of the Clinical Whiteboard Meeting Notes revealed a review was completed for falls and physician notifications daily from 08/13/16-08/25/16 by the IDT team. Further review revealed the Administrative Nurse conducted the reviews on weekends. The RNC and/or Vice President for Operations were present every day for the meeting since 08/12/16. Interviews on 08/26/16 with the DON at 11:55 AM and the RNC at 12:10 PM revealed they had been providing oversight in the daily Whiteboard Meeting with the IDT looking at new orders, falls, assessments, notification, and documentation. The RNC stated she or the Vice President for Operations had been present every day since 08/12/16. 10. Review of Chart Audit Compliance Forms, revealed ten (10) residents' charts were audited by the Nursing Administrative Team daily from 08/13/16 through 08/25/16. Interview with the DON on 08/26/16 at 11:40 AM, revealed she was ensuring the Nursing Administrative Team was conducting ten (10) chart audits daily to ensure licensed staff were notifying the physician and family timely, change in conditions were being addressed, and documentation was completed. She stated once the IJ was removed they would continue to audit five (5) charts per day, five (5) days a week, for two (2) weeks, and then five (5) charts per week for two (2) weeks 11. Review of the Regional Staff Attendance Record revealed the RNC and/or Vice President for Operations were at the facility daily to provide oversight and consultation. Interview with the RNC, on 08/26/16 at 12:10 PM revealed she would continue oversight and consultation until the removal of immediacy. Then oversight would be provided weekly for four (4) weeks, then monthly for six (6) months, to ensure the above audits were completed and any concerns were addressed. 12. Review of a note written by the Administrator revealed she spoke to the Medical Director on 08/08/16 and he suggested sending out residents who had a fall that with a head injury to the hospital for a CT scan. Interview with the Medical Director on 08/15/16 at 10:05 AM, revealed he was at the facility on 08/08/16 and reviewed the resident's record and the facility's investigation. He stated he suggested sending residents out who had had a fall with a head injury to the hospital for a CT scan. 13. Review of a Sign In Sheets revealed a QAPI meeting was held on 08/15/16 and 08/22/16 for recommendations and further follow up regarding the above stated plan. 14. Interview with the RNC on 08/26/16 at 12:10 PM revealed she was present for the QAPI Meetings on 08/15/16 and 08/22/16.

Based on interview, record review, facility policy and procedure review, and review of hospital records, it was determined the facility failed to consult with the resident's physician and notify the resident's interested family member, when there was an accident which resulted in injury and had the potential for requiring physician intervention for one (1) of three (3) sampled residents (Resident #1). Resident #1, who was on blood thinners, sustained a fall on 08/06/16 at approximately 2:00 AM, which resulted in two (2) hematomas to the back of the head; however, Licensed Practical Nurse (LPN) #2 failed to notify the physician and family of the fall with injury per facility policy. In addition, Resident #1 complained of head pain at 3:00 AM when he/she was administered pain medication and was still complaining of head pain and requesting an ice pack at 4:15 AM. However, the nurse did not follow facility policy, and notify the physician that the resident's pain medication was ineffective. At approximately 6:15 AM-6:30 AM, Resident #1 was found unresponsive with his/her pupils fixed. Resident #1 was transported to the hospital and diagnosed with [REDACTED]. The resident passed away at approximately 11:23 PM. Immediate Jeopardy (IJ) was identified on 08/16/16 and was determined to exist on 08/06/16. The facility was notified of the Immediate Jeopardy (IJ) on 08/16/16. An acceptable Allegation of Compliance (AoC) was received on 08/23/16, alleging the removal of the Immediate Jeopardy (IJ) on 08/17/16. The State Survey Agency validated, on 08/26/16, that the Immediate Jeopardy (IJ) was removed on 08/17/16, as alleged. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC) and the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's Falls policy and procedures, last revised 06/01/16, revealed if a fall occurs staff should notify the physician and family. Review of the facility's Pain Management policy and procedure, not dated, revealed staff should determine the degree of relief experienced from pain medication by reassessing pain one (1) hour after administration. When pain medication is ineffective, evaluate pain, and communicate to the physician. Record review revealed the facility admitted Resident #1 on 03/15/12 with [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set (MDS) Assessment, dated 06/09/16, revealed the facility assessed Resident #1's cognition as intact with a Brief Interview of Mental Status (BIMS) score of fifteen (15) which indicated the resident was interviewable. In addition, review of the August 2016 physician's orders [REDACTED]. Review of Resident #1's Nursing Assessment revealed he/she sustained a fall on 08/06/16 at 2:00 AM. Resident #1 was observed sitting on the floor in the bathroom and had two (2) hematomas on the back of his/her head. The Assessment stated he/she hit his/her head on the floor. Further review of the Assessment revealed the physician was made aware of the fall; however, the notification only consisted of Licensed Practical Nurse (LPN) #2 placing the incident report on the physician's clipboard for reports to be taken to him the next day instead of calling and notifying him at the time of the fall, per facility policy. Interviews on 08/12/16 with Certified Nurse Aide (CNA) #1 at 9:15 AM and CNA #2 at 11:15 AM, revealed she and CNA #2 heard a noise and found Resident #1 on the floor in the doorway of the bathroom with his/her legs toward the resident's room. The CNAs stated the resident had two (2) hematomas (size of golf balls) on the back of his/her head, blood was running down the resident's neck onto the floor, and the resident was complaining of his/her head hurting. Interview with CNA #4, on 08/12/16 at 12:10 PM revealed she arrived at work on 08/06/16 at 2:00 AM to relieve CNA #2. She stated CNA #2 and CNA #1 reported to her that Resident #1 had fallen and had two (2) hematomas to the back of the head. CNA #4 stated she was in Resident #1's room at approximately 3:00 AM and she noted blood in the resident's hair, and the resident complained of head pain so she made the nurse aware. She further stated when she entered Resident #1's room at approximately 4:00 AM to 4:15 AM, the resident stated the nurse had given him/her a pain pill but his/her head was still hurting. CNA #4 stated the resident asked her to get a bag of ice. She stated she wrapped the ice in a pillowcase, and the resident laid down with the ice on his/her head. CNA #4 stated she reported this to LPN #2. She stated the next time she went into Resident #1's room was at 6:15 AM, when giving report to CNA #3 and they found the resident unresponsive. She stated they immediately notified the nurses and the resident was sent out to the hospital. Review of Resident #1's Narcotic Count for [MEDICATION NAME] 7.5 mg/325 mg revealed the resident was administered [MEDICATION NAME] on 08/06/16 at 3:00 AM. However, review of the August 2016 Electronic Medication Administration Record [REDACTED]. Interview with LPN #2, on 08/12/16 at 10:20 AM, revealed Resident #1 was found on the floor in the bathroom on 08/06/16. She stated when she assessed the resident; the resident had two (2) bumps on the back of the head down by his/her neck and blood on neck. LPN #2 stated the resident's neuro-checks and vital signs were good, but the resident complained of a small headache. Further interview revealed LPN #2 did not follow the facility's policy and procedures as she did not call the physician or the family to make them aware of the resident's fall. She stated she placed the incident report on the physician's clipboard to be delivered to him during the day and she did not call the family because the resident was his/her own responsible party. In addition, LPN #2 stated she administered pain medication at 3:00 AM due to the resident complaining of head pain and thought she recorded it in the computer. She stated she did not recall if she followed up on the pain medication. Further interview with LPN #2 on 08/16/16 at 2:10 PM revealed she was not made aware the CNA gave ice to the resident to put on his/her head and that the resident was still complaining of pain. However, review of the Neurological Evaluation Flow Sheet revealed LPN #2 conducted a neurocheck on Resident #1 on 08/06/16 at 4:45 AM. Review of a Nursing Note, dated 08/06/16 at 6:08 AM, and interviews on 08/12/16 with LPN #3 at 11:00 AM and Registered Nurse (RN) #1 at 12:40 PM, revealed they were informed by CNAs that Resident #1 was unresponsive. They stated RN #1 did a sternal rub on the resident with no response and when they checked the resident's pupils they were fixed (did not react to light). The resident's oxygen saturation (O2 sat) level was 89%, (normal = 95% to 100%) the resident was placed on oxygen at 2 liters a minute and the resident's O2 sat increased to 96%. Further interview revealed LPN #3 called Emergency Medical Services (EMS). LPN #3 and RN #1 stated the resident's physician should have been notified of the fall at the time of the fall especially since the resident had head injuries and was on blood thinners. In addition, they stated the physician should have been notified that the pain medication was not effective. Review of the Hospital Records, dated 08/06/16, revealed Resident #2 was seen in the emergency room and intubated. The resident was diagnosed with [REDACTED]. The resident's family withdrew care and the resident was placed on comfort measures until the resident passed away on 08/06/16 at 11:23 PM. Interviews on 08/12/16 at 11:00 AM with LPN #3; on 08/12/16 at 12:40 PM with RN #1; on 08/16/16 at 2:50 PM with the Assistant Director of Nursing (ADON); and, on 08/16/16 at 2:55 PM with LPN #5 and LPN #6, revealed it was the facility's policy to notify the physician and family immediately when a resident had a fall with injury. In addition, they stated licensed staff should follow up on as needed pain medication one (1) hour after it was administered to determine if it was effective. Further interview revealed the physician should be notified if the pain medication was not effective. Interview with the Director of Nursing (DON), on 08/12/16 at 3:10 AM and on 08/16/16 at 3:10 PM, revealed she expected the nurse to notify the physician and family after a fall. She stated she also expected the nurse to assess the resident after administering an as needed pain medication to determine if it was effective or not. She stated if the pain medication was not effective the physician would need to be contacted for further orders. Interview, on 08/15/16 at 10:05 AM, with Resident #1's attending Physician, who is also the facility's Medical Director, revealed he would have expected the nurse to make him or the on call physician aware of the fall especially since the resident had a head injury and he/she was on blood thinners. He stated he would have sent the resident out to the hospital for a Computer Topography (CT) scan of the head. He stated because the resident was on a blood thinner he/she was at a higher risk of a subdural hematoma. Interview with the Administrator on 08/16/16 at 3:25 PM, revealed she expected the nurses to notify the physician and family by phone immediately after a fall. She stated she also expected them to follow the facility's policy related to determining the effectiveness of pain medication and physician notification. The facility implemented the following actions to remove the Immediate Jeopardy: 1. The DON conducted an investigation of Resident #1's fall and identified LPN #2 failed to notify the physician and family at the time of the fall. It was also identified that the neuro evaluations were not completed according to the facility's Neurological Assessment/Monitoring Procedure. 2. A Disciplinary Action for LPN #2 was completed by the DON on 08/08/16. On 08/09/16, LPN #2 requested Family Medical Leave. 3. On 08/08/16, the Administrator met with the Medical Director, who was the attending physician for Resident #1. A plan was formulated for Charge Nurses to notify a resident's physician immediately when a resident has an unwitnessed fall and/or has a potential head injury and is receiving anticoagulant therapy. The resident is to be sent to the emergency room for evaluation and treatment. 4. On 08/12/16, current resident charts who had falls for the past four (4) months (from May-August 2016) were audited by the ADON, reviewing falls, fall interventions, care plans, fall assessments, physician and family notifications. Corrections were completed as indicated by the ADON. 5. Immediate education was initiated with licensed nurses on 08/08/16 by the Staff Development Coordinator (SDC) regarding completion of the Event Manager, location of the BIMS score, using an appropriate intervention after each incident, notification of the physician and responsible party with every fall/incident without injury. This education was completed on 08/11/16; and, no licensed nurse worked prior to receiving this education. 6. On 08/12/16, the Regional Nurse Consultant (RNC) completed a competency, the Resident Examination and Assessment Competency, with the DON. On 08/13/16, the RNC also conducted a competency, the Resident Examination and Assessment Competency, with the SDC and two (2) ADONs. 7. The SDC and two (2) ADONs conducted education with the Licensed Nurses which included PRN, Part time and full time nurses on 08/13/16 through 08/15/16 . The education was related to the facilty's policy and procedure for falls, neurological evaluation flow sheet, Event Manager, transcription on physician's orders [REDACTED]. No licensed staff worked prior to receiving this education. In addition, the Resident Examination and Assessment Competency, was completed by the SDC and two ADONs with each licensed nurse. 8. On 08/08/16, the process was initiated to notify the physician, responsible party, and On Call Administrative Nurse with every fall/incident with or without injury. 9. Beginning 08/13/16, the Interdisciplinary Team (IDT) to include but not limited to the DON, ADONs, MDS Coordinators, Medical Records Nurse, Quality of Life Director, Chaplain, Social Service Director, Social Service Assistant, Dietary Manager, and Therapy Manager, will review in the morning clinical meeting (Monday through Friday) telephone orders, change in condition, twenty-four (24) hour report, and medical records of residents to ensure timely notification, of physician and family occurred and any changes in the resident's condition were addressed timely. The RNC has been attending the meeting since 08/12/16 assisting and providing oversight and consultation. On weekends, the Administrative Nurse will be assigned to review telephone orders, SBARS (Situation, Background, and Assessment Recommendations), twenty four (24) hour reports, and medical records of residents to ensure timely notification of physician and family and any changes in resident condition were addressed timely. 10. Beginning 08/13/16, ten (10) residents charts will be audited daily by the Nursing Administration Team (DON, Unit Mangers, SDC, and MDS Coordinators and the Restorative Nurse Manager) for timely physician and family notification, change in condition being addressed, SBARs, telephone orders, and twenty-four (24) hour reports, and documentation being present, until immediacy is lifted. Then five (5) charts per day, five (5) days a week, will be checked for two (2) weeks, and then five (5) charts per week for two (2) weeks. Any issues identified will be addressed at the time of discovery. Results of the audits will be discussed in Quality Assurance Performance Improvement (QAPI) meeting. 11. Administrative oversight will be completed by the Vice President for Operations or RNC, daily until removal of immediacy beginning 08/11/16, then weekly for four (4) weeks, then monthly for six (6) months, to ensure the above audits are completed and any concerns are addressed. Oversight includes assisting with audits, reviewing charts, reviewing audits and providing oversight and consultation. 12. A QA Meeting was held on 08/08/16 with the Medial Director by phone, and an Ad Hoc QAPI meeting was held on 08/15/16 with the Medical Director, Administrator, DOM, RNC, ADONs, SDC, Chaplain, MDS Coordinators, Social Service Director, Human Resource Director, and Medical Records Coordinator were in attendance reviewing the occurrence of Resident #1 and immediate plans put in place. 13. A QAPI meeting will be held weekly until the immediacy has been removed, then monthly for six (6) months for recommendations and further follow up regarding the above stated plan. At that time based on the evaluation, the QAPI Committee will determine at what frequency any ongoing audits will need to continue. 14. Corporate Administrative oversight of the QAPI meeting will be completed by the RNC, Director of Clinical Programs, the Regional Vice President of Operations, or member of the regional staff weekly until removal of the immediacy, then weekly for four (4) weeks, and then monthly for six (6) months. **The State Survey Agency validated the corrective actions taken by the facility as follows: 1. Review of the facility's investigation, not dated, revealed the DON determined LPN #2 failed to conduct neurochecks according to facility policy and failed to notify the physician and family after the resident's fall. Interview with the DON, on 08/26/16 at 11:55 AM revealed she conducted the investigation into Resident #1's fall. She stated she identified LPN #2 had failed to conduct the neurochecks per facility policy and failed to notify the physician and family of the resident's fall. 2. Review of a Disciplinary Action, dated 08/08/16, revealed LPN #2 was counseled by the DON related to insufficient documentation on the Event Report, notification of the physician and family after a fall, and completion of neurochecks per facility policy. Review of a letter, dated 08/09/16 revealed LPN #2 requested Family Medical Leave (FML) with the Human Resource Manager. LPN #2 was placed on FML on 08/09/16. Interview with the DON, on 08/26/16 at 11:55 AM revealed she counseled LPN #2 on her failure to complete the Event Report filling in all blanks, notification of physician and family after a fall, and conducting neurochecks at the appropriate timeframes and using accurate documentation on the form. The DON stated LPN #2 requested FML and it was granted on 08/09/16. 3. Review of a Communication Form per SDC, dated 08/08/16, revealed with every fall/incident with or without injury, the Administrative Nurse, Physician, and the resident's Power of Attorney or family member would be notified. Anytime a resident has a fall with head injury, the resident is to be sent to hospital. The staff signature sheet revealed all licensed staff read the communication sheet between 08/08/16-08/11/16. Interview with the SDC, on 08/26/16, at 11:40 AM, revealed she provided the education on 08/08/16 related to notification of the Administrative Nurse, Physician and the resident's Power of Attorney or family member when a resident had a fall with or without injury. In addition, staff were educated that anytime a resident has a fall with head injury to send the resident to the hospital for evaluation. Interviews on 08/26/16 with LPN #7 at 9:30 AM, LPN #8 at 10:40 AM, LPN #5 at 10:55 AM, RN #1 at 11:00 AM, LPN #4 at 11:25 AM and LPN #9 at 12:00 PM, revealed they were educated on 08/08/16 that when a resident had a fall the to notify the physician, family or POA, and Administrative Nurse. In addition, they stated they should send a resident who had a fall with head injury out to the hospital for evaluation. 4. Review of the Event Reports for May-August 2016 revealed they were reviewed by the ADON on 08/12/16. The ADON identified there were falls where there was no documentation the family had been notified of the falls. Further review revealed each of the families was notified of the fall on 08/12/16 by the Nursing Administrative Team. Interview with the ADON on 08/26/16 at 10:30 AM, revealed she reviewed the event reports for four (4) months (May-August 2016) to determine if the physician and family/POA had been notified of the fall. She stated she identified that some families had not been notified. The Nursing Administrative Teams notified the families on 08/12/16. 5. Review of the Communication Form, dated 08/08/16, revealed the SDC initiated education on 08/08/16 to all licensed staff regarding completion of the Event Manager, location of the BIMS score, using an appropriate intervention after each incident, notification of the physician and responsible party with every fall/incident with or without injury. This education was completed on 08/11/16 and no licensed nurse worked prior to receiving this education. Interview with the SDC, on 08/26/16, at 11:40 AM, revealed she provided education to all licensed staff on 08/08/16-08/11/16 on completion of the Event Manager, using an appropriate intervention after each incident, and notification of the physician and responsible party with every fall/incident with or without injury. Interviews on 08/26/16 with LPN #7 at 9:30 AM, LPN #8 at 10:40 AM, LPN #5 at 10:55 AM, RN #1 at 11:00 AM, LPN #4 at 11:25 AM and LPN #9 at 12:00 PM, revealed the SDC educated them on ensuring an appropriate intervention was put in place after each fall, and notification of the physician and family/POA with every fall with or without injury. 6. Review of the Resident Examination and Assessment Competencies revealed the DON completed the competency on 08/12/16 and the SDC and two (2) ADONs completed the competencies on 08/13/16 with the RNC. Interview with the RNC on 08/26/16 revealed she conducted Resident Examination and Assessment Competencies for the DON, SDC and ADONs. Interviews on 08/26/16 with the SDC at 11:40 AM, and DON at 11:55 AM, revealed they had to complete Resident Examination and Assessment Competencies with the RNC. 7. Review of the Communication Form revealed the SDC and two (2) ADONs conducted education with the Licensed Nurses on 08/13/16 through 08/15/16 regarding policy and procedure for falls, neurological evaluation flow sheet, Event Manager, transcription of Physician Orders, education on narcotic sheets, physician and family notification with every incident, fall interventions, updating the care plans, and post fall assessment. No licensed staff worked prior to receiving this education. In addition, review of the Resident Examination and Assessment Competencies revealed the licensed nurses completed the competencies with the SDC and two (2) ADONs from 08/13/16 through 08/25/16. No licensed nurse worked until their competency was completed. Interview with the SDC, on 08/26/16, at 11:40 AM, revealed she and the ADONs provided education to all licensed staff on 08/13/16-08/15/16 related to falls, neurochecks, narcotic sheets, physician and family notification, and updating care plans. She stated she had to come in over a weekend to check the licensed staff off on completing the Resident Examination and Assessment Competencies. Interviews on 08/26/16 with LPN #7 at 9:30 AM, LPN #8 at 10:40 AM, LPN #5 at 10:55 AM, RN #1 at 11:00 AM, LPN #4 at 11:25 AM and LPN #9 at 12:00 PM, revealed they were educated on how to conduct the neuro checks per the facility's policy, post fall assessments, how to complete the incident in the Event Manager, narcotic sheets, physician and family notification with every incident, updating care plan with appropriate interventions, and the policy and procedure for falls. They all stated they had to come in on the weekend to complete a Resident Examination and Assessment Competency. 8. Review of a Communication Form completed by the SDC, dated 08/08/16, revealed with every fall/incident with or without injury, the Administrative Nurse, Physician, and the resident's Power of Attorney or family member would be notified. Anytime a resident has a fall with head injury, the resident is to be sent to hospital. The staff signature sheet revealed all licensed staff read the communication sheet between 08/08/16-8/11/16. Interview with the SDC, on 08/26/16 at 11:40 AM, revealed she educated licensed staff to notify the Administrative Nurse, Physician, and resident's family/POA when a resident had a fall and sustained a head injury to send the resident to the hospital for evaluation. Interviews on 08/26/16 with LPN #7 at 9:30 AM, LPN #8 at 10:40 AM, LPN #5 at 10:55 AM, RN #1 at 11:00 AM, LPN #4 at 11:25 AM and LPN #9 at 12:00 PM, revealed they had been educated that with every fall/incident, they should notify the physician, family/POA and Administrative Nurse and anytime a resident had a fall with a head injury to send him/her out to the hospital. 9. Review of the Clinical Whiteboard Meeting Notes revealed a review was completed for falls and physician notifications daily from 08/13/16-08/25/16 by the IDT team. Further review revealed the Administrative Nurse conducted the reviews on weekends. The RNC and/or Vice President for Operations were present every day for the meeting since 08/12/16. Interviews on 08/26/16 with the DON at 11:55 AM and the RNC at 12:10 PM revealed they had been providing oversight in the daily Whiteboard Meeting with the IDT looking at new orders, falls, assessments, notification, and documentation. The RNC stated she or the Vice President for Operations had been present every day since 08/12/16. 10. Review of Chart Audit Compliance Forms, revealed ten (10) residents' charts were audited by the Nursing Administrative Team daily from 08/13/16 through 08/25/16. Interview with the DON on 08/26/16 at 11:40 AM, revealed she was ensuring the Nursing Administrative Team was conducting ten (10) chart audits daily to ensure licensed staff were notifying the physician and family timely, change in conditions were being addressed, and documentation was completed. She stated once the IJ was removed they would continue to audit five (5) charts per day, five (5) days a week, for two (2) weeks, and then five (5) charts per week for two (2) weeks 11. Review of the Regional Staff Attendance Record revealed the RNC and/or Vice President for Operations were at the facility daily to provide oversight and consultation. Interview with the RNC, on 08/26/16 at 12:10 PM revealed she would continue oversight and consultation until the removal of immediacy. Then oversight would be provided weekly for four (4) weeks, then monthly for six (6) months, to ensure the above audits were completed and any concerns were addressed. 12. Review of a note written by the Administrator revealed she spoke to the Medical Director on 08/08/16 and he suggested sending out residents who had a fall that with a head injury to the hospital for a CT scan. Interview with the Medical Director on 08/15/16 at 10:05 AM, revealed he was at the facility on 08/08/16 and reviewed the resident's record and the facility's investigation. He stated he suggested sending residents out who had had a fall with a head injury to the hospital for a CT scan. 13. Review of a Sign In Sheets revealed a QAPI meeting was held on 08/15/16 and 08/22/16 for recommendations and further follow up regarding the above stated plan. 14. Interview with the RNC on 08/26/16 at 12:10 PM revealed she was present for the QAPI Meetings on 08/15/16 and 08/22/16.

Based on interview, record review, facility policy review and hospital record review, it was determined the facility failed to ensure each resident receives the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care for one (1) of three (3) sampled residents (Resident #1). Resident #1, who was on [MEDICATION NAME] (blood thinner) sustained a fall on 08/06/16 at 2:00 AM which resulted in two (2) hematomas to the back of the head. Licensed Practical Nurse (LPN #2) failed to conduct neuro-checks consistently and failed to assess the resident's head pain to determine the type and severity of pain at the time of the fall, prior to administering pain medication and one (1) hour after the pain medication had been administered to determine if it was effective per the care plan and/or facility policy. Resident #1 was found in bed unresponsive at 6:15 AM and sent to the emergency room . The resident was diagnosed with [REDACTED]. Immediate Jeopardy (IJ) was identified on 08/16/16 and was determined to exist on 08/06/16. The facility was notified of the Immediate Jeopardy (IJ) on 08/16/16. An acceptable Allegation of Compliance (AoC) was received on 08/23/16, alleging the removal of the Immediate Jeopardy (IJ) on 08/17/16. The State Survey Agency validated, on 08/26/16, that the Immediate Jeopardy (IJ) was removed on 08/17/16, as alleged. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC) and the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy and procedures for Falls, last reviewed 06/01/16, revealed if a fall occurs staff should assess the resident including neurochecks, pain, range of motion, skin, joints, extremities, and vital signs; and neurochecks will be completed on residents that experience an unwitnessed fall or fall that results in head trauma. Document assessment, pertinent facts, and incident in the Event Manager (computer). Review of the facility's policy and procedure for Neurological Assessment/Monitoring, not dated, revealed neurological assessments are indicated upon physician order, an unwitnessed fall, following a fall or other accident/injury involving head trauma, or when indicated by the resident's condition. The four (4) areas that should be monitored are the level of consciousness, ability to move extremities, eye responses and change in pupils, and vital signs. The neurochecks should be completed for seventy-two (72) hours at the following frequency: every fifteen (15) minutes time four (4) checks; every thirty (30) minutes times four (4) checks; every one (1) hour times four (4) checks; every four (4) hours times four (4) checks; and, every eight (8) hours until completed. Review of the facility's Pain Management policy and procedure, not dated, revealed staff should use a pain scale of 0-10 with residents who understand the concept or for residents who cannot understand numerical scale to use a visual analog scale using faces indicating degrees of happy or unhappy. Staff should determine the degree of relief experienced from pain medication and reassess pain in one (1) hour after administration. When pain medication is ineffective, evaluate pain, and communicate to the physician. The Pain Management Clinical Monitoring form shall be initiated on admission and pain medication administration shall occur in the EZMAR (electronic Medication Administration Record). Documentation of indication and effectiveness shall be documented. Review of the Pain Flow Sheet revealed a pain assessment at the time the resident was identified to have pain included the characteristics of the pain, frequency, intensity, non-verbal indicators, or aggravating factors. Assessment one (1) hour after administration of pain medication included the intensity of the pain and the effectiveness of the pain medication. Record review revealed the facility admitted Resident #1 on 03/15/12 with diagnoses, which included [MEDICAL CONDITION], Chronic Back Pain, Restless Leg Syndrome, and [MEDICAL CONDITION]. Review of the Significant Change Minimum Data Set (MDS) Assessment, dated 06/09/16, revealed the facility assessed Resident #1's cognition as intact with a Brief Interview of Mental Status (BIMS) score of fifteen (15) which indicated the resident was interviewable. In addition, the resident required supervision and set up for transfers and minimal assistance of one (1) staff for ambulation in room and corridor. Review of the August 2016 Electronic Medication Administration Record (EMAR) revealed Resident #1 received Aspirin 81 mg (blood thinner) every day and [MEDICATION NAME] (blood thinner) 4 milligrams (mg) every other day and alternate the 4 mg with the 3.5 mg every other day Review of the Comprehensive Care Plan for pain, dated 09/02/14 and last updated 06/21/16, revealed to monitor for any signs and symptoms of pain (crying, grimacing, moaning, guarding, complaints of pain, restlessness, or change in behavior), and monitor for effectiveness of the pain medication. Further review of the August 2016 EMAR revealed the resident also received a [MEDICATION NAME] (synthetic opioid pain medication) 75 micrograms (mcg)/hour patch for pain every three (3) days and [MEDICATION NAME] (medication used to treat neuropathic pain) 300 mg twice a day for pain. In addition, the resident also had an order for [REDACTED]. Review of a Nursing Assessment for Resident #1 completed by Licensed Practical Nurse (LPN) #2, revealed the resident sustained [REDACTED]. Resident #1 was observed sitting on the floor in the bathroom and had two (2) hematomas on the back of his/her head. The resident stated he/she hit his/her head on the floor. Further review of the Assessment, revealed a neurological assessment was completed and was within normal parameters and the resident had no pain. However, interviews on 08/12/16 with LPN #2 at 10:20 AM, CNA #1 at 9:15 AM, and CNA #2 at 11:15 AM, revealed the resident complained his/her head hurt at the time of the fall. LPN #2 stated she must have made a mistake in her documentation. Interview with Certified Nurse Aide (CNA) #1, on 08/12/16 at 9:15 AM, revealed she had went over to Resident #1's hall to assist CNA #2 with resident care and while she was on the hall she heard a noise like a bedpan or urinal falling off the table. CNA #1 stated at that time CNA #2 came out of another resident's room and they noted Resident #1's bathroom light was on which was unusual. CNA #1 stated they entered Resident #1's room and found the resident sitting on the floor in the bathroom doorway with his/her legs sticking out into the room and a small amount of liquid was on the floor around the resident's legs. She stated the resident stated his/her legs went out from under him/her. CNA #1 stated she went to get LPN #2 and some towels/washcloths; and CNA #2 stayed with the resident. When she reentered the room she handed CNA #2 some towels to clean the resident and the floor. CNA #1 stated they identified Resident #1 had a skin tear to his/her left arm and two (2) knots to the right side of his/her head with a gap between them. She stated it looked like blood was coming from them, running down the resident's neck. CNA #1stated the resident complained his/her head was hurting. She stated at that time a call light went off on the other hall and she went to answer it. CNA #1 stated when she left, LPN #1 and CNA #2 were still in the room with the resident. She stated she did not see the nurse assess the resident's injuries before she left the room. Interview with CNA #2, on 08/12/16 at 11:15 AM, revealed on 08/06/16 when she exited another resident's room, CNA #1 heard a noise. They found Resident #1 on the floor in the doorway of his/her bathroom with his/her legs toward the resident's room and blood on the floor and on the side of his/her head. CNA #2 stated she began washing the blood off the resident while CNA #1 went to get LPN #1. She stated there was quite a bit of blood due to the resident being on [MEDICATION NAME]; and, she noted the resident had two (2) huge knots behind his/her right ear. She stated LPN #1 entered the room and asked the resident how he/she felt, and she told LPN #1 about the knots on the back of the resident's head. LPN #2 then asked them to get the resident up. She stated she asked the resident if she could bend his/her legs and she got behind the resident. LPN #2 and CNA #1 lifted the resident up underneath the arms and walked the resident to the bed. She stated she then wiped the resident down with warm washcloths and the resident helped her wipe the inner parts of his/her legs. A pullup was placed on the resident and his/her gown was changed. CNA #2 stated she put a towel on the resident's pillow so blood would not get everywhere; Resident #1 complained of his/her head hurting. She stated she then left the room so she could give CNA #3 report as she was only working until 2:00 AM. CNA #2 stated LPN #1 obtained the blood pressure cuff and when she left LPN #2 was still in the resident's room. Review of Resident #1's Narcotic Count for [MEDICATION NAME] (narcotic pain medication) 7.5 mg/325 mg revealed the resident was administered [MEDICATION NAME] on 08/06/16 at 3:00 AM. However, review of the August 2016 EMAR and Resident #1's Pain Flow Sheet revealed there was no documented evidence the resident's pain was assessed for the characteristics of the pain, frequency, intensity, non-verbal indicators, or aggravating factors prior to the administration of the pain medication or one (1) hour afterward for the effectiveness and intensity of pain after the administration of the pain medication per facility policy. Review of the Neurological Evaluation Flow Sheet, revealed LPN #2 conducted assessments on 08/06/16 at 2:00 AM, 2:15 AM, 2:30 AM, 2:45 AM, 3:15 AM, 4:45 AM and 5:45 AM. There was no documented evidence LPN #2 conducted neurochecks at 3:45 AM and 4:15 AM, per facility policy. Interview with CNA #4, on 08/12/16 at 12:10 PM revealed she came into work on 08/06/16 at 2:00 AM to relieve CNA #2. She stated CNA #2 and CNA #1 reported to her that Resident #1 had fallen and had two (2) hematomas to the back of the head. CNA #4 revealed she was in Resident #1's room at approximately 3:00 AM assisting the resident, when she noted blood in the resident's hair. CNA #4 stated the resident complained of head pain and she made the nurse aware. She further stated when she entered Resident #1's room at approximately 4:00 AM to 4:15 AM, the resident stated the nurse had given him/her a pain pill but his/her head was still hurting. CNA #4 stated the resident asked her to get a bag of ice, she wrapped the ice in a pillowcase, and the resident laid down on his/her left side with the ice on his/her head. CNA #4 stated she reported this to LPN #2. She stated the next time she went into Resident #1's room was at 6:15 AM, when she was giving report to CNA #3. They found the resident unresponsive. She stated they immediately notified the nurses and the resident was sent out to the hospital. Interview with LPN #2, on 08/12/16 at 10:20 AM, revealed Resident #1 was found on the floor in the bathroom on 08/06/16. She stated when she assessed the resident; the resident had two (2) bumps on the back of the head down by his/her neck and blood on his /her neck. LPN #2 stated the resident was assisted by the CNAs to walk to the bed but the resident was talking and was able to walk. LPN #2 stated the resident's neuro-checks and vital signs were good and the resident complained of a small headache. Further interview revealed LPN #2 stated she did not call the physician or the family. She stated she placed the incident report on the physician's clipboard to be delivered to him during the day. In addition, she stated she did not call the resident's family because the resident was his/her own responsible party. LPN #2 stated she conducted neurochecks every fifteen (15) minutes for one (1) hour, then every thirty (30) minutes for two (2) hours and if there were neurochecks that were not documented she did them, but she failed to document them. She stated the last neurocheck she conducted was at 5:45 AM with no concerns. LPN #2 stated she clocked out at 6:30 AM and when she came back up the hall that's when staff found the resident unresponsive and an ambulance was called. She stated she administered pain medication at 3:00 AM due to the resident complaining of head pain and thought she recorded it in the computer. LPN #2 stated she did not recall if she followed up on the pain medication to ensure it was effective. Further interview with LPN #2 on 08/12/16 at 1:15 PM, revealed she was not made aware the CNA gave ice to the resident to put on his/her head and that the resident was still complaining of pain. However, LPN #2 documented she conducted neurochecks on Resident #1 at 4:45 AM and 5:45 AM after the resident had complained of pain to CNA #4 and had been given an ice pack. Review of a Nursing Note, dated 08/06/16 at 6:08 AM, revealed LPN #3 was called to Resident #1's room when he/she was found unresponsive. The resident's pupils were fixed (did not react to light) and a sternum rub was performed with no response. Oxygen saturation (O2 sat) was 89% on room air (normal = 95% - 100%). Oxygen was applied at 2 liters per minute and the resident's O2 sat increased to 96%. Emergency Medical Services (EMS) was called and arrived at 6:45 AM. Report called to hospital. Interview with CNA #3, on 08/12/16 at 11:55 AM, revealed she received report at approximately 6:00 AM that Resident #1 had fallen at 2:00 AM and had two (2) hematomas on the back of the head. She stated when she entered Resident #1's room with CNA #4 at approximately 6:15 AM; the resident was on his/her right side with his/her face into the bedrail. CNA #3 stated she shook the resident twice and he/she still did not respond so she rolled the resident over. She stated there was a towel under the resident's head and an ice pack with blood on it. CNA #3 stated Registered Nurse (RN) #1 did a sternal rub and there was still no response. She stated LPN #3 checked the resident's pupils and called EMS. Interviews on 08/12/16 with LPN #3 at 11:00 AM and Registered Nurse (RN) #1 at 12:40 PM, revealed the resident was unresponsive when they entered the resident's room on 08/06/16 at approximately 6:15 AM. They stated the resident pupils were fixed, the resident was unresponsive to a sternum rub, and his/her O2 sat was low and after applying oxygen, it increased to normal. LPN #3 called EMS and RN #1 noted the resident had a golf ball sized hematoma on the back of the head and blood on the pillow. LPN #3 and RN #1 stated the neurochecks should have been completed according to facility policy and the resident's head pain should have been assessed at the time of the fall, before the pain medication was administered; and, one (1) hour after the pain medication was administered, per facility policy. Review of the Hospital Records, dated 08/06/16, revealed Resident #2 was seen in the emergency room and intubated. The resident was diagnosed with [REDACTED]. The resident's family withdrew care and the resident was placed on comfort measures until the resident passed away on 08/06/16 at 11:23 PM. Interviews on 08/16/16 with the Assistant Director of Nursing (ADON) at 2:50 PM, and LPN #5 and LPN #6 at 2:55 PM revealed licensed staff should conduct neurochecks according to facility policy. They stated when a resident complains of pain the resident's pain should be assessed before pain medication was administered and one (1) hour after pain medication was administered per facility policy. They stated the assessments should be documented on the pain flow sheet. Interview with the Director of Nursing (DON), on 08/12/16 at 3:10 AM and on 08/16/16 at 3:10 PM, revealed during her investigation of Resident #1's fall she had identified LPN #2 had failed to conduct neurochecks at the appropriate frequency per facility policy. She stated she expected the nurse to have assessed the resident's pain per the pain flow sheet and the nurse should have assessed the resident's pain one (1) hour after the pain medication was administered to determine the effectiveness of the pain medication. The facility implemented the following actions to remove the Immediate Jeopardy: 1. The DON conducted an investigation of Resident #1's fall and identified LPN #2 failed to notify the physician and family at the time of the fall. It was also identified that the neuro evaluations were not completed according to the facility's Neurological Assessment/Monitoring Procedure. 2. A Disciplinary Action for LPN #2 was completed by the DON on 08/08/16. On 08/09/16, LPN #2 requested Family Medical Leave. 3. On 08/08/16, the Administrator met with the Medical Director, who was the attending physician for Resident #1. A plan was formulated for Charge Nurses to notify a resident's physician immediately when a resident has an unwitnessed fall and/or has a potential head injury and is receiving anticoagulant therapy. The resident is to be sent to the emergency room for evaluation and treatment. 4. On 08/12/16, current resident charts who had falls for the past four (4) months (from May-August 2016) were audited by the ADON, reviewing falls, fall interventions, care plans, fall assessments, physician and family notifications. Corrections were completed as indicated by the ADON. 5. Immediate education was initiated with licensed nurses on 08/08/16 by the Staff Development Coordinator (SDC) regarding completion of the Event Manager, location of the BIMS score, using an appropriate intervention after each incident, notification of the physician and responsible party with every fall/incident without injury. This education was completed on 08/11/16; and, no licensed nurse worked prior to receiving this education. 6. On 08/12/16, the Regional Nurse Consultant (RNC) completed a competency, the Resident Examination and Assessment Competency, with the DON. On 08/13/16, the RNC also conducted a competency, the Resident Examination and Assessment Competency, with the SDC and two (2) ADONs. 7. The SDC and two (2) ADONs conducted education with the Licensed Nurses which included PRN, Part time and full time nurses on 08/13/16 through 08/15/16 . The education was related to the facilty's policy and procedure for falls, neurological evaluation flow sheet, Event Manager, transcription on physician's orders [REDACTED]. No licensed staff worked prior to receiving this education. In addition, the Resident Examination and Assessment Competency, was completed by the SDC and two ADONs with each licensed nurse. 8. On 08/08/16, the process was initiated to notify the physician, responsible party, and On Call Administrative Nurse with every fall/incident with or without injury. 9. Beginning 08/13/16, the Interdisciplinary Team (IDT) to include but not limited to the DON, ADONs, MDS Coordinators, Medical Records Nurse, Quality of Life Director, Chaplain, Social Service Director, Social Service Assistant, Dietary Manager, and Therapy Manager, will review in the morning clinical meeting (Monday through Friday) telephone orders, change in condition, twenty-four (24) hour report, and medical records of residents to ensure timely notification, of physician and family occurred and any changes in the resident's condition were addressed timely. The RNC has been attending the meeting since 08/12/16 assisting and providing oversight and consultation. On weekends, the Administrative Nurse will be assigned to review telephone orders, SBARS (Situation, Background, and Assessment Recommendations), twenty four (24) hour reports, and medical records of residents to ensure timely notification of physician and family and any changes in resident condition were addressed timely. 10. Beginning 08/13/16, ten (10) residents charts will be audited daily by the Nursing Administration Team (DON, Unit Mangers, SDC, and MDS Coordinators and the Restorative Nurse Manager) for timely physician and family notification, change in condition being addressed, SBARs, telephone orders, and twenty-four (24) hour reports, and documentation being present, until immediacy is lifted. Then five (5) charts per day, five (5) days a week, will be checked for two (2) weeks, and then five (5) charts per week for two (2) weeks. Any issues identified will be addressed at the time of discovery. Results of the audits will be discussed in Quality Assurance Performance Improvement (QAPI) meeting. 11. Administrative oversight will be completed by the Vice President for Operations or RNC, daily until removal of immediacy beginning 08/11/16, then weekly for four (4) weeks, then monthly for six (6) months, to ensure the above audits are completed and any concerns are addressed. Oversight includes assisting with audits, reviewing charts, reviewing audits and providing oversight and consultation. 12. A QA Meeting was held on 08/08/16 with the Medial Director by phone, and an Ad Hoc QAPI meeting was held on 08/15/16 with the Medical Director, Administrator, DOM, RNC, ADONs, SDC, Chaplain, MDS Coordinators, Social Service Director, Human Resource Director, and Medical Records Coordinator were in attendance reviewing the occurrence of Resident #1 and immediate plans put in place. 13. A QAPI meeting will be held weekly until the immediacy has been removed, then monthly for six (6) months for recommendations and further follow up regarding the above stated plan. At that time based on the evaluation, the QAPI Committee will determine at what frequency any ongoing audits will need to continue. 14. Corporate Administrative oversight of the QAPI meeting will be completed by the RNC, Director of Clinical Programs, the Regional Vice President of Operations, or member of the regional staff weekly until removal of the immediacy, then weekly for four (4) weeks, and then monthly for six (6) months. **The State Survey Agency validated the corrective actions taken by the facility as follows: 1. Review of the facility's investigation, not dated, revealed the DON determined LPN #2 failed to conduct neurochecks according to facility policy and failed to notify the physician and family after the resident's fall. Interview with the DON, on 08/26/16 at 11:55 AM revealed she conducted the investigation into Resident #1's fall. She stated she identified LPN #2 had failed to conduct the neurochecks per facility policy and failed to notify the physician and family of the resident's fall. 2. Review of a Disciplinary Action, dated 08/08/16, revealed LPN #2 was counseled by the DON related to insufficient documentation on the Event Report, notification of the physician and family after a fall, and completion of neurochecks per facility policy. Review of a letter, dated 08/09/16 revealed LPN #2 requested Family Medical Leave (FML) with the Human Resource Manager. LPN #2 was placed on FML on 08/09/16. Interview with the DON, on 08/26/16 at 11:55 AM revealed she counseled LPN #2 on her failure to complete the Event Report filling in all blanks, notification of physician and family after a fall, and conducting neurochecks at the appropriate timeframes and using accurate documentation on the form. The DON stated LPN #2 requested FML and it was granted on 08/09/16. 3. Review of a Communication Form per SDC, dated 08/08/16, revealed with every fall/incident with or without injury, the Administrative Nurse, Physician, and the resident's Power of Attorney or family member would be notified. Anytime a resident has a fall with head injury, the resident is to be sent to hospital. The staff signature sheet revealed all licensed staff read the communication sheet between 08/08/16-08/11/16. Interview with the SDC, on 08/26/16, at 11:40 AM, revealed she provided the education on 08/08/16 related to notification of the Administrative Nurse, Physician and the resident's Power of Attorney or family member when a resident had a fall with or without injury. In addition, staff were educated that anytime a resident has a fall with head injury to send the resident to the hospital for evaluation. Interviews on 08/26/16 with LPN #7 at 9:30 AM, LPN #8 at 10:40 AM, LPN #5 at 10:55 AM, RN #1 at 11:00 AM, LPN #4 at 11:25 AM and LPN #9 at 12:00 PM, revealed they were educated on 08/08/16 that when a resident had a fall the to notify the physician, family or POA, and Administrative Nurse. In addition, they stated they should send a resident who had a fall with head injury out to the hospital for evaluation. 4. Review of the Event Reports for May-August 2016 revealed they were reviewed by the ADON on 08/12/16. The ADON identified there were falls where there was no documentation the family had been notified of the falls. Further review revealed each of the families was notified of the fall on 08/12/16 by the Nursing Administrative Team. Interview with the ADON on 08/26/16 at 10:30 AM, revealed she reviewed the event reports for four (4) months (May-August 2016) to determine if the physician and family/POA had been notified of the fall. She stated she identified that some families had not been notified. The Nursing Administrative Teams notified the families on 08/12/16. 5. Review of the Communication Form, dated 08/08/16, revealed the SDC initiated education on 08/08/16 to all licensed staff regarding completion of the Event Manager, location of the BIMS score, using an appropriate intervention after each incident, notification of the physician and responsible party with every fall/incident with or without injury. This education was completed on 08/11/16 and no licensed nurse worked prior to receiving this education. Interview with the SDC, on 08/26/16, at 11:40 AM, revealed she provided education to all licensed staff on 08/08/16-08/11/16 on completion of the Event Manager, using an appropriate intervention after each incident, and notification of the physician and responsible party with every fall/incident with or without injury. Interviews on 08/26/16 with LPN #7 at 9:30 AM, LPN #8 at 10:40 AM, LPN #5 at 10:55 AM, RN #1 at 11:00 AM, LPN #4 at 11:25 AM and LPN #9 at 12:00 PM, revealed the SDC educated them on ensuring an appropriate intervention was put in place after each fall, and notification of the physician and family/POA with every fall with or without injury. 6. Review of the Resident Examination and Assessment Competencies revealed the DON completed the competency on 08/12/16 and the SDC and two (2) ADONs completed the competencies on 08/13/16 with the RNC. Interview with the RNC on 08/26/16 revealed she conducted Resident Examination and Assessment Competencies for the DON, SDC and ADONs. Interviews on 08/26/16 with the SDC at 11:40 AM, and DON at 11:55 AM, revealed they had to complete Resident Examination and Assessment Competencies with the RNC. 7. Review of the Communication Form revealed the SDC and two (2) ADONs conducted education with the Licensed Nurses on 08/13/16 through 08/15/16 regarding policy and procedure for falls, neurological evaluation flow sheet, Event Manager, transcription of Physician Orders, education on narcotic sheets, physician and family notification with every incident, fall interventions, updating the care plans, and post fall assessment. No licensed staff worked prior to receiving this education. In addition, review of the Resident Examination and Assessment Competencies revealed the licensed nurses completed the competencies with the SDC and two (2) ADONs from 08/13/16 through 08/25/16. No licensed nurse worked until their competency was completed. Interview with the SDC, on 08/26/16, at 11:40 AM, revealed she and the ADONs provided education to all licensed staff on 08/13/16-08/15/16 related to falls, neurochecks, narcotic sheets, physician and family notification, and updating care plans. She stated she had to come in over a weekend to check the licensed staff off on completing the Resident Examination and Assessment Competencies. Interviews on 08/26/16 with LPN #7 at 9:30 AM, LPN #8 at 10:40 AM, LPN #5 at 10:55 AM, RN #1 at 11:00 AM, LPN #4 at 11:25 AM and LPN #9 at 12:00 PM, revealed they were educated on how to conduct the neuro checks per the facility's policy, post fall assessments, how to complete the incident in the Event Manager, narcotic sheets, physician and family notification with every incident, updating care plan with appropriate interventions, and the policy and procedure for falls. They all stated they had to come in on the weekend to complete a Resident Examination and Assessment Competency. 8. Review of a Communication Form completed by the SDC, dated 08/08/16, revealed with every fall/incident with or without injury, the Administrative Nurse, Physician, and the resident's Power of Attorney or family member would be notified. Anytime a resident has a fall with head injury, the resident is to be sent to hospital. The staff signature sheet revealed all licensed staff read the communication sheet between 08/08/16-8/11/16. Interview with the SDC, on 08/26/16 at 11:40 AM, revealed she educated licensed staff to notify the Administrative Nurse, Physician, and resident's family/POA when a resident had a fall and sustained a head injury to send the resident to the hospital for evaluation. Interviews on 08/26/16 with LPN #7 at 9:30 AM, LPN #8 at 10:40 AM, LPN #5 at 10:55 AM, RN #1 at 11:00 AM, LPN #4 at 11:25 AM and LPN #9 at 12:00 PM, revealed they had been educated that with every fall/incident, they should notify the physician, family/POA and Administrative Nurse and anytime a resident had a fall with a head injury to send him/her out to the hospital. 9. Review of the Clinical Whiteboard Meeting Notes revealed a review was completed for falls and physician notifications daily from 08/13/16-08/25/16 by the IDT team. Further review revealed the Administrative Nurse conducted the reviews on weekends. The RNC and/or Vice President for Operations were present every day for the meeting since 08/12/16. Interviews on 08/26/16 with the DON at 11:55 AM and the RNC at 12:10 PM revealed they had been providing oversight in the daily Whiteboard Meeting with the IDT looking at new orders, falls, assessments, notification, and documentation. The RNC stated she or the Vice President for Operations had been present every day since 08/12/16. 10. Review of Chart Audit Compliance Forms, revealed ten (10) residents' charts were audited by the Nursing Administrative Team daily from 08/13/16 through 08/25/16. Interview with the DON on 08/26/16 at 11:40 AM, revealed she was ensuring the Nursing Administrative Team was conducting ten (10) chart audits daily to ensure licensed staff were notifying the physician and family timely, change in conditions were being addressed, and documentation was completed. She stated once the IJ was removed they would continue to audit five (5) charts per day, five (5) days a week, for two (2) weeks, and then five (5) charts per week for two (2) weeks 11. Review of the Regional Staff Attendance Record revealed the RNC and/or Vice President for Operations were at the facility daily to provide oversight and consultation. Interview with the RNC, on 08/26/16 at 12:10 PM revealed she would continue oversight and consultation until the removal of immediacy. Then oversight would be provided weekly for four (4) weeks, then monthly for six (6) months, to ensure the above audits were completed and any concerns were addressed. 12. Review of a note written by the Administrator revealed she spoke to the Medical Director on 08/0

Based on interview, review of facility policy, manufacturer instructions, and record review, it was determined the facility failed to ensure the resident's environment remained as free of accident hazards as possible and failed to ensure adequate supervision was provided to prevent accidents for one resident (#1), in the selected sample of three (3) residents. The facility utilized sit to stand and full body mechanical lifts for resident transfers. The facility failed to assess the resident for the safe use of the mechanical lift and determine the risk and benefits for the resident. This failure resulted in Resident #1 sustaining a fractured right femur (thigh bone), during an assisted transfer using the sit-to-stand lift, on 08/01/11. The findings include: A review of the facility's policy and procedure, entitled "Incident Reporting," dated 12/10, revealed "It is the intent of this facility to provide a safe and healthful work environment. This facility shall ensure the resident's environment shall remain as free of accident hazards as possible, and each resident shall receive adequate supervision and assistive devices which shall reduce accidents. An incident report is to be completed for all falls, bruises and skin tears of known or unknown origin, resident-to-resident altercations, resident to employee altercations, medication errors or any other atypical occurrence. Incident and occurrence will be reported to the department supervisor." A review of the manufacturer's "Operating and Product Care Instructions," dated 06/03, revealed the need to attach and tighten the (calf) strap around the lower legs, just below the knees. Further review of the guide revealed a "caution" statement, which stated, "Only use after a satisfactory professional assessment has been carried out on the individual resident. An assessment must be made as to whether the resident required the lower leg straps. Apply these if necessary." A review of the "Fall/Change in Functional Status" note, dated 08/01/11, no time listed, revealed Resident #1 was assisted up by the staff and a mechanical lift (sit to stand). The resident slid out of the lift pad and fell on to the floor. The resident complained of right leg pain and stated it popped twice. The right leg exhibited external rotation. After the fall, the resident was transported to the hospital and returned to the facility, on 08/10/11, with [DIAGNOSES REDACTED]. Proximal and distal fixations screws were used for internal fixation of the previously described spiral fracture in the distal third of the right femur with minimal comminution. An interview with Resident #1, on 08/11/11 at 9:22 AM, revealed the staff put the strap behind the resident and pulled the resident to the edge of the bed. The resident held onto the bar once the strap was in place. The resident stated he/she could bear a little weight on the right leg. The resident stated staff had never used the leg strap before and the resident told them to push his/her leg in the knee support. Per interview, the resident got too close to the edge of the bed and slid down to the floor. The resident's leg went to the right and he/she heard a "pop." The resident stated he/she did not remember anything else, and "blacked out." An interview with Certified Nurse Aide (CNA) #1, on 08/10/11 at 4:09 PM, revealed she and CNA #2 were in Resident #1's room to get him/her out of bed. She stated they got the resident up with the sit to stand mechanical lift and the resident told them his/her catheter was not in the right position. She stated when they raised the resident in the mechanical lift, Resident #1's leg slipped out of the bottom leg holder. CNA #1 stated she did not use a leg strap on the resident at the time. She realized they were not able to get his/her leg back in the support and the resident had to be lowered to the floor. The resident stated his/her leg popped, but nothing was heard. She stated they reviewed the resident's care plan to know how they were supposed to lift the resident, and they used the sit to stand mechanical lift with the resident as indicated on the plan of care. An interview with CNA #2, on 08/10/11 at 4:27 PM, revealed she was in the room with CNA #1, on 08/01/11 at 5:30 AM, to get Resident #1 out of bed. She stated they assisted the resident up in the sit to stand mechanical lift and tried to adjust the position of his/her catheter. CNA #2 stated the sit to stand lift had knee supports and when she looked down, one of the resident's legs was out of the support. The resident told the CNAs his/her leg popped and asked them if they heard it. They each stated, "we did not hear anything." Afterwards, Resident #1 became weak and he/she let go of the mechanical lift handles and his/her arms went up. She stated, at that point, she realized they needed to get the resident back on the bed, but they were not able to do so. The resident was too heavy and was lowered to the floor. The resident's leg was out in the front of the lift and did not go to the side. CNA #2 stated she went to the door and called for the nurse. An interview with Licensed Practical Nurse (LPN) #1, on 08/11/11 at 10:10 AM, revealed she was the nurse on duty, at the time of the fall. She stated she entered the resident's room and observed Resident #1 in the floor, with the lift out in front of him/her. Resident #1's back was against the bed. The CNAs stated the resident complained the catheter tubing was twisted or something was not right with it. They tried to get it straight and the resident's leg popped out of the knee support. The CNAs were not able to get him/her back in the bed and they lowered Resident #1 to the floor. Resident #1 complained of real bad pain in his/her leg and swelling was noted in his/her right ankle. His/her right leg was turned outward and LPN #1 notified the physician and family of the incident. Additional staff were called to the floor to assist the resident to bed. There were 4 or 5 staff on the unit to assist the resident to bed while the ambulance was notified. She stated physical therapy usually completed an assessment on the resident to determine if a mechanical lift needed to be used. The therapist put the intervention on the care plan and obtained a physician's orders [REDACTED]. An interview with Resident #1's Power of Attorney (POA), on 08/12/11 at 11:39 AM, revealed she was contacted by the facility staff, on 08/01/11, between 5:30 AM and 6:00 AM. She was told Resident #1 fell out of the lift, and when she arrived to the facility, the resident was already in the ambulance. The POA revealed Resident #1 told her they let him/her fall and also revealed the resident did not have any previous falls. She stated "if the staff positioned the lift right up against his/her right leg, then the resident should not have any problems." She felt the staff were in a hurry to use the lift and stated, "that lift was used between the three floors." A record review revealed Resident #1 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of the resident's quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident to require extensive assistance of two plus persons for bed mobility and total assistance of two plus persons for transfers. A review of the Comprehensive Care Plan, revision date of 02/11/11, and last updated on 06/29/11, revealed the facility identified the resident was at risk for a fall related injury with interventions which included the use of the mechanical lift (sit-to-stand lift) with all transfers. The comprehensive care plan indicated to use the mechanical lift with all transfers; however, it did not indicate the amount of staff required to assist the resident with transfers. Further review of the record revealed there was no evidence of an assessment to determine if the resident was safe in the use of the sit to stand mechanical lift, prior to or after the 08/01/11 incident. An interview with the Assistant Director of Nursing (ADON), on 08/10/11 at 5:09 PM, revealed there was no policy to evaluate residents for the safe use of a mechanical lift. She stated if a resident was able to bear 20% of his/her weight, then the sit to stand mechanical lift was used with the resident, if he/she wanted to do so. Additionally, she stated if a resident was bed bound or could not do anything for himself/herself, then the full body mechanical lift was used. She stated Resident #1 was evaluated by therapy and he/she only used a particular sit to stand mechanical lift. An interview with Licensed Practical Nurse (LPN) #1, on 08/11/11 at 10:10 AM, revealed physical therapy usually completed an assessment on the resident to determine if a mechanical lift needed to be used. The therapist put the intervention on the care plan and obtained a physician's orders [REDACTED]. However, an interview with the Physical Therapy Assistant (PTA), on 08/11/11 at 1:02 PM, revealed therapy evaluated residents and if there was a need for a lift, then the issue was suggested and discussed with the MDS Coordinator. The MDS Coordinator worked to get that intervention on the resident's care plan. She stated the therapy did not assess the resident for the safe use of a lift. She revealed that was the responsibility of the nurses. An interview with Registered Nurse (RN) #1, on 08/11/11 at 3:54 PM, revealed she thought a lift assessment was completed through the care plan process. The type of lift used was discussed with the resident and family, but was not exactly sure how the process worked. An interview with Director of Nursing (DON), on 08/11/11 at 12:25 PM, revealed there was no actual assessment the facility conducted for the lift and there was no device assessment policy. She stated it was a nursing judgement as to which lift was used for a resident. If there was a question about the resident's ability to participate in a transfer, if the resident was heavy or combative, then a full body lift was used. If a resident could bear weight and participated in the transfer, then they used the sit to stand lift. If a resident's status changed, then the staff would not use the sit to stand mechanical lift for a resident. She revealed Resident #1 used the sit to stand mechanical lift since she started there. The resident did not have much upper body strength and he/she was not able to transfer with two staff and a gait belt. The resident was informed the lift would be used with him/her. When the sit to stand mechanical lift was used, the resident became off balance due to his/her amputation. Resident #1 refused to use a full body mechanical lift. Therapy was involved with his/her care and worked to improve his/her transfer status. Per interview, it was determined the sit to stand lift was no longer safe for Resident #1. An interview with the Maintenance Assistant, on 08/12/11 at 8:08 AM, revealed he checked the mechanical lifts once the staff completed a work order. He stated after Resident #1 fell on [DATE], the sit to stand mechanical lift was removed from the floor because the buckle for the left leg strap was off. The part was ordered by the central supply manager and he replaced the buckle of the knee support. The Maintenance Assistant stated he put the sit to stand mechanical lift back on the floor for use on 08/04/11. An interview with the Quality Assurance representative of the lift manufacturer, on 08/12/11 at 10:55 AM, revealed the inservice on the product was to be completed by the sales representative. They were responsible for inservicing the facility staff on who can use the lift and who could not use the lift. The lift came equipped with leg straps when it was ordered. The straps could be used with the resident, depending on the condition of the resident. However, an interview with the Staff Development Coordinator (SDC), on 08/11/11 at 8:29 AM, revealed she was responsible for training the CNAs and ensured they knew how to use the lifts. She stated, during the training, she went over the manual for the specific mechanical lift and completed a demonstration with the lift. When CNAs were hired, they were to be checked off on the mechanical lifts for competency. The SDC observed the CNAs the majority of the time when using the lifts on the floor. If she observed the CNAs operate the mechanical lift incorrectly, then she immediately intervened and provided education to the CNAs at that time. She revealed if the resident was able to bear 20% of his/her weight, the sit to stand mechanical lift could be used with the resident. She stated if extra security was needed or desired for the residents, then the CNAs could use the leg straps. A review of "CNA Skills Competency," revealed CNA #1 demonstrated proficiency on the use of the "lifts" on 07/22/11, and CNA #2 demonstrated proficiency on the use of the "lifts" on 06/30/11. The facility provided no evidence of an investigative report for Resident #1's incident, which occurred on 08/01/11. The Administrator informed the surveyor, on 08/11/11 at 5:00 PM, the facility did investigate the incident and the incident report, as well as interviews with the staff, were attached to the incident report and they were considered a part of the facility's Quality Assurance program. The Administrator stated she was unable to determine a cause of the incident.